nasopharynx and its diseases

DISEASES OF DISEASES OF NASOPHARYNXNASOPHARYNX

DEPT OF OTORHINOLARYNGOLOGYDEPT OF OTORHINOLARYNGOLOGYJ J M M CJ J M M C

DAVANAGEREDAVANAGERE

ADENOIDSADENOIDSAdenoids are also called as Adenoids are also called as nasopharyngeal tonsilnasopharyngeal tonsilSituated at junction of the roof and Situated at junction of the roof and posterior wall of the nasopharynxposterior wall of the nasopharynxComposed of vertical ridges of lymphoid Composed of vertical ridges of lymphoid tissue separated by deep clefts and tissue separated by deep clefts and covered by ciliated columnar epitheliumcovered by ciliated columnar epitheliumAdenoids have no crypts and no capsule Adenoids have no crypts and no capsule unlike palatine tonsil unlike palatine tonsil consists of B and T-lymphocytesconsists of B and T-lymphocytes

DEVELOPMENTDEVELOPMENT

Development starts at 16Development starts at 16thth week of intra- week of intra- uterine lifeuterine lifeClinically not present at 1Clinically not present at 1stst month after month after birthbirthAdenoids are identifiable by 4Adenoids are identifiable by 4thth month-2 month-2 yrsyrsHypertrophy/hyperplasia starts at 3-5 Hypertrophy/hyperplasia starts at 3-5 years of ageyears of ageInvolutes at pubertyInvolutes at puberty

CLINICAL IMPORTANCECLINICAL IMPORTANCE

11STST month after birth any mass in month after birth any mass in nasopharynx – Encephalocoele should be nasopharynx – Encephalocoele should be suspectedsuspectedAbsence or decrease in size of adenoids Absence or decrease in size of adenoids at 4months-2yearsat 4months-2years hypogammaglobenemia / wiskot-aldrich hypogammaglobenemia / wiskot-aldrich syndrome should be suspectedsyndrome should be suspectedEctopic hypophysis-remnant rathke’s Ectopic hypophysis-remnant rathke’s pouchpouchchronophil adenoma in females chronophil adenoma in females after 50 yerasafter 50 yeras

ADENOID HYPERPLASIA / ADENOID HYPERPLASIA / ADENOIDITIS - ETIOLOGYADENOIDITIS - ETIOLOGY

Physiological enlargementPhysiological enlargement 3-5 years of age 3-5 years of age (some children develop generalized lymphoid (some children develop generalized lymphoid hyperplasia)hyperplasia)Recurrent attacks of rhinitis, sinusitis, tonsillitisRecurrent attacks of rhinitis, sinusitis, tonsillitisAllergy of upper respiratory tractAllergy of upper respiratory tract

CLINICAL FEATURESCLINICAL FEATURES

NASAL SYMPTOMSNASAL SYMPTOMSNasal obstructionNasal obstructionNasal dischargeNasal dischargeSinusitis (commonly chronic maxillary Sinusitis (commonly chronic maxillary

sinusitis)sinusitis)Epistaxis Epistaxis Voice changeVoice change


EAR COMPLAINTSEAR COMPLAINTS

Tubal obstructionTubal obstructionRecurrent attacks of acute otitis mediaRecurrent attacks of acute otitis mediaChronic suppurative otitis media and Chronic suppurative otitis media and

serous otitis mediaserous otitis media


Adenoid facies: elongated face with dull Adenoid facies: elongated face with dull expression, open mouth, prominent and expression, open mouth, prominent and crowded teeth, hitched up upper lip, crowded teeth, hitched up upper lip, pinched in appearance of nose, high pinched in appearance of nose, high arched palatearched palatePulmonary hypertension / cor-pulmonalePulmonary hypertension / cor-pulmonale

DIAGNOSISDIAGNOSIS

Posterior rhinoscopic examinationPosterior rhinoscopic examination difficult to perform in childrendifficult to perform in childrenRigid or flexible nasopharyngoscopyRigid or flexible nasopharyngoscopyX-ray lateral view of the nasopharynxX-ray lateral view of the nasopharynxDetailed nasal examination to be Detailed nasal examination to be conducted to rule out other causes of conducted to rule out other causes of nasal obstructionnasal obstruction

TREATMENTTREATMENT

When symptoms are not marked breathing When symptoms are not marked breathing exercises, decongestant nasal drops, exercises, decongestant nasal drops, antihistaminics, antibiotics can be usedantihistaminics, antibiotics can be used

When symptoms are marked When symptoms are marked adenoidectomy is doneadenoidectomy is done

ACUTE NASOPHARYNGITISACUTE NASOPHARYNGITIS

Etiology: may be due to isolated infection Etiology: may be due to isolated infection or secondary to generalized upper or secondary to generalized upper respiratory tract infectionrespiratory tract infectionViruses: influenza, para-influenza, rhino Viruses: influenza, para-influenza, rhino virus, adeno virusvirus, adeno virusBacteria: streptococci, pneumococcus, Bacteria: streptococci, pneumococcus, haemophilus influenzaehaemophilus influenzae


Clinical features: Clinical features: Dryness and burning sensation of the Dryness and burning sensation of the

throat above soft palate throat above soft palate Pain and discomfort localized to the back Pain and discomfort localized to the back

of nose with some difficulty in swallowingof nose with some difficulty in swallowing In severe infections there is fever and In severe infections there is fever and

enlarged cervical lymph nodesenlarged cervical lymph nodesExamination reveals congested and Examination reveals congested and

swollen mucosa often covered with whitish swollen mucosa often covered with whitish exudateexudate


Treatment:Treatment:Mild cases: spontaneous recovery seen. Mild cases: spontaneous recovery seen.

Analgesics may be used to relieve painAnalgesics may be used to relieve painSevere cases require systemic antibioticsSevere cases require systemic antibiotics If associated with adenoids topical If associated with adenoids topical

decongestant drops can be useddecongestant drops can be used

CHRONIC NASOPHARYNGITISCHRONIC NASOPHARYNGITIS

Etiology : associated with chronic Etiology : associated with chronic infections of nose, paranasal sinuses and infections of nose, paranasal sinuses and pharynxpharynxCommonly seen in heavy smokers, Commonly seen in heavy smokers, drinkers and those exposed to dust and drinkers and those exposed to dust and fumes fumes


Clinical features:Clinical features: postnasal discharge with irritation at the back of postnasal discharge with irritation at the back of the nose is most common complaintthe nose is most common complaintPatient will have consistent desire to clear throat Patient will have consistent desire to clear throat by hawking or inspiratory snortingby hawking or inspiratory snortingExamination of nasopharynx reveals congested Examination of nasopharynx reveals congested mucosa and mucopus or dry crustsmucosa and mucopus or dry crustsIn children adenoids are often enlarged and In children adenoids are often enlarged and infectedinfected


Treatment: Treatment: chronic infections of the nose, paranasal chronic infections of the nose, paranasal sinuses and oropharynx should be treatedsinuses and oropharynx should be treatedSmoking and drinking should be stoppedSmoking and drinking should be stoppedAvoid dust and fumesAvoid dust and fumesAlkaline nasal douche to remove crusts Alkaline nasal douche to remove crusts and mucopusand mucopusSteam inhalation Steam inhalation

THORNWALDT’S DISEASETHORNWALDT’S DISEASE(PHARYNGEAL BURSITIS(PHARYNGEAL BURSITIS

It is infection of pharyngeal bursa which is It is infection of pharyngeal bursa which is a median recess representing attachment a median recess representing attachment of notochord to endoderm of primitive of notochord to endoderm of primitive pharynxpharynxIt is located in the posterior wall of It is located in the posterior wall of nasopharynx in the adenoid massnasopharynx in the adenoid mass


Clinical features:Clinical features:Persistent post nasal discharge with crusting in Persistent post nasal discharge with crusting in nasopharynxnasopharynxNasal obstructionNasal obstructionTubal obstruction and resulting serous otitis Tubal obstruction and resulting serous otitis mediamediaDull type of occipital headacheDull type of occipital headacheRecurrent sore throatRecurrent sore throatLow grade feverLow grade fever

Examination reveals a cystic and fluctuant swellingExamination reveals a cystic and fluctuant swellingPosterior wall of nasopharynxPosterior wall of nasopharynx


Treatment:Treatment:Antibiotics Antibiotics Marsupialisation of cystic swelling and Marsupialisation of cystic swelling and adequate removal of its lining membrane adequate removal of its lining membrane

TUMORS OF NASOPHARYNXTUMORS OF NASOPHARYNXJUVENILE NASOPHARYNGEAL JUVENILE NASOPHARYNGEAL

ANGIOFIBROMAANGIOFIBROMA

It is a benign tumor of nasopharynxIt is a benign tumor of nasopharynxExact etiology is not knownExact etiology is not knownIt is a rare tumorIt is a rare tumorSeen in adolescent males in 2Seen in adolescent males in 2ndnd decade of decade of life (most commonly at age of 14 years life (most commonly at age of 14 years with range 7-19 years)with range 7-19 years)Its growth is thought to be testosterone Its growth is thought to be testosterone dependent dependent

JUVENILE NASOPHARYNGEAL JUVENILE NASOPHARYNGEAL ANGIOFIBROMAANGIOFIBROMA

PathogenesisPathogenesis Ringertz (1938): inequalities in growth of skull Ringertz (1938): inequalities in growth of skull

bones result in hypertrophy of underlying bones result in hypertrophy of underlying periosteum in response to hormonal influence periosteum in response to hormonal influence

Ewing (1941): arises from embrygenic fibro-Ewing (1941): arises from embrygenic fibro-cartilage between basi-occiput and basi-cartilage between basi-occiput and basi-sphenoidsphenoid

Burner (1942): suggested origin from conjoined Burner (1942): suggested origin from conjoined pharyngo-basilar and bucco-pharyngeal fasciapharyngo-basilar and bucco-pharyngeal fascia

Osborn (1973): either from hamartomas or fetal Osborn (1973): either from hamartomas or fetal erectile tissueerectile tissue hormonal influence hormonal influence

Girgis (1973): undifferentiated epithelial cellsGirgis (1973): undifferentiated epithelial cells linked to paraganglianomas linked to paraganglianomas


Origin of tumor: still now it is a matter of Origin of tumor: still now it is a matter of debatedebate it is believed to arise from the posterior it is believed to arise from the posterior part of nasal cavity close to the superior margin part of nasal cavity close to the superior margin of sphenopalatine foramenof sphenopalatine foramenPathology: GrossPathology: Gross firm, lobulated, pink to white. firm, lobulated, pink to white. It has no capsuleIt has no capsule

MicroscopyMicroscopy composed of vascular spaces of composed of vascular spaces of varying sizes and shape. It contains fibrous varying sizes and shape. It contains fibrous stroma, thin walled sinusoids, lined by flattened stroma, thin walled sinusoids, lined by flattened epithelium absent muscular coatepithelium absent muscular coat


Extension of the tumor-Extension of the tumorit is benign and locally invasive it is benign and locally invasive Nasal cavity: causes obstruction, epistaxis, nasal Nasal cavity: causes obstruction, epistaxis, nasal

dischargedischarge Paranasal sinusesParanasal sinuses Pterygo-maxillary fissure, infratemporal fossaPterygo-maxillary fissure, infratemporal fossa May involve orbit including inferior and superior orbital May involve orbit including inferior and superior orbital

fissuresfissures Cranial cavity: middle fossa commonly involved through Cranial cavity: middle fossa commonly involved through

erosion of foramen lacerum. Tumor lies lateral to carotid erosion of foramen lacerum. Tumor lies lateral to carotid artery, cavernous sinusartery, cavernous sinus

It may extend to sphenoid sinus into sella tursica where it It may extend to sphenoid sinus into sella tursica where it lies medial to carotid arterylies medial to carotid artery

May extend to anterior cranial fossa through ethmoidal May extend to anterior cranial fossa through ethmoidal roof or cribriform plateroof or cribriform plate


Clinical features:Clinical features: Age/sex: 14-19 year/maleAge/sex: 14-19 year/male Most commonly patient presents with recurrent Most commonly patient presents with recurrent

epistaxis or profuse epistaxisepistaxis or profuse epistaxis Progressive nasal obstructionProgressive nasal obstruction Conductive hearing loss: SOMConductive hearing loss: SOM Mass in nasopharynx on examination which is sessile, Mass in nasopharynx on examination which is sessile,

smooth, lobulated, pink or whitish, firm (should not be smooth, lobulated, pink or whitish, firm (should not be palpated)palpated)

Broadening of nasal bridge, proptosis, cheek swelling, Broadening of nasal bridge, proptosis, cheek swelling, infra-temporal involvement, II to VI nerves involvementinfra-temporal involvement, II to VI nerves involvement


Investigations:Investigations: X-ray: soft tissue lateral view of nasopharynx, X-ray: soft tissue lateral view of nasopharynx,

paranasal sinuses, skull baseparanasal sinuses, skull base CT/MRI: anterior bowing of posterior wall of CT/MRI: anterior bowing of posterior wall of

maxillary sinus, erosion of sphenoid sinus and maxillary sinus, erosion of sphenoid sinus and greater wing of sphenoid, extension into greater wing of sphenoid, extension into pterygopalatine and infra-temporal fossapterygopalatine and infra-temporal fossa

Angiography (digital subtraction angiography) of Angiography (digital subtraction angiography) of carotid arterycarotid artery

Biopsy is no longer justifiable Biopsy is no longer justifiable


Differential diagnosis (diagnosis is rarely Differential diagnosis (diagnosis is rarely doubtful)doubtful)

Antro - choanal polypsAntro - choanal polypsLarge adenoidLarge adenoidChondromasChondromas


Treatment: only surgicalTreatment: only surgicalVarious surgical approaches depending on Various surgical approaches depending on origin and extensionorigin and extension

Trans-palatal Trans-palatal Trans-palatal + sublabial approachTrans-palatal + sublabial approachLateral rhinitomyLateral rhinitomyMid-facial degloving approachMid-facial degloving approach Infra-temporal fossa approachInfra-temporal fossa approachRadiotherapy is reserved for extensive intra-Radiotherapy is reserved for extensive intra-

cranial extension and recurrent tumorscranial extension and recurrent tumors


Treatment: hormonal therapy can be given Treatment: hormonal therapy can be given to reduce Vascularity of tumor pre-to reduce Vascularity of tumor pre-operativelyoperativelyStilbesterol 2.5mg TID for 3 weeks prior to Stilbesterol 2.5mg TID for 3 weeks prior to surgery surgery Embolization of feeding vessels is done Embolization of feeding vessels is done prior to surgery to reduce bleedingprior to surgery to reduce bleeding

OTHER BENIGN TUMORS OF OTHER BENIGN TUMORS OF NASOPHARYNXNASOPHARYNX

Teratomas: seen at birthTeratomas: seen at birthPleomorphic adenomaPleomorphic adenomaChordomaChordomaHamartoma (malformed normal tissue) Hamartoma (malformed normal tissue) haemangioma haemangiomaChoristoma: mass of normal tissue in Choristoma: mass of normal tissue in abnormal siteabnormal siteparaganglianomasparaganglianomas

MALIGNANT TUMORS OF MALIGNANT TUMORS OF NASOPHARYNXNASOPHARYNXNASOPHARYNGEAL NASOPHARYNGEAL

CARCINOMACARCINOMA

Incidence- common in china particularly in Incidence- common in china particularly in southern states and Taiwan. It is southern states and Taiwan. It is uncommon in India and constitutes 0.5% uncommon in India and constitutes 0.5% of all cancersof all cancersIncidence if nasopharyngeal cancer in Incidence if nasopharyngeal cancer in china is 30-50/100000 populationchina is 30-50/100000 populationSex: male: female = 2-3 : 1 Sex: male: female = 2-3 : 1 Age: in Chinese risk starts by 15-19 yrs of Age: in Chinese risk starts by 15-19 yrs of age. Average age group is 25-64 yearsage. Average age group is 25-64 years

NASOPHARYNGEAL CARCINOMANASOPHARYNGEAL CARCINOMAAetiologyAetiology

Genetic: Chinese have higher genetic Genetic: Chinese have higher genetic susceptibility (even in migrants)susceptibility (even in migrants)

Environmental: air pollution, smoking, Environmental: air pollution, smoking, nitrosamines from dry salted fish, smoke from nitrosamines from dry salted fish, smoke from burning incense and woodburning incense and wood

Occupation: wood workers, foresters, welders, Occupation: wood workers, foresters, welders, coal workers, metal workers are commonly coal workers, metal workers are commonly effected effected

Viral: epstein-barr virus- Ig A is the serological Viral: epstein-barr virus- Ig A is the serological marker. It is elevated months or years prior to marker. It is elevated months or years prior to the clinical onsetthe clinical onset

Epithelial tumor cells have intimate relation with Epithelial tumor cells have intimate relation with T-lymphocytes which are CD-8 positiveT-lymphocytes which are CD-8 positive

NASOPHARYNGEAL CARCINOMA-NASOPHARYNGEAL CARCINOMA-NATURAL HISTORYNATURAL HISTORY

Inception

silent period

Focal invasion

Primary lymph node station

Genetic, environmental, viral factors

Blood stained mucus, ET blockage

Locoregional spreadretropharyngeal

Systemic spread

Parapharyngeal, skull base

NASOPHARYNGEAL CARCINOMANASOPHARYNGEAL CARCINOMA

• HistopathologyHistopathology: squamous cell carcinoma: squamous cell carcinoma Well differentiatedWell differentiated Moderately differentiatedModerately differentiated Poorly differentiatedPoorly differentiated• Non-keratinizing carcinoma: transitional cell Non-keratinizing carcinoma: transitional cell

carcinomacarcinoma• Undifferentiated carcinomaUndifferentiated carcinoma LymphoepitheliomaLymphoepithelioma Anaplastic carcinomaAnaplastic carcinoma Spindle cell carcinomaSpindle cell carcinoma Clear cell carcinoma Clear cell carcinoma

NASOPHARYNGEAL CARCINOMANASOPHARYNGEAL CARCINOMA

Gross appearanceGross appearanceProliferativeProliferativeUlcerative Ulcerative InfiltrativeInfiltrative

Commonest site: lateral wall, fossa of Commonest site: lateral wall, fossa of RosenmullerRosenmuller

W.H.O CLASSIFICATION W.H.O CLASSIFICATION

Epithelial tumors: benign, malignantEpithelial tumors: benign, malignantSoft tissue: benign, malignantSoft tissue: benign, malignantMalignant lymphomasMalignant lymphomasTumors of bone and cartilageTumors of bone and cartilageMiscellaneous tumors: benign and Miscellaneous tumors: benign and malignantmalignantSecondary tumorsSecondary tumorsTumor like lesionsTumor like lesions

CLINICAL FEATURESCLINICAL FEATURESAge: 50-70 years (in India)Age: 50-70 years (in India)

35-64 years (in Chinese)35-64 years (in Chinese)Sex: M : F:: 2-3 : 1Sex: M : F:: 2-3 : 1Symptoms Symptoms

Nasal: obstruction, discharge, denasal speech, Nasal: obstruction, discharge, denasal speech, epistaxisepistaxis

Otological: eustachian tube obstruction, conductive Otological: eustachian tube obstruction, conductive deafness, tinnitus, dizziness, otalgiadeafness, tinnitus, dizziness, otalgia

Ophthalmo-neurological: VI nerve involvement Ophthalmo-neurological: VI nerve involvement results in squint and diplopia, III, IV, V nerve results in squint and diplopia, III, IV, V nerve involvement results in ophthalmoplegia, facial nerve involvement results in ophthalmoplegia, facial nerve involvement results in absent corneal reflex, involvement results in absent corneal reflex, horner’s syndromehorner’s syndrome


Neck: painless lymph node most Neck: painless lymph node most commonly jugulo-digastric, spinal commonly jugulo-digastric, spinal accessory (posterior triange nodeaccessory (posterior triange node

Distant metastasis: thoraco lumbar spine, Distant metastasis: thoraco lumbar spine, liver, lungsliver, lungs

DIAGNOSISDIAGNOSIS

Posterior rhinoscopyPosterior rhinoscopyFibro-optic endoscopyFibro-optic endoscopyRigid endoscopeRigid endoscopeExamination under general anaesthesiaExamination under general anaesthesiaBiopsyBiopsyX-ray skullX-ray skullCT- scanCT- scan

STAGING-AJCC (1992)STAGING-AJCC (1992)

TREATMENTTREATMENT

Radiotherapy: treatment of choice, Radiotherapy: treatment of choice, megavoltage radiation of 6000-7000 radsmegavoltage radiation of 6000-7000 radsBrachytherapy: Brachytherapy:

Rapid fall of radiation at short distanceRapid fall of radiation at short distanceHigher doseHigher doseSpares neighboring structuresSpares neighboring structuresTrans nasal intra cavity brachytherapy Trans nasal intra cavity brachytherapy

using iridium 192 using iridium 192

TREATMENTTREATMENTSurgery: plays minor role. It is limited to radical neck dissection Surgery: plays minor role. It is limited to radical neck dissection for radio resistant nodes and post reduction salvage surgery for for radio resistant nodes and post reduction salvage surgery for recurrent tumorsrecurrent tumorsApproaches:Approaches:

Trans nasal-maxillaryTrans nasal-maxillary Lateral rhinotomyLateral rhinotomy Leforte-I osteotomyLeforte-I osteotomy Extended subtotal maxillectomyExtended subtotal maxillectomy TranspalatalTranspalatal Mid facial deglovingMid facial degloving Maxillary swingMaxillary swing Mandibular swingMandibular swing Infra temporal fossa approachInfra temporal fossa approach Trans pharyngeal, trans temporal, trans cervicalTrans pharyngeal, trans temporal, trans cervical

RESULTSRESULTS

Depends on histological type, stage, age, Depends on histological type, stage, age, sex, presence of nodessex, presence of nodes905 recurrence in 2-3 years905 recurrence in 2-3 yearsSurvival rate: 40-50% (5 years)Survival rate: 40-50% (5 years)Better outcome in patients below 40 years Better outcome in patients below 40 years of ageof age

nasopharynx and its diseases

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