Is nasopharyngoscopy necessary in adult-onset otitis media with effusion?

We appreciate the comments and historical perspective of Drs. Deeb and Ashktorab regarding our Triological Society Best Practice publication, “Is Nasopharyngoscopy Necessary in Adult-Onset Otitis Media with Effusion?” We sought to identify the most relevant publications directly addressing our question and to characterize the level of evidence so that we could generate a best practice summary. The reference provided by Dr. Deeb, does not include information on the incidence of nasopharyngeal carcinoma (NPC) presenting in adults with unilateral otitis media with effusion (OME) in endemic or lowrisk areas. Two of the five articles from low risk areas that we selected as most relevant included all adults with OME and did not report adequate individual patient data on whether OME was unilateral or bilateral to allow for comparison. In reviewing additional candidate studies on the topic from low risk areas, we were similarly unable to extract adequate individual patient data to enable meaningful comparisons. Two of the five studies that we selected as most appropriate in our article were from high risk areas. Unfortunately, most of the studies in high risk areas, including the study by Ho and another from an expanded literature search, are either lower levels of evidence or do not provide adequate individual patient data on the unilateral or bilateral nature of the OME. As a result, generation of a stronger recommendation for the universal performance of nasopharyngoscopy in all adult patients with OME, regardless of whether unilateral or bilateral, is hampered by lack of higher quality data on the topic. This should not be taken to imply that nasopharyngoscopy is not an important potential component of the workup of OME in adults, particularly in high risk areas. Given the level of evidence on this topic and the lack of studies focusing on adults with isolated unilateral OME, we feel our recommendation that the clinician should use clinical judgment to guide the decision whether nasopharyngoscopy is necessary is appropriate. Part of this clinical judgment should include bilateral versus unilateral OME and the presence of other risk factors, signs, or symptoms of NPC. While historical perspective and experience support nasopharyngeal examination as a prudent measure in adults with unilateral OME, we did not find the existing data to support the generation of a more firm recommendation for universal application of this diagnostic measure, particularly in low risk areas.