nasopharyngeal cancers

1. Nasopharynx
Presented by: Dr.Isha Jaiswal
Moderator:Dr.Rohini Khurana
Date: 11th December 2013

2. Nasopharynx
-Behind the nasal cavity
-Extends from skull
Base superiorly to the
soft palate inferiorly
- Communicates inferiorly with
the oropharynx through the
velo-pharyngeal sphincter
- The nasopharyngeal tonsil lies in
the roof
- The pharyngeal opening of ET
lies in the lateral wall

3. ANATOMICAL EXTENT OF
NASOPHARYNX
Roof
Floor
Anterior wall
Posterior wall
Lateral wall

4. ROOF: formed by basiocciput &
basispenoid.

5. FLOOR: Formed by soft palate anteriorly; deficient
posterior called as nasopharyngeal isthmus via which it
communicates with the oropharynx .

6. Anterior :continuous with the nasal
cavity via choanae.

7. Posterior wall:.
Bounded by:
 Atlas vertebra
Axis vertebra
Sup. Constrictor ms
Buccopharyngeal
fascia
Retropharyngeal
space
Prevertebral fascia

8. Lateral wall: contain openings of eustachian tube
bounded by elevation called as torus tubarius.
LATERAL VIEWMEDIAL VIEW

9. SINUS OF MORGAGNI
Space between base of
skull & sup.connstictor.
Through it enters-
 Eustachian tube
 Tensor &Levator veli
palatini muscle
 Asc. Palatine
artery(facial artery)
a-mucosa
b-pharyngobasilar fascia
c-muscular coat
d-buccopharyngeal fascia

10. FOSSA OF ROSENMULLER
Fossa of
rosenmuller

11. What is Waldeyer’s ring?

12. Arterial supply: External carotid artery
• Ascending pharyngeal
• Spheno palatine artery
• Facial arteries
Venous drainage
• The pterygoid venous plexus (superiorly)
• The pharyngeal plexus (inferiorly)
• Finally drain in int. jugular vein
Nerve supply:
Sensory -Ant. to ET opening: maxillary nerve (V2)
Post. to ET opening: glossopharyngeal nerve (IX)
Motor –pharyngeal plexus formed by IX,X & cranial part of XI
nerve.

13. LYMPHATICDRAINAGE
Lateral
Retropharyngeal L.N
also called as nodes
of Röuviere, are the
first nodes in the
lymphatic drainage of
Nasopharynx.
Extends from base of
skull to C3 cervical
vertebra.

14. Lymphatic drainage

15. MUCOSA OF NASOPHARYNX
respiratory type (ciliated pseudostratified
columnar with goblet cells) near the nasal
cavities
 non-keratinising stratified squamous type
near the pharyngeal isthmus

19. RADIOANATOMY

20. Radioanatomy

21. TORUS TUBARIUS

22. ADENOIDS: nasopharyngeal tonsil

23. FOSSA OF ROSENMULLER

24. NASOPHARYNGEAL CANCER

25. Epidemology
NPC shows a distinct racial and geographical
distribution.
The annual incidence rate (per 100,000 per year)
ranged from <1 among whites to >20 among
Southern Chinese populations.
Incidence common in southern China and
Taiwan and they constitute high risk group. USA
& rest part of world constitute low risk group.
 It is uncommon in India and constitutes 0.5% of
all cancers

26. AGE & SEX DISTRIBUTION
 bimodal age distribution is observed in low
risk group. First peak incidence at 15 to
25years,second peak at 50 to 59 years of age
 incidence in high-risk populations rises after
30 years of age, peaks at 40 to 60 years, and
declines thereafter.
Sex ratio; M:F= 2:1 to 3:1

27. ETIOLOGY OF NPC
GENETIC
ENVIORMENTVIRAL

28. GENETIC FACTORS
Chinese have higher genetic susceptibility for
NPC .
Genomic studies have revealed 3 HLA locus.
HLA A2; HLA B46; HLA B17 are associated with
increased risk of NPC

29. ENVIORMENTAL FACTOR
DIET: Chinese salted fish food contain
nitrosamines: carcinogen
Lack of vit C in diet
Burning of incense & woods: polyaromatic
hydrocarbon:carcinogen
Alcohol consumption & Cigarette smoking
occupational exposure to dust, smoke, and
chemical fumes

30. VIRUS
HPV associated with keratinizing type NPC???
EBV associated with NON keratinizing type NPC .
EBV-DNA or RNA presence in cell indicates that
the virus has entered the tumor cell before
clonal expansion.
EBV’s tumerogenic potential is due to two latent
genes: LATENT MEMBRANE PROTEINS (LMP)
EBV-NUCLEAR ANTIGEN (EBNA)

31. NASOPHARYNGEAL CARCINOMA-NATURAL HISTORY
Inception
silent period
Focal invasion
Primary lymph node
station
Genetic, environmental, viral
factors
Blood stained mucus, ET
blockage
Locoregional spread
retropharyngeal
Systemic spread
Paraphar
yngeal,
skull base

32. Clinical Manifestation

33. NPC
symptoms
NASAL
NEURAL
NECK
MASS
EAR

34. SYMPTOMSOF NPC
• Neck mass: may be due to primary tumour or
secondary neck nodes. Bilateral metastasis to
lymph node is common
Nasal : Discharge, bleeding, obstruction
Aural: tinnitus, hearing loss
Cranial nerve palsy : Most common 6th nerve
Weight loss

35. Clinical Manifestation
• Neck lump 60%
• Ear (s) plugging & fullness 41%
• Hearing loss 37%
• Nasal bleeding 30%
• Nasal obstruction 29%
• Head pain 16%
• Ear pain 14%
• Neck pain 13%
• Weight loss 10%
• Diplopia 8%
Symptom & sign of NPC frequency at diagnostic in Mayo clinic
series

36. Extension pathways.

37. Localized tumour: m.c site FOSSA OF ROSENMULLER
may present as neck mass,dysphagia.

39. Anterior Spread into nasal cavity

40. nasal symptoms
Blood-tinge anterior or posteriornasal
drainage
Obstruction of nasal pathway
Epistaxis
Halithosis
Nasal congestion
sinusitis

41. Posterior spread:
into retropharyngeal lymph node.
retropharyngeal
lymph node

42. Post.lateral spread & involvement of
prevertebral muscles.

43. Retropharyngeal & parapharyngeal
space involvement
Retropharyngeal
L.N involved
Parapharyngeal
spread leads to
E.T blockade &
serous otitis
media.

44. Large tumour extending into nasal
cavity,parapharyngeal & prevertebral space

45. Superior spread: into base of skull, may
involve cavernous sinus

46. Superior spread: infilteration of orbital cavity via
inferior Orbital fissure

47. RETROPAROTID SYNDROME :also called
as VILLARET SYNDROME. Occur due to
enlarged lateral retropharyngeal lymph node
metastasizing to retroparotid space.
 Involves 9 to12 cranial nerve & cervical sympathetic
 trunk.
 Patient presents with difficulty in speech &swallowing,
 Altered taste sensations in post.1/3 of tongue.
 Weakness of
 sternocleidomastoid & trapezius muscle.
 Unlateral atrophy of tongue & horner’s syndrome
Ophthalmo-neurological SYMPTOMS:

48. PETROSPHENOID SYNDROME of JACOD:
tumour invasion to base of skull may involve II to VI
cranial nerve.
(II)nerve involvement lead to decreased vision,amurosis
VI nerve involvement results in squint and diplopia.
III, IV, VI nerve involvement results in
ophthalmoplegia.
V nerve involvement results in facial pain & absent
corneal reflex.
Ophthalmo-neurological SYMPTOMS:

49. TROTTER’S TRIAD
NPC
Hearing
loss
Palatal
palsy
Facial
pain

50. HORNER’S SYNDROME

51. Inferior Spread: to oropharynx may lead to
dysphagia,regurgitation

52. Lateral spread:otologic symptoms
• Result from eustachian tube involvement
• Sensation of ear blockage
• Serous otitis media
• Conductive hearing loss
• Tinitus

53. nasopharyngeal tumor with infratemporal
fossa extension

54. LYMPHATIC SPREAD

55. Frequency of lymph node
manifestration
• Upper jugular-94%
• Middle juular-85%
• Retropharyngeal
node-80%
• Posterior cervical -
46%
• Lower jugular-19%
• Supraclavicular -17%
• Submental-17%

56. • LYMPHATIC SPREAD most common to upper, middle
deep cervical & retropharyngeal lymph nodes.

58. Diagnostic Evaluation

59. Clinical evaluation
History taking
Physical examination:
-palpation of neck node
-Testing of cranial nerve
-Vision & hearing assesment
-Examination for distant metastasis:palpation of
abdomen chest & spine.

60. CRANIAL NERVE TESTING

62. The Olfactory nerve
(CN I) is simply tested
by offering
something familiar
for the patient to
smell and identify.
Olfactory nerve test

63. fundoscopy should be
performed on both eyes.
Visual reflexes comprise
direct and concentric
light reflexes. -
• OPTIC NERVE TESTING

64. Occulomotor, trochlear & abducens
nerve testing
• The Oculomotor
nerve ( III), Trochlear
nerve (IV) and
Abducent Nerve (VI)
are involved in
movements of the
eye. They supply the
extraocular muscles
of eye.

65. Trigeminal nerve (CN V) is involved in sensory
supply to the face and motor supply to the
muscles of mastication

66. Corneal reflex
The corneal reflex should
also be examined as the
sensory supply to the
cornea is from this nerve.
Do this by lightly touching
the cornea with the cotton
wool. This should cause the
patient to shut their
eyelids.

67. To test the motor supply, ask the patient to clench their
teeth together, observing and feeling the bulk of the
masseter and temporalis muscles.
perform the jaw jerk on the patient
by placing your left index finger on
their chin and striking it with a
tendon hammer. This should cause
slight protrusion of the jaw.

68. Crease up the forehead
The Facial nerve (CN VII) supplies motor branches
to the muscles of facial expression. -
Keep eyes closed against
resistance
Puff out the cheeks Reveal the teeth

69. Vestibulocochlear (VIII) nerve test
Rinne test - place
tuning fork on the
mastoid process .
Webers test - place the
tuning fork at centre of
the forehead -
Rinne test - place
tuning fork beside
the ear

70. Glossopharyngeal nerve (IX) test
• The Glossopharyngeal
nerve (CN IX) provides
sensory supply to the
palate. It can be tested
with the gag reflex or by
touching the arches of
the pharynx.
vagus nerve (CN X) provides motor supply to the pharynx.
Ask the patient to speak .The uvula should be observed
before and during the patient saying “aah”. Check that it
lies centrally and does not deviate on movement.

71. Spinal acessory nerve(XI) test
Sternocldeiomastoid ms.
test against resistance
Trapezius ms. test against
resistance

72. Hypoglossal nerve (XII) test
Ask the patient to
stick their tongue
out. If the tongue
deviates to either
side, it suggests a
weakening of the
muscles on that side.

73. Radiologic evaluation
• Nasopharyngoscopy
• X Ray head & neck
• CT scan head & neck ( for evaluation &
treatment planning )
• MRI ( if intracranial extension )
• Bone scan
• Pet scan

74. Endoscopic nasopharyngoscopy

75. MRI
.
Advantages:
Superior in assessing
primary tumour, invasion into
surrounding soft tissue
pharyngobasilar fascia,
skull base invasion,
intracranial invasion, as
well as cavernous sinus
extension and
perineural disease
 Advantages:
Superior to MRI and CT
for
assessing lymph node
metastasis, especially
cervical nodal
metastases,
and distant metastases,
especially occult
metastatic disease
PETCTImaging techniques

76. Histopathologic evaluation
• Biopsy
• Most common site are roof of nasophalynx
& Rosenmuller fossa
• Most common histological type:
squamous cell carinoma ( SCC)
KERATINIZING TYPE
NON KERATINIZING TYPE –diffretiated &
undiffentiated subtypes
BASALOID TYPE

77. Immunology
• Indirect immunofluorescence for IgG & IgA
antibodies to viral capsid antigen (VCA) &
early antigen (EA)
– Most specific test for diagnosis
– Highly predictive of the clinical
course:monitoring of EBV DNA in serum of
affected pt.using RTPCR is useful for
monitoring therapy.
– not yet commercially available