Cancer Behind the Nose: Why Nasopharyngeal Cancer Often Goes Undetected

Nasopharyngeal cancer (NPC) arises in the nasopharynx—the upper part of the throat located behind the nose and above the back of the mouth. Though considered rare in India, its subtle onset and nonspecific symptoms make it a diagnostic challenge. In many cases, the disease progresses significantly, before a confirmed diagnosis is made, which can impact both treatment outcomes and long-term survival.

NPC differs from other head and neck cancers in its location, behaviour, and the population it affects. Unlike oral cavity cancers strongly linked to tobacco and alcohol, NPC has a distinct set of risk factors and requires a different approach to detection and management.

Early Signs Are Often Missed

The nasopharynx is not easily visualised during a routine examination, and symptoms often shows common upper respiratory infections or ear-related issues. Patients may report nasal congestion, mild hearing loss, or a blocked ear sensation, particularly on one side. These signs are frequently attributed to allergies or sinus problems, leading to delays in appropriate referrals and investigations.

In some cases, the first visible symptom may be a painless swelling in the neck caused by enlarged lymph nodes. As the disease advances, symptoms may include nosebleeds, headaches, double vision, or facial numbness, depending on the extent of tumour growth and nerve involvement.

Risk Factors

NPC has a multifactorial origin. One of the strongest associations is with Epstein-Barr Virus (EBV) infection. While EBV is common and often harmless, in some individuals it plays a role in triggering malignant changes in the nasopharyngeal tissue. Genetic susceptibility, certain dietary habits—such as consumption of salt-cured fish—and environmental exposures may also contribute.

Unlike other head and neck malignancies, tobacco and alcohol are not major contributors in most NPC cases. This distinction often makes it more difficult to identify high-risk individuals through traditional lifestyle screening methods.

Diagnosis and Staging

Given the vague symptom profile, NPC is often diagnosed through a combination of nasal endoscopy and biopsy. A flexible endoscope helps visualise the tumour in the nasopharyngeal space. Once confirmed, further imaging with MRI or PET-CT is used to determine the extent of disease and detect any regional or distant spread.

The cancer is typically staged based on the size of the primary tumour, involvement of nearby structures, lymph node spread, and distant metastases. At presentation, many patients already have stage III or IV disease, primarily because early-stage tumours produce few or no symptoms.

Treatment and Prognosis

Radiation therapy remains the cornerstone of NPC treatment, as the tumour is generally radiosensitive. In most cases, intensity-modulated radiation therapy (IMRT) is used to precisely target the tumour while minimising damage to surrounding tissues. Concurrent chemotherapy is often added in advanced cases to improve outcomes.

Surgical intervention is less common in NPC than in other head and neck cancers due to the tumour’s anatomical location, though it may be considered in recurrent or residual disease. When diagnosed early, the prognosis is favourable, with five-year survival rates exceeding 80% in early-stage cases. However, late-stage disease carries a higher risk of complications and recurrence.

When to Refer

Referral to an ENT specialist or head and neck oncologist is warranted when symptoms such as unilateral ear blockage, persistent nasal congestion, or unexplained neck swelling last more than a few weeks and do not respond to routine treatment. In particular, symptoms that occur on one side only should prompt further evaluation.

General practitioners and dentists—often the first points of contact—play a critical role in recognising these subtle red flags and facilitating early referrals.

Nasopharyngeal cancer may be rare, but the cost of a missed or delayed diagnosis can be significant. Its early signs are easy to dismiss, often mistaken for benign or seasonal issues. For that reason, awareness remains a key tool in improving outcomes. Recognising persistent, unexplained symptoms and ensuring timely specialist evaluation can make a meaningful difference in both survival and quality of life.

By Dr. Rajeev Sharan, HOD Sr Consultant, Head & Neck Oncology, HCG Cancer Hospital, Kolkata