Nasopharyngeal Cancer: Why Haemoptysis Is Not Always a Lung Problem

Key takeaways:

• Nasopharyngeal carcinoma (NPC) is one of the most common head and neck cancers in Chinese men in Southeast Asia

• Haemoptysis — coughing up blood — can be the first and only symptom of NPC, and is frequently misattributed to the lungs or throat

• The nasopharynx cannot be seen without specialist equipment — a normal GP or general examination does not exclude a nasopharyngeal tumour

• EBV (Epstein-Barr virus) blood titres are a key diagnostic and monitoring tool in NPC

• When caught early, NPC is highly treatable with chemoradiotherapy

• A painless neck lump, unilateral blocked or muffled hearing, or unexplained nosebleeds alongside haemoptysis should prompt urgent ENT referral

The nasopharynx sits directly behind the nasal cavity and is invisible on routine examination — specialist nasendoscopy is required to visualise it.

I recently saw an 70-year-old Chinese man who had been coughing up blood for several months. He had seen multiple doctors. Nobody had referred him to ENT. When he finally sat in my clinic — sent by an astute internist — the diagnosis was immediately apparent on nasendoscopy: a large mass in the nasopharynx, with two significantly enlarged lymph nodes in the neck. His only initial symptom had been haemoptysis. His lungs were clear.

It is a presentation that stays with you.

What is the nasopharynx?

The nasopharynx is the uppermost part of the throat, sitting directly behind the nasal cavity and above the soft palate. It connects the back of the nose to the rest of the airway.

It is completely invisible on routine examination — you cannot see it by looking in someone's mouth or nose with a pen torch. Examining it requires a flexible nasendoscope passed through the nostril, or a rigid endoscope passed transorally under anaesthesia. This is why nasopharyngeal pathology is so often missed until it is advanced.

Who gets nasopharyngeal carcinoma?

NPC has a striking epidemiological pattern. According to the World Health Organization (WHO), NPC has one of the most distinct geographic and ethnic distributions of any cancer:

• Incidence is dramatically higher in South China, Southeast Asia, and among overseas Chinese populations worldwide

• Chinese men in Singapore, Malaysia, Hong Kong, and Southern China have among the highest rates globally

• The peak incidence occurs between the ages of 40 and 60, though it can occur at any age

• Men are affected approximately two to three times more often than women

• NPC is rare in Western Caucasian populations

Singapore's Chinese population carries this elevated risk. NPC remains one of the top ten cancers in Singaporean men.

What causes NPC?

NPC has three recognised causative factors that interact:

1. Epstein-Barr virus (EBV) EBV is the most important aetiological factor in NPC, particularly in the non-keratinising subtypes that predominate in Southeast Asia (WHO Type II and Type III). EBV DNA is found in virtually all tumour cells in endemic NPC. The virus is not sufficient on its own — most people infected with EBV never develop NPC — but it plays a central role in tumour development.

2. Genetic susceptibility Certain HLA (human leukocyte antigen) haplotypes common in Chinese populations confer increased susceptibility. Family history of NPC also increases risk.

3. Environmental and dietary factors Consumption of salt-preserved fish and other salted foods, particularly in childhood, has been associated with increased NPC risk in epidemiological studies. Smoking is also a contributing factor.

What are the symptoms of NPC?

NPC is often called a silent cancer because early tumours may produce no symptoms at all. When symptoms do appear, they are frequently attributed to more common and benign conditions.

Symptoms to be aware of:

• Haemoptysis — coughing up blood, which may originate from the nasopharynx rather than the lungs

• A painless lump in the neck — caused by lymph node metastasis, often the presenting complaint

• Unilateral blocked or muffled hearing — caused by Eustachian tube dysfunction as the tumour grows

• Unilateral nasal obstruction or discharge

• Unexplained nosebleeds (epistaxis)

• Facial pain or numbness if the tumour extends intracranially

• Double vision in advanced disease

The key clinical lesson: a painless neck lump in a middle-aged or older Chinese man must be considered NPC until proven otherwise, regardless of what other symptoms are or are not present.

What is the role of EBV blood testing?

EBV serology and EBV DNA quantification play an important role in the diagnosis, staging, and monitoring of NPC.

EBV VCA IgA (Viral Capsid Antigen) This antibody titre is elevated in the majority of NPC patients, particularly in endemic populations. A significantly elevated VCA IgA titre in a Chinese patient with relevant symptoms is a strong indicator warranting urgent ENT assessment and nasendoscopy.

EBV EA IgA (Early Antigen) Also elevated in many NPC patients. Used in combination with VCA IgA.

Plasma EBV DNA (cell-free) This is now the most clinically important EBV marker in NPC management:

• Detectable plasma EBV DNA is found in the majority of patients with undifferentiated NPC

• Pre-treatment EBV DNA levels correlate with tumour burden and stage

• Post-treatment EBV DNA is a sensitive marker for residual disease or relapse — a rising titre after treatment is often the earliest indicator of recurrence, preceding imaging findings by weeks to months

• EBV DNA is used for surveillance at 3–6 monthly intervals after treatment completion

Important caveat: EBV serology alone is not diagnostic. Elevated titres must be interpreted alongside clinical examination and imaging. A normal EBV titre does not exclude NPC.

How is NPC diagnosed?

Diagnosis requires:

1. Flexible nasendoscopy — direct visualisation of the nasopharynx in clinic under local anaesthetic

2. Biopsy — tissue diagnosis is essential; this may be done in clinic or under general anaesthesia depending on tumour location and patient factors

3. MRI of the nasopharynx and neck — the imaging modality of choice for local staging, soft tissue detail, and skull base involvement

4. CT chest, abdomen, pelvis — to assess for distant metastases

5. PET-CT — increasingly used for staging, particularly to detect nodal and distant disease

6. EBV DNA — baseline levels for staging and future monitoring

How is NPC treated?

NPC is one of the most radiosensitive of all head and neck cancers. This is both good news and a defining feature of its management.

Chemoradiotherapy — the primary treatment

For locoregionally advanced NPC (the majority of presentations), concurrent chemoradiotherapy (CRT) is the standard of care:

• Radiotherapy is delivered to the nasopharynx and bilateral neck nodes using intensity-modulated radiotherapy (IMRT), which allows high doses to the tumour while sparing surrounding structures such as the parotid glands, spinal cord, and brainstem

• Concurrent cisplatin-based chemotherapy enhances radiosensitivity and improves survival outcomes

• For early-stage disease (T1N0), radiotherapy alone may be sufficient

• Induction chemotherapy followed by CRT, or adjuvant chemotherapy after CRT, may be used in high-burden disease

Five-year survival rates for NPC treated with modern CRT range from approximately 60–90% depending on stage at presentation. Early-stage disease carries an excellent prognosis.

Salvage surgery — for residual or recurrent disease

When NPC recurs locally after radiotherapy, or when residual disease remains, surgical salvage is considered:

• Nasopharyngectomy — surgical resection of the nasopharynx — is technically demanding given the anatomical location and proximity to the skull base, internal carotid arteries, and cranial nerves

• Approaches include endoscopic endonasal nasopharyngectomy and open skull base approaches depending on extent of disease

• Salvage surgery carries significant morbidity and requires careful patient selection

• Neck dissection is performed for residual or recurrent neck disease following radiotherapy

Re-irradiation is an alternative salvage modality in selected cases, though cumulative radiation toxicity limits its use.

When should you seek an ENT opinion?

See an ENT specialist promptly if you have any of the following:

• Haemoptysis where a lung cause has been excluded or not yet fully evaluated

• A painless neck lump persisting for more than two to three weeks

• Unilateral hearing loss, blocked ear, or persistent fluid in the ear in an adult

• Persistent unilateral nasal obstruction or bloody nasal discharge

• Any combination of the above in a Chinese male aged 40 and above

Nasendoscopy in clinic is a quick, well-tolerated procedure. It takes minutes and provides direct visualisation of the nasopharynx. There is no reason to wait.

This content is for general educational and public awareness purposes only. It does not constitute medical advice, diagnosis, or treatment, and does not establish a doctor-patient relationship. Please consult a qualified specialist for an individual clinical assessment.