Slides prepared by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal , for teaching undergraduate and postgraduate MBBS students in the field of otorhinolaryngology. A clear and concise explanation of the basic concepts in the subject matter concerned. He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students

1. Nasopharyngeal
Carcinoma
Dr. Krishna Koirala
2019-02-11

2. Introduction
• Non lymphomatous squamous-cell carcinoma
that occurs in the epithelial lining of the
nasopharynx
• Frequently arises from the pharyngeal recess
(fossa of Rosenmüller) posteromedial to the
medial crura of the eustachian tube opening in
the nasopharynx

3. Fossa of Rosenmuller

4. Epidemiology
• Accounts for 85% adult nasopharyngeal malignancies
and 30% pediatric nasopharyngeal malignancies
• Common in Chinese and North African people
• Male preponderance of 3:1
• Bimodal age presentation with small peak at 15-25
yrs and a large peak at 55-65 yrs

5. Etiology
• Genetic
– Commonest in Southern Chinese ( Mongoloid race)
– HLA association
• Viral : Epstein-Barr Virus
• Environmental
– Exposure to nitrosamines (dry salted fish),
polycyclic hydrocarbons (smoke of incense / wood)
– Smoking , chronic nasal infection, poor ventilation
of nasopharynx

6. W.H.O. Classification (Histological)
• Type 1 :
− Keratinizing squamous cell carcinoma (common in
the older adult population)
• Type 2:
− Non-keratinizing (transitional) carcinoma
• Type 3:
− Undifferentiated carcinoma ( common in childhood
and adolescents , associated with high EBV Ab
titre)

7. Clinical Features
1. Neck swelling (60%)
• Lateral retropharyngeal LN of Rouviere
• B/L, enlarged jugulodigastric, upper & middle deep
cervical nodes and posterior triangle nodes
2. Nasal (40%)
• Blood stained nasal mucus, epistaxis, nose block,
foul smelling nasal discharge
3. Otologic (30%) : Conductive deafness, tinnitus

8. 4. Ophthalmologic (20%)
• Diplopia & ophthalmoplegia (involvement of CN III,
IV, VI), Proptosis (orbit invasion) & blindness
(involvement of CN II)
5. Neurologic (20 %)
• Jugular foramen syndrome: CN IX, X, XI involved by
lateral retropharyngeal lymph node
• Horner's syndrome: sympathetic chain involvement

9. 6. Severe Headache
• Skull base erosion
7. Trotter's triad
– Conductive deafness: Eustachian Tube block
– Ipsilateral temporo -parietal neuralgia: Trigeminal
nerve involvement
– Ipsilateral palatal paralysis: Vagus nerve involved
8. Distant metastasis
• Bone, lungs & liver

11. Investigations
1. Nasopharyngoscopy and Diagnostic Nasal Endoscopy
– Mass seen in nasopharynx at fossa of
Rosenmüller
2. Nasopharyngeal tumor biopsy: blind /under vision
3. F.N.A.C. of neck node
4. C.T. scan head and neck : Tumor extent, skull base
erosion, Cervical lymph node metastasis

12. 5. M.R.I. head & neck: for intracranial extension
6. Tests for metastases
− C.T. chest and abdomen, bone scan, P.E.T. scan,
liver function tests
7. Serologic tests
– Immuno-fluorescence for IgA antibodies to Viral
Capsid Antigen, Ig G antibodies to Early Antigen

13. Diagnostic Nasal Endoscopy
• Gross
–Proliferative
–Ulcerative
–Infiltrative

14. Computerized Tomogram Scan

15. Magnetic Resonance Imaging

16. Endoscopic Biopsy

17. Whole body bone scan

18. Positron Emission Tomography

19. T.N.M. staging
• T1 : confined to nasopharynx
• T2 : soft tissue involvement in oropharynx or nasal
cavity or Parapharyngeal space
• T3 : invasion of bony structures or P.N.S.
• T4 : intracranial, involvement of orbit, cranial nerves,
infratemporal fossa, hypopharynx

20. N0 : no evidence of regional lymph node involvement
N1 : unilateral
N2 : bilateral (above supraclavicular fossa, < 6 cm)
N3 : > 6 cm or in supraclavicular fossa
M 0 : no evidence of distant metastasis
M 1 : distant metastasis present

21. • Stage I : T1 N0 M0
• Stage II : T2 or N1 M0
• Stage III : T3 or N2 M0
• Stage IV : T4 or N3 or M1

22. Treatment modalities
1. Teletherapy or External beam radiotherapy
2. Brachytherapy
3. Chemotherapy
4. Surgery
5. Immunotherapy against E.B.V.
6. Vaccination against EBV: experimental

23. External beam irradiation
2 lateral fields: nasopharynx, skull base and upper neck
sparing temporal lobe, pituitary and spinal cord
1 anterior field: lower neck; sparing spinal cord & larynx

24. Brachytherapy
• Treatment of cancer by the insertion of radioactive implants
directly into the tissue
• Used for small tumor, residual or recurrent tumor
– Interstitial: Radioactive source (Radium, Iridium, Iodine,
Gold) inserted into tumor tissue
– Intracavitary: Radioactive source placed inside the
catheter or moulds & inserted into nasopharynx
– High dose rate (HDR): High intensity radiation delivered
with precision under computer guidance

25. Interstitial Brachytherapy

26. Intracavitary Brachytherapy

27. High Dose Rate Brachytherapy

28. Chemotherapy
• Drugs used
−Cisplatin
−5-Fluorouracil
• Indications
–Radiation failure
–Palliation in distant metastasis

29. Surgery
1. Nasopharyngectomy, Cryosurgery : for residual or
recurrent tumor
2. Radical neck dissection : for radio-resistant neck
node metastasis
3. Palliative debulking : for T4 tumors
4. Myringotomy & grommet insertion : for persistent
otitis media with effusion

30. Radical neck dissection & Interstitial
Brachytherapy

31. Treatment Protocol
T1 : External Radiotherapy (6500 c Gy)
T2 : External Radiotherapy (7000 c Gy)
T3 / T4 : Radiotherapy + Chemotherapy 
Brachytherapy / Salvage surgery if required
N0 : External Radiotherapy (5000 c Gy)
N+ : External Radiotherapy (6000 c Gy) +
Chemotherapy

32. Prognosis
• W.H.O. Type 2 and 3 carcinomas have good
response to radiotherapy and better survival rates
• Average 5 year survival rates for treated patients
Stage I : 95 – 100 %
Stage II : 60 – 80 %
Stage III : 30 – 60 %
Stage IV : 20 – 30 %

33. Follow up protocol for ca nasopharynx
• Final assessment (2–3 months after the end of treatment)
– Local and regional exam plus nasopharyngeal endoscopy, FDG-PET/CT
and/or MRI
• First two years
– Local and regional exam plus nasopharyngeal fibroscopy (every 3 to 4
months)
– Chest X-ray, thyroid function test, CT/MRI (yearly)
• Two to five years
– Local and regional exam plus nasopharyngeal fibroscopy
(every 6 months)
– Chest X-ray, thyroid function test, CT/MRI (yearly)