Recommended
More Related Content
What's hot
What's hot (20)
Similar to Tumours of pharynx
Similar to Tumours of pharynx (20)
More from Manpreet Nanda
More from Manpreet Nanda (20)
Recently uploaded
Recently uploaded (20)
Tumours of pharynx
- 2. Tumours of Nasopharynx BENIGN TUMOURS Juvenile Nasopharyngeal Angiofibroma (mc) Craniopharyngioma Rhabdomyoma Teratoma, Paraganglioma Chondroma, Chordoma Hamartoma, Haemangioma Pleomorphic adenoma, Warthin’s tumour
- 3. Juvenile Nasopharyngeal Angiofibroma Histologically benign but locally aggressive vascular tumour occupying nasopharynx seen in adolescent males causing recurrent unprovoked episodes of epistaxis Incidence 0.05 to 0.1% of head & neck cancers Etiology Age gp – 10 – 25 years of age, adolescents (mc), regresses/ stops growing after 25 yrs of age Sex – males (exclusive) Nasal erectile vascular tissue(hamartomatous nidus of inf turbinate tissue) mislocated in nasopharynx -> gets activated when testosterone acts on it -> NPA Abnormal growth of nasopharyngeal fibrocartilage/ fibrovascular stroma Origin from non chromaffin preganglionic cells of terminal branches of maxillary artery
- 4. Genetic/ Heredity Trauma Infection Allergy Pathology Contains both vascular and fibrous tissue Covered with nasopharyngeal mucosa – deceives vascularity Pink grey or purple red colour, sessile or pedunculated No capsule – invades locally Thin walled vessels just endothelial lined, no muscular coat – bleeding which cant be controlled by adrenaline
- 5. Extension Origin – above sup margin of sphenopalatine foramen in lat wall of nasopharynx, attached to roof of choana, post part of middle turbinate, post part of nasal septum Locally invasive Anteriorly – nasal cavity, orbit Posteriorly – destroys pterygoid plates, extends to vidian nerve Superiorly – sphenoid sinus->cavernous sinus, middle cranial fossa Sphenoid sinus -> post ethmoids, ant cranial fossa Laterally -> pterygopalatine fossa -> maxillary sinus -> infratemporal fossa -> cheek
- 6. Clinical features Nasal U/L gradually increasing nasal obstruction, later B/L Recurrent painless unprovoked episodes of nasal bleed Nasal discharge Loss of smell Mouth breathing/ snoring Rhinolalia clausa Ear Blockage in ear due to ET blockage leading to serous otitis media and conductive hearing loss, otalgia, tinnitus
- 7. Eyes Pain, proptosis, lacrimation, diplopia, rarely blindness Face Cheek swelling, broadening of nasal bridge, frog face deformity CNS II CN – blindness III, IV, VI CN – diplopia V CN – neuralgic pain Increased intracranial pressure – headache, blurring of vision, projectile vomiting General – Anaemia, sexual underdevelopment NO LYMPH NODE INVOLVEMENT
- 8. Signs Post rhinoscopy Pink, purple, reddish globular sessile lobulated mass, firm in consistency obstructing one or both choana, may be visible below nasopharyngeal isthmus Ant rhinoscopy Globular pinkish mass in post part of nasal cavity, septum deviated to opposite side NO PROBE TEST, NO DIGITAL PALPATION Oral cavity – soft palate bulge D/D – Infected AC polyp, carcinoma, rhinosporodiosis, craniopharyngioma
- 9. Diagnosis Clinical DNE Biopsy – Only excision biopsy Radiology X ray soft tissue nasopharynx lateral view – soft tissue in NP CT Scan with contrast – gold standard Vascular dumb bell shaped tumour in nasal cavity, nasopharynx, pterygopalatine foramen Anterior bowing of posterior wall of maxillary sinus and post bowing of pterygoids – Holman Miller sign/ Antral sign MRI – intracranial/ orbit extension
- 10. Digital Subtraction Angiography (DSA)/ Carotid angiography Tumour can be seen Also used to embolise feeding vessel on same side – internal maxillary artery Materials used – gelfoam, PVA Helps to reduce bleeding intraoperatively Operate 24- 48 hours after embolization Always arrange blood transfusion before surgery Other methods to reduce bleeding – estrogen therapy, pre op RT, cryotherapy
- 11. Staging Sessions/ Fisch () I A – limited to nasopharynx and nose (I) I B – Extend to PNS (II) II A – Minimal extension to pterygomaxillary fossa (II) II B – Full occupation of pterygomaxillary fossa with bony erosion of orbit (II) III A – Erosion of skull base with minimal intracranial extension (III) III B – Extensive intracranial extension with extending to cavernous sinus, optic chiasma, pituitary fossa (IV)
- 12. Treatment Surgical excision – TOC Complete excision Approaches Wilson’s transpalatal approach – Preferred if tumour limited to nose and nasopharynx – U incision made at the junction of soft and hard palate – separation of hard and soft palate – part hard palate removed for better exposure, complication – oroantral fistula Lateral rhinotomy approach with medial maxillectomy – if extends beyond nasopharynx into Sardana’s approach – transpalatine along with sublabial, extension to sublabial area Endoscopic approach – endonasal – for small and medium sized tumours
- 13. Mid facial degloving approach – good cosmetic results Le fort’s type I osteotomy/ trans maxillary approach - extension to PNS, pterygopalatine fossa Biller’s transmandibular lip splitting approach – infratemporal fossa, pterygoid muscles Craniotomy Other modalities RT – advanced disease, intracranial extension Complication – osteoradionecrosis, secondary malignancies, cataract, optic atrophy High recurrence with RT
- 14. CT Very aggressive tumours Doxorubicin, Vincristine Prognosis Early diagnosis -> good prognosis
- 15. Nasopharyngeal Malignancies Carcinoma (mc) Non Hodgkin’s lymphoma Rhabdomyosarcoma Plasmocytoma Chordoma Adenoid cystic carcinoma
- 16. Nasopharyngeal Carcinoma Incidence – 2% of malignancies of head and neck Age group – Bimodal – 10 -20 years (more aggressive), 50 – 70 years M:F = 3:1 MC in Chinese/ mongoloids – south china, Taiwan, Indonesia, Hong kong, Thailand, Malaysia, NE India mainly Nagaland Etiology Enviromental factors – Air pollution, wood burning, incense sticks smoke, chemical fumes inhalation, exposure to nickel, chromium, radioactive material, polycystic hydrocarbons, household smoke and fumes Dietary ingestion of nitrosamines in form of salted fish, smoked food, Chinese herbal medicine usage, alcohol, smoking, tobacco, opium Vitamin C deficiency Genetic – chromosomal abnormalities
- 17. EB Virus – increased antibody titres – in 90% especially undifferentiated/ poorly differentiated cancers Pathology Proliferative type – Nasal obstruction Ulcerative type – epistaxis Infiltrative type – CN involved, invasive Histological classification Type I – well differentiated keratinizing scc – 25% Type II – differentiated non keratinizing – 12% Type III – undifferentiated/ anaplastic non keratinizing – 63% Type II and III – transitional cell carcinoma, lymphoepithelioma
- 18. Spread MC site of origin – fossa of rosenmuller in lateral wall of nasopharynx Superiorly – intracranial cavity by destruction of basisphenoid and basiocciput Laterally – parapharyngeal space, infratemporal fossa Anteriorly – Nasal cavity, PNS, orbit Inferiorly – oropharynx, soft palate Lymphatic – early lymphatic spread, B/L involvement common in advance cases, retropharyngeal and parapharyngeal lymph nodes to upper deep cervical and posterior group of lymph nodes CN – VI (1st nerve involved), V, IX, X, XI, XII Haematogenous – Bone (Spine, shoulder, pelvis, skull), liver and lungs
- 19. C/F Cervical – Lump in neck – 60-80%, 50% B/L –MC symptom Ear – Hearing loss (CHL) U/L due to SOM unresolving associated with otalgia, tinnitus, giddiness due to ET blockage – 2nd MC symptom Nose – Nasal obstruction (u/l or b/l) associated with blood stained nasal discharge and foul smell – 3rd MC symptom, rhinolalia clausa Epistaxis Eye – diplopia (VI CN), epiphora, proptosis, loss of corneal reflex, diminished vision CNS – headache (V CN), ophthalmoplegia (III,IV and VI CN), Neck and facial pain (V CN), jugular foramen syndrome (IX, X, XI CN), exophthalmos and blindness (II CN), horner’s syndrome (cervical sympathetic chain) Weight loss, loss of appetite
- 20. L/E Pharyngeal – palatal swelling or soft palate bulge Post rhinoscopy – diffuse bulge or ulceroproliferative growth in nasopharynx Ant rhinoscopy – mass in nose, friable, bleeds on touch, blood stained discharge Trotter’s triad Conductive hearing loss (ET blockage), I/L temporo parietal/ mandibular pain – V CN, Soft palate paralysis/ decreased mobility – X CN Trismus – pterygoid muscles
- 21. Diagnosis Pan endoscopy – to rule out 2nd tumour DNE, PTA, Tympanogram Biopsy under vision FNAC CT Scan – HRCT Neck and Nasopharynx – toc MRI CT Lung, Abdomen, Chest X Ray USG abdomen Bone Scan Serology - EBV
- 22. TNM Staging T1 – Nasopharynx T2a – Oropharynx, Nasal cavity without parapharyngeal spread T2b – With parapharyngeal spread T3 – Bony structures, PNS T4 – Intracranial, CN, infratemporal fossa N1 – I/L LN upto 6 cm N2 – C/L or B/L LN upto 6 cm N3a – Any LN > 6 cm N3b – Involves supraclavicular fossa Supraclavicular fossa / Ho’s triangle – clavicle medially and laterally, where neck meets the shoulder
- 23. Staging I – T1 II A – T2a II B – T2b or N1 III – T3 or N2 IV A – T4 IV B – N3 IV C – M1
- 24. Treatment RT - TOC External beam RT – 6000 - 7000 rads Main treatment Stage III and IV – RT and CT 5 FU and cisplatin Residual/ recurrence RND 2nd dose of external RT Brachytherapy Surgery
- 25. Surgical approaches Fisch approach Biller’s approach Maxillary swing approach Nasopharyngectomy Prognosis Stage III and IV – RT more effective – good prognosis Early diagnosis – good prognosis
- 26. Tumours of Oropharynx Benign tumours Mucous retention cyst – Vallecula, yellowish – pedunculated or sessile smooth cyst Most of the patients are asymptomatic with accidental finding on examination Few – foreign body sensation in throat Treatment If pedunculated – excision If cystic – marsipulization ( incision and drainage with removal of cyst wall)
- 27. Papilloma – Seen over tonsils, soft palate, faucial pillars – pedunculated Asymptomatic or local irritation of throat Treatment – excision Pleomorphic adenoma – Hard palate, soft palate, treatment – excision Haemangioma – Palate, tonsil, post pharyngeal wall, congenital, females, regresses after age of 2 years Dysphagia, bleeding If persists after 3 years – surgical resection, cryotherapy, coagulation by LASER, diathermy
- 28. Malignancy of oropharynx Etiology Common in South Asia, Males, age group 50 – 70 years Alcohol Smoking Betelnut chewing Poor orodental hygiene Atmospheric pollution HPV 16 – SCC Tonsil
- 29. Types SCC – 90% Lymphoma – 20% (Tonsils) – Non Hodgkin’s lymphoma Minor salivary gland tumours – soft palate, hard palate, pillars – ca, adenoid cystic ca Sites Lateral wall – MC – Tonsils 50% Base of tongue & Vallecula – 2nd MC – 40% Post pharyngeal wall – 10%
- 30. C/F Associated with lymph node swelling Early symptoms Neck swelling, throat irritation, burning sensation with acidic food, lump in throat Late symptoms Dysphagia, odynophagia, dysarthria, hot potato voice, trismus Other symptoms Unilateral referred otalgia, ulcer in throat, increase salivation, drooling of saliva, muffled speech, neck pain, oral bleed, hemoptysis
- 31. Signs Ulcerative lesion/ endophytic lesion – base of tongue, vallecula Exophytic/ Proliferative lesion – tonsillar fossa, soft palate, post pharyngeal wall IDL examination – base of tongue, vallecula, tonsillo lingual sulcus Digital palpation Post rhinoscopy – nasopharyngeal surface of soft palate Tongue movements restricted, deviation of tongue Lymph node enlargement – I, II, III. IV, V, base of tongue lesions (70%) can be B/L mainly JD LN, Post pharyngeal wall 60% can be B/L, Tonsils 50% mainly JD, Faucial – LN Ib, II
- 32. Distant Metastasis Bone, liver, lung TNM Staging T staging Tx , Tis T1 – upto 2 cm, T2 - > 2 upto 4cm, T3 - > 4 cm T4a – involves surrounding structures – muscles of tongue, larynx, hard palate, mandible, medial pterygoids T4b – involves lateral pterygoids, nasopharynx, skull base, carotid N M
- 33. Stage I – T1, Stage II – T2, Stage III – T3 or N1, Stage IV a – T4a or N2, Stage IV b – T4b or N3, Stage IV c – M1 Diagnosis Biopsy – punch biopsy , under GA if trismus, hidden areas Excisional biopsy – lymphomas (tonsillectomy) Pan endoscopy – secondary primary FNAC – LN USG Neck – LN X Ray Mandible/ OPG Chest X Ray CT Scan with contrast, MRI, PET Scan
- 34. D/D – Tuberculosis ulcer, syphilis, Vincent’s angina. Quinsy Treatment Surgery – local excision and neck dissection RT CT Combined Palliative – advanced tumours – pain relief, tracheostomy, gastrostomy Prognosis – poor as late presentation
- 35. Early stage – RT, organ preservation, laser excision If N0 – Selective neck dissection, N1 – RND Advanced stage – surgical resection along with mandibulectomy along with RND (COMMANDO operation) followed by post operative RT Concurrent CT RT Tonsillar fossa B/L Neck dissection may be required
- 36. Lymphomas B cell high grade Non Hodgkin’s lymphoma M:F 2:1, children and young adults Site – tonsil (mc), base of tongue EBV associated with it Smooth bulky mass, U/L swelling of tonsil Treatment – RT, RT and CT
- 37. Tumours of Hypopharynx Benign tumours Lipoma (mc), papilloma, adenoma, fibroma, leiomyoma Malignant tumours SCC 95% Lymphomas – AIDS Sarcoma Sites – Pyriform sinus (60%) Post cricoid (30%) Post pharyngeal wall (10%)
- 38. Etiology Alcohol (mc) Smoking Genetic Radiation Plummer vinson syndrome/ Patterson brown Kelly syndrome/ sideropenic anaemia – hypochromic microcytic iron deficiency anaemia – POST CRICOID Low socio economic status
- 39. Age group > 50 yrs, male – commonest cause of dysphagia in elderly male Post cricoid – females, 20 – 40 yrs age Pathology Proloferative/ exophytic/ cauliflower like – post pharyngeal wall Ulcerative/ endophytic Ulceroproliferative Microscopy Well differentiated (mc), moderately differentiated, poorly differentiated, anaplastic Spread – lymphatic, direct, hematogenous
- 40. Lymphatic spread Pyriform sinus – 75% chance of lymph node spread, 30% B/L, LEVEL II and III Post cricoid – 20% chance of lymph node spread, B/L common, paratracheal lymph node, IV, VI, VII Post pharyngeal wall – 40% chance of lymph node spread, RP LN (mc), IV Hematogenous – lung, liver, bone Direct – paraglottic space leading to fixation of vc, supraglottis, oropharynx, cricopharyngeal sphincter, laryngeal cartilages, thyroid gland
- 41. C/F Progressive dysphagia more to solids for more than 1 month. Dysphagia is a late symptom but early in post cricoid malignancy Neck swelling Sticking of food in throat, lump in throat (1st symptom), FB sensation in throat, pricking sensation in throat Hoarseness Stridor Choking spells, shortness of breath, aspiration Referred otalgia Spitting of blood Odynophagia/ pain in neck – late symptom
- 42. Signs IDL Ulcerative/ proliferative growth Pooling of saliva – post cricoid malignancy Fixed VC Oedema/ erythema of arytenoids/ post cricoid area – post cricoid malignancy Neck – LN metastasis Widening and splaying of larynx Larynx pushed forwards – post cricoid malignancy Laryngeal crepitus absent – post cricoid malignancy
- 43. Diagnosis X Ray Neck – AP/Lat – cartilage erosion, pre vertebral widening, airway patency Chest X ray – mediastinal widening, aspiration pneumonia, secondaries Barium swallow with fluoroscopy – oesophagus, upper esophageal sphincter FNAC DL Scopy/ hypopharyngoscopy and biopsy CECT – primary modality, cartilage invasion PET – recurrent, residual disease, distant metastasis MRI
- 44. TNM Staging T1 – limited to one site of hypopharynx and upto 2 cm T2 – Greater than 1 site or > 2 cm without fixation of larynx T3 – Greater than 4 cm with fixation of larynx T4a – involves thyroid, cricoid cartilage, thyroid gland, oesophagus, supraglottis, cricopharyngeal sphincter T4b – involves prevertebral, carotid, mediastinum N M STAGING
- 45. Treatment Early stage – RT Advanced stage – Surgery and post op RT CT – adjuvant/ palliative Surgery – Early stage – laser excision, partial pharyngectomy, partial laryngopharyngectomy Late stage – total laryngo pharyngo esophagectomy with gastric pull up/ colonic transposition Reconstruction – PMMC flap, free flaps – radial forearm, lateral thigh, enteric flaps – jejunal , omental Neck dissection – selective (N0), RND
- 46. Prognosis Early diagnosis – rare - good prognosis – 80% 5 year survival Late diagnosis – poor prognosis – 30% 5 year survival Post cricoid malignancy – poor prognosis – early B/L LN metastasis, vertebral column spread