Nasopharynx and its diseases


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Nasopharynx and its diseases

  2. 2. ADENOIDSAdenoids are also called asnasopharyngeal tonsilSituated at junction of the roof andposterior wall of the nasopharynxComposed of vertical ridges of lymphoidtissue separated by deep clefts andcovered by ciliated columnar epitheliumAdenoids have no crypts and no capsuleunlike palatine tonsilconsists of B and T-lymphocytes
  3. 3. DEVELOPMENTDevelopment starts at 16th week of intra-uterine lifeClinically not present at 1st month afterbirthAdenoids are identifiable by 4th month-2yrsHypertrophy/hyperplasia starts at 3-5years of ageInvolutes at puberty
  4. 4. CLINICAL IMPORTANCE1ST month after birth any mass innasopharynx – Encephalocoele should besuspectedAbsence or decrease in size of adenoidsat 4months-2yearshypogammaglobenemia / wiskot-aldrichsyndrome should be suspectedEctopic hypophysis-remnant rathke’spouchchronophil adenoma in femalesafter 50 yeras
  5. 5. ADENOID HYPERPLASIA / ADENOIDITIS - ETIOLOGYPhysiological enlargement 3-5 years of age(some children develop generalized lymphoidhyperplasia)Recurrent attacks of rhinitis, sinusitis, tonsillitisAllergy of upper respiratory tract
  6. 6. CLINICAL FEATURES NASAL SYMPTOMS Nasal obstruction Nasal discharge Sinusitis (commonly chronic maxillary sinusitis) Epistaxis Voice change
  7. 7. CLINICAL FEATURES EAR COMPLAINTS Tubal obstruction Recurrent attacks of acute otitis media Chronic suppurative otitis media and serous otitis media
  8. 8. CLINICAL FEATURESAdenoid facies: elongated face with dullexpression, open mouth, prominent andcrowded teeth, hitched up upper lip,pinched in appearance of nose, higharched palatePulmonary hypertension / cor-pulmonale
  9. 9. DIAGNOSISPosterior rhinoscopic examinationdifficult to perform in childrenRigid or flexible nasopharyngoscopyX-ray lateral view of the nasopharynxDetailed nasal examination to beconducted to rule out other causes ofnasal obstruction
  10. 10. TREATMENTWhen symptoms are not markedbreathing exercises, decongestant nasaldrops, antihistaminics, antibiotics can beusedWhen symptoms are markedadenoidectomy is done
  11. 11. ACUTE NASOPHARYNGITISEtiology: may be due to isolated infectionor secondary to generalized upperrespiratory tract infectionViruses: influenza, para-influenza, rhinovirus, adeno virusBacteria: streptococci, pneumococcus,haemophilus influenzae
  12. 12. ACUTE NASOPHARYNGITIS Clinical features: Dryness and burning sensation of the throat above soft palate Pain and discomfort localized to the back of nose with some difficulty in swallowing In severe infections there is fever and enlarged cervical lymph nodes Examination reveals congested and swollen mucosa often covered with whitish exudate
  13. 13. ACUTE NASOPHARYNGITIS Treatment: Mild cases: spontaneous recovery seen. Analgesics may be used to relieve pain Severe cases require systemic antibiotics If associated with adenoids topical decongestant drops can be used
  14. 14. CHRONIC NASOPHARYNGITISEtiology : associated with chronicinfections of nose, paranasal sinuses andpharynxCommonly seen in heavy smokers,drinkers and those exposed to dust andfumes
  15. 15. CHRONIC NASOPHARYNGITIS Clinical features: postnasal discharge with irritation at the back ofthe nose is most common complaintPatient will have consistent desire to clear throatby hawking or inspiratory snortingExamination of nasopharynx reveals congestedmucosa and mucopus or dry crustsIn children adenoids are often enlarged andinfected
  16. 16. CHRONIC NASOPHARYNGITISTreatment:chronic infections of the nose, paranasalsinuses and oropharynx should be treatedSmoking and drinking should be stoppedAvoid dust and fumesAlkaline nasal douche to remove crustsand mucopusSteam inhalation
  17. 17. THORNWALDT’S DISEASE (PHARYNGEAL BURSITISIt is infection of pharyngeal bursa which isa median recess representing attachmentof notochord to endoderm of primitivepharynxIt is located in the posterior wall ofnasopharynx in the adenoid mass
  18. 18. THORNWALDT’S DISEASE (PHARYNGEAL BURSITIS Clinical features: Persistent post nasal discharge with crusting in nasopharynx Nasal obstruction Tubal obstruction and resulting serous otitis media Dull type of occipital headache Recurrent sore throat Low grade feverExamination reveals a cystic and fluctuant swellingPosterior wall of nasopharynx
  19. 19. THORNWALDT’S DISEASE (PHARYNGEAL BURSITISTreatment:AntibioticsMarsupialisation of cystic swelling andadequate removal of its lining membrane
  20. 20. TUMORS OF NASOPHARYNX JUVENILE NASOPHARYNGEAL ANGIOFIBROMAIt is a benign tumor of nasopharynxExact etiology is not knownIt is a rare tumorSeen in adolescent males in 2nd decade oflife (most commonly at age of 14 yearswith range 7-19 years)Its growth is thought to be testosteronedependent
  21. 21. JUVENILE NASOPHARYNGEAL ANGIOFIBROMA Pathogenesis Ringertz (1938): inequalities in growth of skull bones result in hypertrophy of underlying periosteum in response to hormonal influence Ewing (1941): arises from embrygenic fibro- cartilage between basi-occiput and basi- sphenoid Burner (1942): suggested origin from conjoined pharyngo-basilar and bucco-pharyngeal fascia Osborn (1973): either from hamartomas or fetal erectile tissue hormonal influence Girgis (1973): undifferentiated epithelial cells  linked to paraganglianomas
  22. 22. JUVENILE NASOPHARYNGEAL ANGIOFIBROMAOrigin of tumor: still now it is a matter ofdebate it is believed to arise from the posteriorpart of nasal cavity close to the superior marginof sphenopalatine foramenPathology: Gross firm, lobulated, pink to white.It has no capsuleMicroscopy composed of vascular spaces ofvarying sizes and shape. It contains fibrousstroma, thin walled sinusoids, lined by flattenedepithelium absent muscular coat
  23. 23. JUVENILE NASOPHARYNGEAL ANGIOFIBROMA Extension of the tumor- it is benign and locally invasive Nasal cavity: causes obstruction, epistaxis, nasal discharge Paranasal sinuses Pterygo-maxillary fissure, infratemporal fossa May involve orbit including inferior and superior orbital fissures Cranial cavity: middle fossa commonly involved through erosion of foramen lacerum. Tumor lies lateral to carotid artery, cavernous sinus It may extend to sphenoid sinus into sella tursica where it lies medial to carotid artery May extend to anterior cranial fossa through ethmoidal roof or cribriform plate
  24. 24. JUVENILE NASOPHARYNGEAL ANGIOFIBROMA Clinical features: Age/sex: 14-19 year/male Most commonly patient presents with recurrent epistaxis or profuse epistaxis Progressive nasal obstruction Conductive hearing loss: SOM Mass in nasopharynx on examination which is sessile, smooth, lobulated, pink or whitish, firm (should not be palpated) Broadening of nasal bridge, proptosis, cheek swelling, infra-temporal involvement, II to VI nerves involvement
  25. 25. JUVENILE NASOPHARYNGEAL ANGIOFIBROMA Investigations: X-ray: soft tissue lateral view of nasopharynx, paranasal sinuses, skull base CT/MRI: anterior bowing of posterior wall of maxillary sinus, erosion of sphenoid sinus and greater wing of sphenoid, extension into pterygopalatine and infra-temporal fossa Angiography (digital subtraction angiography) of carotid artery Biopsy is no longer justifiable
  26. 26. JUVENILE NASOPHARYNGEAL ANGIOFIBROMA Differential diagnosis (diagnosis is rarely doubtful) Antro - choanal polyps Large adenoid Chondromas
  27. 27. JUVENILE NASOPHARYNGEAL ANGIOFIBROMA Treatment: only surgical Various surgical approaches depending on origin and extension Trans-palatal Trans-palatal + sublabial approach Lateral rhinitomy Mid-facial degloving approach Infra-temporal fossa approachRadiotherapy is reserved for extensive intra- cranial extension and recurrent tumors
  28. 28. JUVENILE NASOPHARYNGEAL ANGIOFIBROMATreatment: hormonal therapy can be givento reduce Vascularity of tumor pre-operativelyStilbesterol 2.5mg TID for 3 weeks prior tosurgeryEmbolization of feeding vessels is doneprior to surgery to reduce bleeding
  29. 29. OTHER BENIGN TUMORS OF NASOPHARYNXTeratomas: seen at birthPleomorphic adenomaChordomaHamartoma (malformed normal tissue) haemangiomaChoristoma: mass of normal tissue inabnormal siteparaganglianomas
  30. 30. MALIGNANT TUMORS OF NASOPHARYNX NASOPHARYNGEAL CARCINOMAIncidence- common in china particularly insouthern states and Taiwan. It isuncommon in India and constitutes 0.5%of all cancersIncidence if nasopharyngeal cancer inchina is 30-50/100000 populationSex: male: female = 2-3 : 1Age: in Chinese risk starts by 15-19 yrs ofage. Average age group is 25-64 years
  31. 31. NASOPHARYNGEAL CARCINOMA Aetiology Genetic: Chinese have higher genetic susceptibility (even in migrants) Environmental: air pollution, smoking, nitrosamines from dry salted fish, smoke from burning incense and wood Occupation: wood workers, foresters, welders, coal workers, metal workers are commonly effected Viral: epstein-barr virus- Ig A is the serological marker. It is elevated months or years prior to the clinical onset Epithelial tumor cells have intimate relation with T-lymphocytes which are CD-8 positive
  32. 32. NASOPHARYNGEAL CARCINOMA- NATURAL HISTORY Inception Genetic, environmental, viral factors silent period Systemic spread Focal invasion Blood stained mucus, ET Parapha blockage ryngeal, skull base Primary lymph node Locoregional station retropharyngeal spread
  33. 33. NASOPHARYNGEAL CARCINOMA• Histopathology: squamous cell carcinoma Well differentiated Moderately differentiated Poorly differentiated• Non-keratinizing carcinoma: transitional cell carcinoma• Undifferentiated carcinoma Lymphoepithelioma Anaplastic carcinoma Spindle cell carcinoma Clear cell carcinoma
  34. 34. NASOPHARYNGEAL CARCINOMA Gross appearance Proliferative Ulcerative Infiltrative Commonest site: lateral wall, fossa of Rosenmuller
  35. 35. W.H.O CLASSIFICATIONEpithelial tumors: benign, malignantSoft tissue: benign, malignantMalignant lymphomasTumors of bone and cartilageMiscellaneous tumors: benign andmalignantSecondary tumorsTumor like lesions
  36. 36. CLINICAL FEATURES Age: 50-70 years (in India) 35-64 years (in Chinese) Sex: M : F:: 2-3 : 1 Symptoms Nasal: obstruction, discharge, denasal speech, epistaxis Otological: eustachian tube obstruction, conductive deafness, tinnitus, dizziness, otalgia Ophthalmo-neurological: VI nerve involvement results in squint and diplopia, III, IV, V nerve involvement results in ophthalmoplegia, facial nerve involvement results in absent corneal reflex, horner’s syndrome
  37. 37. CLINICAL FEATURES Neck: painless lymph node most commonly jugulo-digastric, spinal accessory (posterior triange node Distant metastasis: thoraco lumbar spine, liver, lungs
  38. 38. DIAGNOSISPosterior rhinoscopyFibro-optic endoscopyRigid endoscopeExamination under general anaesthesiaBiopsyX-ray skullCT- scan
  39. 39. STAGING-AJCC (1992)
  40. 40. STAGING-AJCC (1992)
  41. 41. TREATMENT Radiotherapy: treatment of choice, megavoltage radiation of 6000-7000 rads Brachytherapy: Rapid fall of radiation at short distance Higher dose Spares neighboring structures Trans nasal intra cavity brachytherapy using iridium 192
  42. 42. TREATMENT Surgery: plays minor role. It is limited to radical neck dissection for radio resistant nodes and post reduction salvage surgery for recurrent tumors Approaches: Trans nasal-maxillary Lateral rhinotomy Leforte-I osteotomy Extended subtotal maxillectomy Transpalatal Mid facial degloving Maxillary swing Mandibular swing Infra temporal fossa approach Trans pharyngeal, trans temporal, trans cervical
  43. 43. RESULTSDepends on histological type, stage, age,sex, presence of nodes905 recurrence in 2-3 yearsSurvival rate: 40-50% (5 years)Better outcome in patients below 40 yearsof age