CASE PRESENTATION A 38-year-old woman initially presented with a 3-week history of decreased hearing in the left ear. Evaluationrevealedaleftserousotitismedia,withno evidenceofanasopharyngealmass.Shewastreated forallergicrhinitis,withsubsequentresolutionofher serous effusion. During the third trimester of her subsequent pregnancy, she noted a progressive globussensationandleft-sidedintermittentotalgia. A CT scan after her pregnancy showed a 22-cm enhancing mass at the left carotid bifurcation. In addition, prominent soft tissue was noted in the nasopharynx and tongue base, with bilateral 1-cm level II nodes. She was subsequently referred for furtherevaluationandmanagement.Shehadhadan upper respiratory infection 2 weeks before the CT scanbutnofevers,chills,ornightsweats.Shesmoked one pack of cigarettes per day for 20 years but otherwisewasingoodhealth. Physical examination at the time of referral revealed an obese, anxious woman, with a slightly hyponasal voice. There was a left-sided serous middle ear effusion. No trismus was present, but prominent Waldeyer’s ring lymphoid tissue was. Fiberoptic nasolaryngoscopy revealed prominent nasopharyngeal lymphoid tissue abutting the left eustachian tube orifice with purulent exudate. A laryngeal and hypopharyngeal examination was unremarkable. A mildly tender, 2-cm mass was detected at the left carotid bulb, and rubbery, mobile small lymph nodes were found at level II bilaterally. There were no cranial nerve deficits. Question 1: What is your differential diagnosis at this time? Dr. Carroll: The salient features of the history and physical examination of this patient include: unilateral serous otitis in a smoker, neck mass, fullness in Waldeyer’s ring, and progression of symptoms with pregnancy. Initial diagnostic considerations includenasopharyngealororopharyngeal neoplasm (epithelial or lymphoid). Progression of symptoms with pregnancy could be due to benign lymphoid hyperplasia, but an estrogen receptor (+) malignancy such as metastatic breast carcinoma could also be responsible, particularly in a 38-year-old woman. Dr. Stenson: Nasopharyngeal carcinoma with metastatic lymphadenopathy should be the diagnosis of exclusion. Other diagnoses to consider would be lymphoma as well as infection of the adenoid tissue secondary to her recent upper respiratory infection. The finding of an enhanced Department of Otolaryngology and Communicative Disorders, The Cleveland Clinic Foundation, 9500 Euclid Avenue (A71), Cleveland, Ohio 44195 Head & Neck 26: 301–306 Published online 12 February 2004 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.20017