Key nasal symptoms to elicit ^[1]:

• Congestion / blockage / obstruction
• Nasal discharge (anterior vs posterior; nature: clear, mucopurulent, blood-stained)
• Sneezing, itchiness
• Olfactory disturbances / loss of smell (and consequent loss of taste)
• Facial pressure / pain
• Epistaxis

Why each matters:

• Unilateral obstruction + epistaxis = red flag for neoplasm (see below).
• Post-nasal drip (posterior discharge) causes chronic cough, throat clearing, and is often confused with GERD-related laryngopharyngeal reflux.
• Loss of smell (anosmia/hyposmia) can be conductive (polyps blocking olfactory cleft) or sensorineural (viral damage to olfactory neurons).

Associated system symptoms ^[1]:

• Eye: itchiness, visual disturbances (orbital complication of sinusitis, tumour invasion)
• Ear: otalgia, aural fullness, hearing loss (Eustachian tube dysfunction from nasopharyngeal pathology)
• Throat: dental pain (maxillary sinusitis), snoring (nasal obstruction)
• Systemic: fever (infection)

Background history ^[1]:

• Comorbidities: asthma, atopy, immunodeficiency — united airway disease concept
• Social/occupational history — hardwood dust exposure (adenocarcinoma risk)
• Drug history — β-blockers, CCBs, OCP, topical sympathomimetics (rhinitis medicamentosa)
• Smoking — risk factor for sinonasal carcinoma AND NPC
• Family history — NPC has strong familial clustering

External nose examination ^[1]: Look for deformity — crooked nose, deviated nose, saddle nose (septal perforation/collapse, granulomatous disease, cocaine use).

Anterior rhinoscopy ^[1]: Using a Thudichum speculum + headlight. Look at: septum (deviation, perforation, haematoma), inferior turbinates (pale/boggy = allergic; red/swollen = infective), discharge in middle meatus.

Nasoendoscopy (rigid or flexible) ^[1]: Gold standard for visualising the entire nasal cavity, middle meatus, nasopharynx, and Eustachian tube orifices. Essential for NPC diagnosis.

• Crooked nose, deviated nose, saddle nose — cosmetic or functional; saddle nose implies loss of septal cartilage support (trauma, cocaine, granulomatosis with polyangiitis, relapsing polychondritis).

Clinical features:

• Open wound, swelling/discoloration over nasal bone, tenderness, mobility of nose, deformity Management:
• Treat epistaxis and open wound first
• No treatment if no deformity
• Closed reduction within 7–10 days (before bone sets)

Why 7–10 days? After 10–14 days, the fractured bone begins to unite in its displaced position, making closed reduction impossible; open reduction would then be needed.

Septal haematoma:

• Collection of blood under perichondrium
• Risk of ischaemia, septal perforation and collapse (cartilage is avascular — it gets nutrition from perichondrium; a haematoma strips perichondrium away → ischaemic necrosis)
• Infection → meningitis, cavernous sinus thrombosis (valveless veins of face communicate with cavernous sinus)
• Urgent incision and drainage

Causes ^[1]:

• URTI (most common — viral infection → mucosal oedema → sinus ostium obstruction → bacterial superinfection)
• Dental abscess / extraction (premolar/molar teeth) — roots of upper premolars and molars are in close proximity to the maxillary sinus floor
• Trauma

Predisposing factors ^[1]:

• Poor drainage: septal deviation, turbinate hypertrophy, nasal polyposis
• Poor immunity

When to suspect bacterial (vs viral) rhinosinusitis ^[1]:

• Symptoms of viral URTI > 10 days, OR worsening after 5–7 days ("double sickening")

This "double sickening" concept is key: a common cold typically improves by day 7–10. If symptoms persist beyond 10 days without improvement, or if they initially improve then worsen again at day 5–7, bacterial superinfection is likely.

Organisms ^[1]:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
• Anaerobic organisms (dental source)

Symptoms ^[1]:

• Nasal obstruction, nasal discharge (anterior or post-nasal drip), facial pain, reduction of smell, fever

Signs ^[1]:

• Facial tenderness
• Oedema, mucopurulent discharge in middle meatus / nasopharynx

Treatment ^[1]:

• Analgesics
• Antibiotics (amoxicillin first-line; amoxicillin-clavulanate if resistant)
• Intranasal steroid spray (reduces mucosal oedema → promotes drainage)
• Short-term (< 7 days) nasal decongestant e.g. oxymetazoline, ephedrine (why < 7 days? → rhinitis medicamentosa risk with prolonged use)
• Nasal douching (saline irrigation physically flushes out debris/mucus)

Complications ^[1]:

Orbital complications:

• Orbital cellulitis, orbital abscess — the lamina papyracea (paper-thin medial orbital wall) separates the ethmoid sinuses from the orbit; infection easily spreads through this Intracranial:
• Cavernous sinus thrombosis — via valveless ophthalmic veins
• Meningitis, encephalitis, brain abscess — direct spread through posterior wall of frontal sinus or cribriform plate

Definition: Symptoms persisting ≥ 12 weeks.

Clinical features ^[1]:

• Purulent nasal and post-nasal discharge
• Nasal obstruction
• Facial discomfort
• Headache
• Halitosis

CRS is subdivided into CRS with nasal polyposis (CRSwNP) and CRS without nasal polyposis (CRSsNP) — they differ in pathophysiology (Th2-eosinophilic vs Th1-neutrophilic) and treatment response.

Medical Management ^[1]:

• Intranasal steroid — cornerstone of management
• Short-term antibiotics for superimposed infection
• Long-term antibiotics (macrolide, doxycycline) — for their anti-inflammatory effect, NOT primarily antimicrobial. Macrolides modulate cytokine production and reduce biofilm formation.
• Nasal saline irrigation
• Anti-histamine for atopy
• Surgery: Endoscopic Sinus Surgery (ESS) — widens natural sinus ostia to restore mucociliary drainage

Associated diseases ^[1]:

• Asthma → Samter's triad
• Allergic fungal sinusitis
• Cystic fibrosis

Triad of:

1. Asthma
2. Nasal polyposis
3. Aspirin sensitivity

Mechanism ^[1]:

Aspirin inhibits cyclooxygenase (COX) → diverts arachidonic acid metabolism away from prostaglandins/thromboxanes → toward the leukotriene pathway → overproduction of leukotrienes → bronchospasm + eosinophilic mucosal inflammation → nasal polyps + asthma exacerbation

This is why leukotriene receptor antagonists (e.g. montelukast) are particularly useful in these patients. Aspirin desensitisation is another treatment option.

• Type I hypersensitivity reaction
• Aeroallergens → IgE-mediated mast cell degranulation
• United airway disease concept: AR and asthma share epidemiology, pathophysiology, and treatment
  • AR patients: 15–38% have asthma
  • Asthma patients: 6–85% have nasal symptoms
  • Treating allergic rhinitis improves asthma control

Early phase (minutes — mast cell degranulation):

• Sneezing, itching, rhinorrhoea, nasal obstruction

Late phase (4–8 hours — eosinophil/T-cell recruitment):

• Nasal congestion, hyperresponsiveness to both allergens and non-specific irritants (temperature changes, strong odours)

• Other atopy: asthma, eczema, allergic conjunctivitis
• Triggers: seasonal (pollen), perennial (dust mites, pets)
• Intermittent vs persistent symptoms, severity (ARIA classification)
• Associated problems: sinusitis, otitis media, sleep disturbance

House dust mites (most common in HK), cockroach, furry pets, pollen, mould, multi-allergen

Allergen avoidance → Pharmacotherapy → Immunotherapy → Surgery

Pharmacotherapy ^[1]:

• Oral antihistamine (2nd-generation preferred — less sedating: cetirizine, loratadine, fexofenadine)
• Intranasal steroid (most effective single agent for moderate-severe AR)
• Leukotriene receptor antagonists — especially in patients with asthma
• Saline irrigation
• Refractory: short-term systemic steroid, decongestant

Allergy Testing & Immunotherapy ^[1]:

• Skin Prick Test — in vivo, results in 15–20 mins, cheap, but affected by antihistamines
• In vitro specific IgE (RAST) — not affected by medications, useful when skin testing is contraindicated
• Immunotherapy (subcutaneous or sublingual) — modifies the immune response; indicated when pharmacotherapy fails and allergen avoidance is impractical

Offending drugs:

• Anti-hypertensives: β-blockers, calcium channel blockers
• Sedatives
• Antidepressants
• Oral contraceptives

Key concept:

• Reactive vasodilation of nasal mucosa after prolonged use (> 5–7 days) of topical sympathomimetic agents (e.g. oxymetazoline, xylometazoline)
• Short-term relief → chronic obstruction (rebound congestion — the mucosa becomes dependent on the decongestant; withdrawal → severe swelling)
• Management:
  • Prevention (limit use to < 7 days)
  • Intranasal steroid (wean off decongestant while using INS)
  • Surgery: turbinate reduction / turbinectomy (for refractory cases)

Red flags:

• Unilateral obstruction
• Epistaxis
• Bleeding
• Cacosmia (sensation of foul smell — tumour necrosis)
• Proptosis, diplopia, epiphora (orbital invasion)
• Neurological symptoms (cranial nerve involvement / intracranial extension)

• Associated with HPV
• Inverted mucosal surface into stroma (epithelium grows inward rather than outward — hence "inverted")
• Benign but locally aggressive
• Unilateral, lateral nasal wall
• 2–10% risk of MALIGNANT transformation (to SCC)
• Treatment: Surgery (endoscopic medial maxillectomy — must excise with bone of attachment to prevent recurrence)

Risk factors:

• Smoking
• Hardwood dust exposure → adenocarcinoma (occupational — furniture workers; classic exam association)

Histological types:

• Squamous cell carcinoma (most common)
• Adenocarcinoma
• Sinonasal undifferentiated (anaplastic) carcinoma (aggressive)
• Adenoid cystic carcinoma (perineural spread; slow-growing but relentless; associated with late distant metastases — characteristically to lungs) ^[3]

• Arises from olfactory epithelium (at the cribriform plate)
• Late presentation with intracranial extension (because the cribriform plate is thin)
• Treatment: Craniofacial / cranionasal resection with adjuvant radiotherapy

• CT — best for bone detail (erosion, destruction)
• MRI — best for soft tissue, distinguishing tumour from retained secretions, assessing dural/orbital/intracranial invasion

Management:

• Surgery: endoscopic approach, open approach, craniofacial/cranionasal resection and reconstruction
• Adjuvant chemotherapy, radiotherapy

• > 70% of new cases occur in East and Southeast Asia
• 10th most common cancer in Hong Kong (Hong Kong Cancer Registry)
• Global gradual decline in incidence (likely due to changing dietary habits, improved hygiene)
• M:F = 2.5:1
• Sometimes called "Canton cancer" due to its high prevalence in Southern Chinese ^[2]

• Non-keratinizing (most common in endemic areas):
  • Differentiated
  • Undifferentiated (formerly "lymphoepithelioma")
  • > 95% of cases in endemic area
  • Associated with EBV infection
• Keratinising squamous
• Basaloid squamous

The non-keratinizing type is more radiosensitive and has a better prognosis than the keratinizing type — this is why RT is the primary treatment.

• EBV infection — virtually all non-keratinizing NPC contains EBV DNA; the virus drives cell proliferation and evades immune surveillance
• Host genetics / family history — HLA susceptibility loci; first-degree relatives have 6–8× increased risk
• Environmental factors:
  • Active and passive tobacco smoking
  • Alcohol
  • Preserved foods (salted fish, preserved vegetables — contain nitrosamines)
  • Oral hygiene

EBV and Cancer ^[4]: EBV is also associated with Burkitt lymphoma, Hodgkin lymphoma, nasal NK/T-cell lymphoma, post-transplant lymphoproliferative disease, and gastric adenocarcinoma. NPC is the most important epithelial malignancy linked to EBV.

Common site of origin: Fossa of Rosenmüller — superior and posterior to the Eustachian tube cartilage (the pharyngeal recess — a natural mucosal fold where the tumour is often hidden).

Presenting symptoms by system:

• Nose: epistaxis, nasal obstruction
• Ear: hearing loss, tinnitus, aural fullness (Eustachian tube obstruction → serous OME)
• Eye: diplopia (cavernous sinus / CN III, IV, VI invasion)
• Head and Neck: facial numbness (CN V₂/V₃ involvement), neck mass (cervical lymphadenopathy — often the presenting complaint)

Neck mass is the presenting complaint in ~70% of cases ^[2]. The lymph node is typically at level II (upper jugular) or level V (posterior triangle).

Anti-EBV IgA antibodies ^[1]:

• EA-IgA, VCA-IgA, EBNA1-IgA
• Low sensitivity and low specificity for screening in asymptomatic participants — these antibodies can be elevated in other EBV-related conditions and healthy carriers

Serum EBV DNA ^[1]:

• Used for at-risk groups (e.g. positive family history with first-degree relatives)
• Cell-free EBV DNA in plasma has shown higher sensitivity and specificity in recent HK-based studies (Chan et al., NEJM 2017 — a landmark HK study showing that plasma EBV DNA screening can detect early-stage NPC)

• Nasoendoscopy + biopsy — definitive diagnosis
• Ultrasound neck ± fine needle aspiration cytology (FNAC) — assess cervical lymph nodes
• MRI with contrast — staging (assess local extent: parapharyngeal space, skull base, intracranial extension)
• ¹⁸F-FDG PET/CT — for distant metastasis staging and treatment response assessment

• Early stage: Intensity-Modulated Radiotherapy (IMRT) — radiotherapy alone is sufficient for T1-2N0-1
• Advanced/late stage: Concurrent chemotherapy and radiotherapy (cisplatin-based concurrent chemo-RT is standard)
• Residual disease / recurrence:
  • Surgery (e.g. open maxillary swing approach, endoscopic or robotic nasopharyngectomy)
  • Chemotherapy, second-dose radiotherapy
  • Immunotherapy (PD-1 inhibitors showing promise)

Why IMRT? IMRT allows precise dose delivery to the tumour while minimising radiation to adjacent critical structures (brainstem, spinal cord, parotid glands, temporal lobes). NPC is inherently radiosensitive (especially non-keratinizing type), making RT the primary modality.

Long-term complications of RT for NPC:

• Xerostomia (parotid damage)
• Hearing loss (cochlear damage)
• Hypothyroidism (thyroid gland in radiation field)
• Hypopituitarism (pituitary in radiation field) ^[5]
• Radiation-induced cranial neuropathy (including bilateral vocal cord palsy — see past paper Q67 2021)
• Osteoradionecrosis of mandible
• Secondary malignancies
• Temporal lobe necrosis

• Neonates are obligate nasal breathers (cannot coordinate oral breathing until ~4–6 months)
• Cyclical hypoxia: hypoxia → cry → relief → close mouth → hypoxia (classic exam description)
• Growth failure
• Bilateral cases require urgent treatment (airway emergency — need oral airway / intubation, then surgical repair)

Unilateral choanal atresia may present later with unilateral nasal discharge and obstruction.

• Adenoids produce B-cells (part of Waldeyer's ring — lymphoid tissue)
• Involute in later childhood, largely disappear in early adulthood
• Indications for adenoidectomy:
  • Obstructive sleep apnoea syndrome
  • Recurrent rhinosinusitis
  • Recurrent otitis media with effusion

Clinical features:

• Irritable child
• Unilateral foul-smelling nasal discharge, sometimes blood-stained
• Excoriation around the nostril
• Occasionally radio-opaque (on X-ray)

Risks:

• Button battery → septal perforation (EMERGENCY) — the battery creates an electrical circuit with nasal mucosa, causing liquefactive necrosis within 2 hours
• Local spread of infection → sinusitis / meningitis
• Inhalation of foreign body → aspiration
• Injury from clumsy attempts at removal by unskilled person

1. NPC Classical Presentation Stem: Middle-aged Chinese man + blood-stained post-nasal drip + unilateral OME/hearing loss + neck mass → NPC. Investigation = nasoendoscopy + biopsy. Treatment depends on stage (IMRT alone for early; concurrent chemo-RT for advanced).

2. NPC Treatment Discrimination:

   • Tumour confined to nasopharynx, no nodal disease → IMRT alone (Answer C in 2023 MCQ Q64)
   • Tumour occupying whole nasopharynx + level II lymph node → Concurrent chemo-RT (Answer A in 2022 MCQ Q66)

3. Samter's Triad: Asthma + nasal polyps + aspirin sensitivity. Know the COX-inhibition → leukotriene shunting mechanism.

4. Rhinitis Medicamentosa: Prolonged topical decongestant use → rebound congestion. Trap: the answer is NOT "more decongestant."

5. Septal Haematoma: Post-trauma cherry-red boggy septum → urgent I&D. Consequence: saddle nose, meningitis, cavernous sinus thrombosis.

6. NPC Biopsy Finding: "Undifferentiated carcinoma" on nasopharyngeal biopsy in a Chinese patient → non-keratinizing NPC (WHO type). Associated with EBV.

7. Post-RT NPC Complications: Bilateral vocal cord palsy → emergency tracheostomy (2021 MCQ Q67). Hypopituitarism as late complication of cranial RT ^[5].

8. Nasal Foreign Body: Unilateral foul nasal discharge in a child → foreign body until proven otherwise. Button battery = emergency.

9. FNA to neck mass in NPC: The expected cytology is undifferentiated carcinoma (2025 MCQ Q23).

Stem: "Blood stained post-nasal drip with enlarged neck lymph nodes in a 40-year-old man" Answer: H. Nasopharyngeal carcinoma Rationale: Classic triad of blood-stained post-nasal drip + neck lymphadenopathy in a middle-aged man in Hong Kong. Discriminator: allergic rhinitis (option D) presents with clear discharge and itching, not blood-stained discharge with neck lumps.

Stem: "A 50-year-old man complained of blood-stained post-nasal drip and left side hearing loss. Physical examination showed presence of otitis media with effusion on left side and no palpable cervical lymph nodes. What is the MOST APPROPRIATE investigation to confirm the diagnosis?" Options: A. Lateral neck X-ray; B. Nasoendoscopy and biopsy; C. PET; D. US neck Answer: B. Nasoendoscopy and biopsy Rationale: Even without palpable nodes, unilateral OME + blood-stained post-nasal drip in a middle-aged Chinese man = suspect NPC. Nasoendoscopy allows direct visualisation and biopsy of the nasopharynx. Lateral neck X-ray is outdated and has poor sensitivity. PET is for staging, not initial diagnosis. US neck assesses nodes but cannot visualise the nasopharynx.

Stem: "A 67-year-old gentleman diagnosed with advanced NPC 8 years ago was treated with radical radiotherapy and chemotherapy. He presented to A&E with difficulty in breathing and stridor. Laryngoscopy showed bilateral vocal cord palsies. What type of surgery did he need?" Options: A. Bronchial toileting; B. Emergency tracheostomy; C. Injection laryngoplasty; D. Thyroplasty Answer: B. Emergency tracheostomy Rationale: Bilateral vocal cord palsy (from radiation-induced recurrent laryngeal nerve damage) causes airway obstruction. This is an airway emergency → tracheostomy. Injection laryngoplasty and thyroplasty are for unilateral vocal cord palsy to improve voice, not for acute bilateral palsy with stridor. Bronchial toileting doesn't address the fixed cords.

Stem: "A 60-year-old Chinese man complained of blood-stained post-nasal drip and left-side hearing loss. Physical examination showed presence of OME on the left side. There was a 2 cm left level II cervical lymph node. Nasoendoscopy showed a tumour occupying the whole nasopharynx and biopsy showed undifferentiated carcinoma. Which is the MOST APPROPRIATE treatment?" Options: A. Concurrent chemo-RT; B. Immunotherapy; C. IMRT; D. Nasopharyngectomy + neck dissection Answer: A. Concurrent chemotherapy and radiotherapy Rationale: Large tumour occupying the whole nasopharynx + level II cervical LN = advanced stage NPC. Advanced NPC requires concurrent chemo-RT, not IMRT alone (which is for early stage). Surgery (option D) is for recurrence, not primary treatment. Immunotherapy (option B) is for recurrent/metastatic NPC after standard treatment fails.

Stem: "A 60-year-old Chinese man complained of blood-stained post-nasal drip and left side hearing loss. Physical examination showed presence of OME on the left side. Nasoendoscopy showed a tumour occupying the whole nasopharynx and biopsy showed undifferentiated carcinoma. MRI showed that the tumour was confined to the nasopharynx with no enlarged cervical lymph nodes. Which is the MOST APPROPRIATE treatment?" Options: A. Concurrent chemo-RT; B. Immunotherapy; C. IMRT; D. Nasopharyngectomy + neck dissection Answer: C. Intensity modulated radiotherapy Rationale: KEY DISCRIMINATOR from 2022 Q66 — this time, tumour is confined to nasopharynx with NO cervical lymph nodes on MRI = early stage. Early-stage NPC is treated with IMRT alone. Compare with 2022 where the 2cm level II node made it advanced → concurrent chemo-RT.

Stem: "A 60-year-old gentleman who is a chronic smoker came to your clinic with a 5 cm right neck mass which has been there for 2 months. He also has progressive hoarseness." Options: A–H (various H&N cancer sites) Answer: B. Carcinoma of the glottis Rationale: Progressive hoarseness in a smoker = glottic carcinoma (vocal cord involvement). NPC (option G) typically presents with epistaxis/nasal obstruction/OME/neck mass but NOT hoarseness (unless very advanced with vagus nerve involvement, which is uncommon at presentation).

Stem: Same patient — "He also has facial asymmetry." Answer: H. Parotid gland cancer Rationale: Facial asymmetry = facial nerve (CN VII) involvement. The facial nerve runs through the parotid gland → parotid malignancy can cause CN VII palsy. NPC can cause cranial neuropathy but typically CN V (numbness) or CN VI (diplopia), not facial asymmetry.

Stem: "A 50-year-old man has newly diagnosed nasopharyngeal carcinoma. Fine needle aspiration cytology to right level V mass is performed." Answer: J. Undifferentiated carcinoma Rationale: > 95% of NPC in endemic areas (Southern China/HK) is non-keratinizing undifferentiated carcinoma. Level V (posterior triangle) is a classic nodal site for NPC metastasis.

Stem: "Recurrent clear nasal discharge with nasal itchiness and sneezing in child" Answer: D. Allergic rhinitis Rationale: Classic allergic triad: clear rhinorrhoea + nasal itchiness + sneezing. In a child, this is straightforward. Discriminator: NPC (option H) would have blood-stained discharge; chronic suppurative OM (option E) is ear, not nose.