1. Cancer of thenasopharynx BY Dr , Ibrahim HabibBarakat M.D. ( E.N.T.) salamatuall@yahoo.com www.facebook.com/Dr.Ibrahim.Barakat

4. Epidemiology of nasopharyngeal ca. Incidence : Rare o.6 per 100,000 l yr in U S A Southern China is 50 times > U S A ِ Age : 4TH to 5th decade Sex : male : female 2 to 3 : 1 Etiology : Multifactorial : Viral , dietry , occupational , cigarette smoking

6. Viruses & human malignancies

8. Anatomy of the nasopharynx Anterior : post. Nasal choana , nasal septum Post : 2 cervical vertebrae , prevertebral and buccopharyngeal fascia Sup: basisephenoid , basioccipt Inf : sup . Surface of soft palate Lateral : maxilloph. Space , pterigoid plate, paraph. Space

9. pharynx

11. Fossa of Rosenmuller Eustachian tube opens in lateral wall of the nasopharynex , surrounded by torus tubarius ( cartilagenous elevation ) . A recess behind torus tubarius is called Rosenmuller fossa . Clinical importance : location for cancer to arise .

13. Blood supply of nasopharynx Arterial : branches from E.C.A. Venous : pharyangeal plexus to I.J.V.

14. Nerve supply of nasopharynx Branches from cranial nerve V2 , IX , X . Sympathetic n.

15. Lymphatic drainage of the nasopharynx Retropharyngeal . Parapharyngeal . Jugular chain . L . N . Of spinal accesory chain in posterior triangle. Supraclavicular L . N . Contralateral neck.

16. Epithelial lining of nasopharynx 60% of nasopharynx is lined with Stratified squamous epithelium

18. Spread of nasopharyngeal ca. Ant : nasal cavity , paranasal sinuses , pterigopalatine fossa, orbital apex . Inferiorly : oropharynx. Superiorly : skull base , sphenoid body & sinus. Laterally : paraph. , pterigoid structures.

21. Pathology of tumors of nasopharynx Epithelial benign Epithelial malignant Papilloma Pleomorphic adenoma Oncocytoma Basal cell adenoma Ectopic pituitary adenoma Nasopharyngeal carcinoma. 1- Squamous cell ca. 2- Non keatinizing ca. 3- Undifferentiated ca. Adenocarcinoma. Papillary adenocarcinoma. Mucoepidermoid carcinoma. Adenoid cyctic ca. Polymorph low grade adeno ca.

22. Pathology of tumors of nasopharynx Non epithelial Benign Non epithelial malignant Angiofibroma. Fibroma. Haemangioma. Osteoma. Haemangioma. Haemangiopericytoma. Paraganglioma. Meningioma. Craniopharyngioma. Angiosarcoma. Kaposi sarcoma. Malignant haemagiopericytoma. Fibrosarcoma. Rabdomyosarcoma. Osteosarcoma. Malignant nerve sheath tumor. Chondrosarcoma. Chordoma. Malignant melanoma. Malignant lymphoma. 2ry tumors

24. Tumour like lesions 1- Cyst. 2-Heterotopic pituitary tissue. 3- Menengocele , meningoencephalocele. 4- fibroinflammatory pseudotumour, 5- infective granuloma. 6- wegner,s granuloma. 7- Pseudoepthliomatous hyperplasia. 8- granuloma pyogenicum. 9- lymphoid hyperplasia. 10- oncocytic metaplasia.

31. Symptoms of nasopharyngeal ca Neck mass , blood tinged mucus .Epistaxis Nasal obstruction Change of voice Pain – Ozona - otalgia – headache Decreased hearing Cranial neuropathies

32. Hallmark of terminal disease Severe pain & headache ((skull base erosion

33. Cranial neuropathies in N.PH.ca Cn VI most frequently affected . Cn ( II toVI ) Jacod’s syndrome due to cavernus sinus invasion . Cn ( IX – XII ) & sympathetic n. Villaret’s syndrome retropharyngeal invasion

34. 5years boy presented with neck mass . On examination he had nasopharyngeal mass on the same side ( left )

38. Nasopharyngeal lymphepithelioma

39. Symptoms of advanced disease Trismus Dysphagia Proptosis Lung , bone , liver metastasis

41. examination Complete examination of head & neck. Examination of nasopharynx with endoscopy Flexible or rigid Biopsy

42. Nasal cavity

43. Posterior nasal cavity

44. nasopharynx

45. Nasopharyngeal carcinoma

46. oropharynx

47. Upper hypopharynx

48. Lower hypopharynx

49. larynx

52. investigation laboratory radiological .c.b.c. ca , PO4 , alkaline phosphate. Urin analysis Liver function Kidney function Serum IgA E.B.V. caspid antigen EBV DNA X- ray chest C.T. scan M R I P .E .T. Bone scintigraphy

60. PET scan

61. Staging system for n.ph.caT stage TX : primary tumor can’t be assessed . TO : no evidence of primary tumor . Tis : carcinoma in situ .

62. Staging systems for N . Ph . Ca. T stage( 1ry tumour extent) T1 confined to nasopharynx T2 extend to oropharynx or nasal cavity a without parapharyngeal extention B with parapharyngeal extention T3 invade bones or PNS T4 involvement of cranial nerves , intracranial content , infratemporal fossa , hypopharynx , orbit

63. N stage lymph node disease N0 No L . N . Metastasis . N1 unilateral L . N (s) < or = 6 cm N2 bilateral L . N (s) < or = 6 cm N3 3a L . N (s) > 6 cm 3b with extension to supraclavicular fossa

64. M stage distant metastasis M0 abscent M1 present

68. Intensity modulated radiotherapy.chemotherapy

69. Acute side effects of R. T. Skin reaction altered taste Weight loss fatigue mucositis Xerostomia

70. Chronic side effects of R. T. Hypothyroidism Chronic S . O . M .

71. Serious side effects of R . T . Severe trismus Osteoradionecrosis Pituitary dysfunction Carotid artery stenosis Brain necrosis Cranial neuropathy Spinal myelitis R.T. induce 2nd malignant salivary g. , skin , thyroid sarcoma

72. Surgical approaches to nasopharynx 1- transnasal – maxillary . A- lat. Rhinotomy . B- LeFort I osteotomy . c- extended subtotal maxillectomy . 2- transpalatal . 3- sublabial midfacial degloving approach . 4- transfacial – maxillary swing . 5-transmandibular & mandibular swing . 6- infratemporal approach . 7- others A- lateral transtemporal sphenoidal . B- transpharyngeal . C- transcervical .

73. Intracavitary brachytherapy

75. PROGNOSIS Well differentiated n. ph. Ca. has poorer local control rates. Advanced undifferentiated n. ph. Ca. has higher distant metastasis . .Accepted 5 years survival rate is ( 40 %– 50 %) Better result in female patient under age of 40 Very poor prognosis in pregnancy concurrent within 1st year of treatment. Relapse and distant failure occurs within the 1st 2 or 3 years

77. Thank you