NASOPHARYNX

evaluation of nasopharyngeal masses

The nasopharynx is not visible without special instruments available to a doctor. For this reason, a growth or mass in the nasopharynx is occasionally noted incidentally when a doctor is looking in this area for other reasons, and often noted when a different problem, like an enlarged neck lymph node or persistent fluid in one ear in an adult is noted. Because of the various ways a mass of the nasopharynx may come to attention, the order of tests performed may be different in one case versus another. Typically, evaluation includes performing endoscopy to look at the nasopharynx in the clinic. A biopsy of the mass may be performed in the clinic (when the situation is favorable) or in the operating room. Imaging with a CT or MRI scan may be done, reserving the PET-CT scan for situations in which cancer is proven and other types of imaging do not provide all the information needed.

Symptoms that lead to the diagnosis

Symptoms of nasopharyngeal carcinoma tend to fall into four groups [1, 2]:

• A painless lump in the neck. This is the most common first sign. Because the nasopharynx drains to lymph nodes on both sides of the upper neck, about three-quarters of patients already have lymph node involvement when diagnosed.

• Nasal symptoms, such as one-sided blockage, blood-streaked mucus, or nosebleeds.

• Ear symptoms, such as fullness, muffled hearing, or ringing in one ear, caused by a tumor blocking the opening of the Eustachian tube.

• Skull-base and nerve symptoms in more advanced disease, such as headache, double vision, or facial numbness.

Early symptoms are easy to attribute to allergies or a cold; in a Hong Kong series of 4,768 patients, the average time from first symptom to diagnosis was 8 months, and longer delays meant later stages [3].

Fluid behind one eardrum in an adult

Fluid in the middle ear (serous otitis media) is common in children but unusual in adults without an obvious cause such as a cold or a flight. A 2022 systematic review found that 5.5% of adults with isolated serous otitis media of unknown cause were found to have a nasopharyngeal cancer. Careful endoscopic examination of the nasopharynx was very reliable: a normal-looking nasopharynx missed a cancer in only 0.35% of these patients [4]. For this reason, an adult with persistent fluid behind one eardrum should have the nasopharynx examined.

Endoscopy and biopsy

The nasopharynx is examined in the office with a thin flexible or rigid endoscope passed through the nose after a numbing spray (see fiberoptic laryngoscopy). A visible mass is sampled with an incisional biopsy, either in the office or under anesthesia. When a neck node is the first sign, a needle biopsy of the node that shows EBV-positive carcinoma points strongly to the nasopharynx as the source, even before a primary tumor is seen [5].

Imaging

MRI is the preferred test for the nasopharynx itself because it shows spread into the skull base, the nerves, and the soft tissues around the throat better than CT. PET-CT is recommended for more advanced disease (larger tumors or extensive neck nodes) to look for spread to bone, lung, or liver [5, 2].

Plasma EBV DNA blood test

Most nasopharyngeal carcinomas shed fragments of Epstein-Barr virus DNA into the bloodstream, and the amount can be measured with a blood test. It was detectable in 94 of 99 patients with advanced disease in one study, and higher pretreatment levels or DNA persisting after radiation predicted worse survival [6]. The test is used at diagnosis to help estimate risk, during treatment to judge response, and afterward as part of surveillance [2, 5]. It is useful mainly for the EBV-associated (non-keratinizing) types described below.

Staging

Staging uses the TNM system of the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC). The 8th edition, used in most of the outcome data on this page, was refined for the era of intensity-modulated radiation [7]:

• T (tumor): T1 is confined to the nasopharynx or extends into the nose or oropharynx; T2 extends into the parapharyngeal space or the adjacent pterygoid or prevertebral muscles; T3 involves the bones of the skull base, the cervical spine, or the sinuses; T4 extends inside the skull or involves cranial nerves, the hypopharynx, the orbit, or the parotid gland.

• N (nodes): N1 is lymph node spread on one side of the neck, or to the retropharyngeal nodes, 6 cm or smaller and above the lower border of the cricoid cartilage; N2 is spread to both sides of the neck within the same limits; N3 is any node larger than 6 cm or below the cricoid cartilage.

• Stage groups: stage I is T1N0; stage II is T2 or N1; stage III is T3 or N2; stage IVA is T4 or N3; stage IVB is spread beyond the head and neck (distant metastasis).

A 9th edition, adopted in January 2025, simplifies the groups: non-metastatic disease is now stage I to III, and stage IV is reserved for metastatic disease, subdivided by whether there are three or fewer distant lesions (IVA) or more (IVB) [8].

CAUSES OF NASOPHARYNGEAL CARCINOMA

Nasopharyngeal carcinoma (NPC), or nasopharynx cancer, is the most common cancer originating in the nasopharynx. NPC differs significantly from other cancers of the head and neck in its occurrence, causes, clinical behavior, and treatment. It is much more common in regions of East Asia and Africa than elsewhere, with viral, dietary and genetic factors implicated in its causation [9, 2]. The highest rates are in southern China, Southeast Asia, and North Africa; in the United States it is uncommon, although the incidence of the EBV-related, non-keratinizing types has been rising among some groups [10].

The viral influence is associated with infection with Epstein-Barr virus (EBV), but since this virus is so common (more than 90% of adults worldwide have been infected by middle age) [11], we know other factors play a role in development of NPC. EBV genetic material is found in essentially every cancer cell of the non-keratinizing types, which supports a direct role for the virus in those cancers [1]. Other likely causes include genetic susceptibility and consumption of food (in particular salted fish) containing carcinogenic volatile nitrosamines.

• Salted fish and preserved foods. In a Hong Kong study of patients under age 35, eating Cantonese-style salted fish at least weekly at age 10 was associated with a more than 30-fold higher risk, and exposure in early childhood mattered most [12]. A 2022 dose-response meta-analysis found more modest increases in risk (about 45% higher with high intake of salted fish), with similar associations for processed meats and preserved vegetables [13]. The importance of salted fish has declined as diets in southern China have changed [9].

• Family history and genes. In a large southern Chinese study, having a parent, sibling, or child with NPC raised a person's risk more than fourfold [14]. Genome-wide studies have linked NPC risk to the HLA genes that govern how the immune system recognizes EBV, among other regions [15].

• Other exposures. Passive smoking and household air pollution have modest associations [9].

Human papilloma virus (HPV) appears to cause a minority of cases of NPC. In a pooled analysis, HPV DNA was found in about a third of keratinizing tumors and less often in non-keratinizing tumors, and roughly a fifth of keratinizing tumors were HPV-positive and EBV-negative [16].

Types of nasopharyngeal carcinoma

The World Health Organization (WHO) has identified three subtypes of nasopharyngeal carcinoma, which in the current classification are [17, 18]:

• keratinizing squamous cell carcinoma (formerly "type 1"), typically found in older adults and more closely linked with tobacco and alcohol, like other head and neck cancers [2]

• non-keratinizing carcinoma, which is divided into a differentiated form (formerly "type 2") and an undifferentiated form (formerly "type 3," and once called lymphoepithelioma)

• basaloid squamous cell carcinoma, a rare variant

The undifferentiated non-keratinizing type is the most common type overall and accounts for the great majority of cases in southern China and Southeast Asia [2]. NPC is rare in children and adolescents (about 0.5 cases per million per year in the United States, compared with 8.4 per million in adults), but when it does occur in young people it is almost always this type: 87% in a national U.S. cancer registry study [19]. Both non-keratinizing forms are associated with EBV and with elevated levels of Epstein-Barr virus antibodies and DNA in the blood, but keratinizing squamous cell carcinoma usually is not [17, 16].

Screening with plasma EBV DNA

Because EBV DNA appears in the blood early, it has been studied as a screening test in high-risk populations. In a Hong Kong study of 20,174 men aged 40 to 62 without symptoms, those with a positive test had it repeated about 4 weeks later, and persistently positive participants had endoscopy and MRI. The test had a sensitivity of 97.1% and specificity of 98.6% and found 34 cancers. Of the screen-detected cancers, 71% were stage I or II, compared with 20% in an earlier unscreened group, and 3-year progression-free survival was 97% versus 70% [20]. Screening of this kind makes sense where NPC is common. In low-incidence areas such as the United States, most positive tests would be false alarms, so population screening is not offered there.

Treatment of nasopharyngeal carcinoma

Because of its location, surgery is not the mainstay treatment of nasopharyngeal carcinoma (NPC). Radiation therapy (± chemotherapy) is used for the cancer in the nasopharynx and for any lymph nodes at risk or definitely involved with cancer spread (metastasis). Surgery is typically unnecessary, and reserved for situations in which cancer is spread to the neck lymph nodes and is not completely cleared with radiation (± chemotherapy), or in which the cancer comes back after treatment. The Eustachian tube air passage from the nasopharynx to the ear usually does not function well in patients with NPC, and so a pneumatic ventilation tube in the ear(s) is often needed. As with all throat cancer treatments, working with speech pathology to maintain jaw and throat function is highly advisable.

Radiation therapy

Modern treatment uses intensity-modulated radiation therapy (IMRT), which shapes the dose to the tumor and nodes while limiting dose to the salivary glands, inner ears, brain, and spinal cord. A randomized trial of 616 patients compared IMRT with older two-dimensional radiation: 5-year local control was 90.5% versus 84.7%, 5-year overall survival was 79.6% versus 67.1%, and side effects were significantly lower with IMRT [21]. A U.S. multicenter trial (RTOG 0225) reproduced these results, with only 3.1% of patients having severe late dry mouth [22]. A typical course is about 7 weeks of daily treatments.

Adding chemotherapy

For all but the earliest cancers, chemotherapy is given with radiation. The landmark U.S. Intergroup 0099 trial compared radiation alone with radiation plus cisplatin during treatment and additional chemotherapy afterward in advanced NPC; 3-year survival was 47% versus 78% [23]. An individual-patient meta-analysis of 19 trials and 4,806 patients confirmed that adding chemotherapy improves survival (an absolute gain of 6.3% at 5 years), and that the benefit comes mainly from chemotherapy given at the same time as radiation (concurrent chemoradiation) [24].

Treatment is now tailored to stage and risk:

• Stage I: radiation alone [5].

• Low-risk stage II and some stage III (T3N0) cancers: in a randomized trial of 341 patients with small nodes and low EBV DNA, IMRT alone was as effective as chemoradiation (3-year failure-free survival 90.5% versus 91.9%), with far fewer severe side effects (17% versus 46%) [25].

• Locoregionally advanced cancers (stage III to IVA): concurrent cisplatin and radiation remain the backbone, usually with chemotherapy added before (induction) or after (adjuvant) [2, 26].

Induction chemotherapy

Induction chemotherapy is given before chemoradiation to shrink the tumor and treat microscopic spread early. In a phase 3 trial of 480 patients with locoregionally advanced NPC, three cycles of gemcitabine and cisplatin before chemoradiation improved 3-year recurrence-free survival from 76.5% to 85.3% [27]. With longer follow-up, 5-year overall survival was 87.9% versus 78.8%, without more severe late side effects; patients whose blood EBV DNA was low before treatment (under 4,000 copies/mL) did not appear to benefit [28].

Adjuvant (maintenance) capecitabine

For high-risk patients, an oral chemotherapy pill, capecitabine, can be taken after chemoradiation to reduce the chance of distant spread. In a trial of 406 patients, low-dose ("metronomic") capecitabine taken twice daily for a year improved 3-year failure-free survival from 75.7% to 85.3%; the most common significant side effect was hand-foot syndrome (redness and peeling of the palms and soles), severe in 9% [29]. A second trial using standard-dose capecitabine found a similar benefit [30].

Immunotherapy (PD-1 inhibitors)

PD-1 inhibitors are antibodies that release a brake on the immune system so that it can attack the cancer. They have changed the treatment of NPC that has spread or come back:

• In the JUPITER-02 trial (289 patients), adding toripalimab to gemcitabine and cisplatin lengthened median progression-free survival from 8.2 to 21.4 months and reduced the risk of death by 37%, regardless of PD-L1 status. Immune-related side effects (such as thyroid inflammation) were more common, 54% versus 22% [31, 32]. Toripalimab with this chemotherapy was approved by the U.S. Food and Drug Administration in 2023.

• Camrelizumab gave a similar benefit in the CAPTAIN-1st trial [33].

PD-1 inhibitors are now being studied for earlier, curable disease. In the CONTINUUM trial of 425 high-risk patients, adding sintilimab to induction chemotherapy and chemoradiation improved 3-year event-free survival from 76% to 86%, at the cost of more side effects [34].

Outcomes by stage

In a prospective study of 518 patients treated with IMRT (± chemotherapy) and staged by the AJCC 8th edition, 5-year overall survival was 90% for stage I, 84% for stage II, 84% for stage III, and 75% for stage IVA; survival free of death from NPC was 100%, 95%, 90%, and 80% [35]. With IMRT, the most common way NPC fails is distant spread (to bone, lung, or liver) rather than regrowth in the nasopharynx [2, 36]. For cancer that has spread at diagnosis or recurs, chemotherapy plus immunotherapy now gives many patients years of disease control; in JUPITER-02, median survival with chemotherapy alone was 33.7 months and had not yet been reached with the addition of toripalimab [32].

Late effects

Because the nasopharynx sits next to the ears, salivary glands, skull base, and brain, long-term effects are common even with IMRT. In a study of 107 survivors seen a median of 7.5 years after treatment, 47% had at least one severe late effect [37]:

• Hearing loss was the most common: 72% had significant hearing loss on testing. Radiation dose to the inner ear and cisplatin each add to the risk [37, 38]. Regular hearing tests and hearing aids are part of survivorship care (see hearing).

• Low thyroid function developed in 69%, so thyroid blood tests are checked periodically [37].

• Dry mouth, thick mucus, chewing and swallowing problems, and dental problems were the most bothersome symptoms reported by patients [37]. Some patients need temporary tube feeding during treatment (see G-tube placement), and swallowing therapy helps maintain function (see swallowing).

• Trismus (tight jaw), memory and concentration problems, and, less often, damage to the temporal lobes of the brain or the cranial nerves [2, 37].

• Depression, anxiety, and fatigue were common and strongly tied to quality of life [37].

Ear fluid and ventilation tubes

Middle ear fluid is common both at diagnosis and after radiation, and it often persists. The evidence on ventilation tubes is mixed:

• In a randomized trial of tubes placed before radiation versus observation, tubes did not improve hearing over 4 years [39].

• In a randomized trial of patients with persistent fluid after radiation, tubes improved hearing considerably (average air-bone gap 9 dB versus 27 dB), and only 10% developed infection or drainage [40].

• Other series report more trouble. In one long-term study of 85 irradiated patients, fluid persisted in 53% and 19% developed chronically draining ears [41]. A review of six studies found that repeated myringotomy (a small opening in the eardrum without a tube) led to fewer complications than tubes, and suggested reserving tubes for persistent fluid or for patients who cannot tolerate repeated procedures [42].

Hearing aids are a reasonable alternative when hearing loss persists.

Surgery for cancer that persists or returns

About 5% to 15% of patients have cancer that persists or returns in the nasopharynx, and fewer than 10% have return of disease in the neck alone [36, 2].

• Neck: cancer remaining or returning in the neck nodes is treated with neck dissection (see neck tumors). In one series of 31 patients, neck dissection controlled the neck disease in 65%, and 5-year survival was 67% [43].

• Nasopharynx: small recurrences can often be removed through the nose with endoscopic surgery. In a randomized trial of 200 patients with resectable recurrences, endoscopic nasopharyngectomy gave better 3-year survival than a second course of IMRT (85.8% versus 68.0%), largely because re-irradiation caused more severe late damage [44].

• Re-irradiation: for larger recurrences, a second course of radiation is possible but risky. Giving it twice a day in smaller doses (hyperfractionation) lowered severe late complications from 57% to 34% and improved 3-year survival from 55.0% to 74.6% compared with standard once-daily treatment [45].

Follow-up

After treatment, follow-up includes endoscopy of the nasopharynx, a neck examination, MRI at intervals (typically starting about 3 months after treatment), blood EBV DNA testing for EBV-associated cancers, thyroid testing, and hearing tests [5].

Additional links

Further reading from national cancer organizations:

• This link to the American Cancer Society interactive website provides an introduction to nasopharyngeal cancer (carcinoma).

• The National Cancer Institute's PDQ summary of nasopharyngeal cancer treatment (patient version).

Summary

Nasopharyngeal carcinoma is a cancer of the space behind the nose that is closely linked to the Epstein-Barr virus. It often shows up first as a painless neck lump, nasal blockage or bleeding, or fluid behind one eardrum in an adult, and it is diagnosed with endoscopy, biopsy, and MRI. Treatment is radiation, usually with chemotherapy given during, and often before or after, the radiation; surgery is reserved mainly for cancer that persists or returns. Five-year survival ranges from about 90% for stage I to about 75% for stage IVA with modern treatment, and PD-1 immunotherapy has improved outcomes for cancer that has spread. Long-term care focuses on hearing, ear fluid, dry mouth, swallowing, thyroid function, and surveillance for recurrence.

Last reviewed: October 4, 2026

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