An elderly man with an air-fluid level in the middle ear

A 68-year-old Malay man who is a rubber tapper, presented with a large painful right-sided neck swelling for 6 months, which was gradually increasing in size and associated with odynophagia, dysphagia, hoarseness and significant weight loss. He did not complain of any ear symptoms, but on further questioning, he admitted having a 3-week history of occasional tinnitus and reduced hearing on the right ear. Other ear symptoms were negative.