Tumors of the nasopharynx

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L.4+5 Tumors of the pharynx

Tumers of the pharynx are usually classified according to their site

of origin (nasopharyngeal, oropharyngeal, &hypopharyngeal).

Nasopharyngeal Tumers

A. Benign tumers:
Benign tumers in the nasopharynx are rare & the commonest tumer is juvenile
nasopharyngeal angiofibroma.

Juvenile nasopharyngeal angiofibroma:
It’s a benign fibrovascular tumer, usually arises from the
sphenopalatine foramen (at the junction of the nasopharynx with the nasal
cavity) forming a bilobed dumb-bell swelling straddling the foramen. It usually
affects males between 8-16 yr. old due to hormonal activity &it has a high
tendency to bleed (a cardinal symptom of the disease).
Extension:
Anteriorly to the nasal cavity
Posteriorly to the sphenoid sinus
Medially to the nasopharynx
Laterally to the sphenopalatine foramen


Clinical features:
1. .Recurrent spontaneous sudden sever epistaxis (the cardinal symptom).
2. .Progressive nasal obstruction.
3. .Hyponasal speech (rhinolalia clausa) due to nasal obstruction.
4. .Conductive deafness due to Eustachian tube obstruction (unilateral).
5. .On examination a smooth, lobulated, rubbery mass is found in the nasopharynx
which is reddish or gray in colour.
6. .Late features due to extension include:
- -Broadening of the nasal bridge.
- -Unilateral prominence of the cheek.
- -Proptosis (displacement of the globe of the eye).

Diagnosis:

1. .Clinical features.
2. .Radiology:
- -Plain x-ray: show sinusitis, destruction of the wall of the sinus.
- -CT scan: show the dimensions & extension of the tumer & its consistency.
- -MRI: show the details of the soft tissues & the mass.
- - Angiography: shows the vascularity of the tumer & also for preoperative
embolization to decrease bleeding during surgery.
Note:
Biopsy is contraindicated because of uncontrolled bleeding.

Major blood supply of angiofibroma:

1. .Ipsilateral internal maxillary artery.
2. .Contralateral = = =.
3. . Ascending pharyngeal artery.
4. .Large tumers have blood supply from internal carotid & vertebral arteries.

Treatment:

1. .Surgical excision of the tumer is the treatment of choice. The patient
should be well prepared & nourished & we must prepare 4-6 pints of blood
before operation.

2. .Radiotherapy :

Usually used in the following:
- -Inoperable tumer.
- -Intracranial extension.
- -Recurrent tumer.

Complications of surgery:

1. .Palatal fistula.
2. .Anesthesia of the cheek.
3. .Ectropian of the lower eyelid.
4. .Crustation of the nasal cavity.
5. .Recurrence.

B.Malignant tumers of the nasopharynx:

Malignant tumers in the nasopharynx are more common than benign tumers.
Sequamous cell carcinoma is the most common malignant tumer specially occur in
chines people other tumers are very rare as follows:

1. .Epithelial tumers: nasopharyngeal CA, adeno CA, adenoid cystic CA,

mucoepidermoid CA.
2.None epithelial tumers:
-Lymphomas
-Sarcomas (chondrosarcoma, osteosarcoma, rhabdomyosarcoma)
-Malignant melanoma.

Sequamous cell carcinoma

It’s the commonest malignant tumer in the nasopharynx with varying
degrees of differentiation.

Clinical types: 1. Prolifrative (like a polyp causing obstructive

symptoms).
2. Ulcerative (causing bleeding).
3. Infiltrative (causing deep invasion).
Etiology:
Unknown but many factors can play a role such as:
Smoking, alcohol, deep x-ray therapy, E.B Virus (especially in lymphoma).


Site:
The commonest site is the fossa of Rosen Muller & could occur in the
posterosuperior wall.

Clinical features:

1. . Metastases in the lymph nodes of the neck: Its often the presenting symptom
unilateral or bilateral & the first group involved are retropharyngeal lymph
nodes (which can not be palpated) then to the cervical lymph nodes that’s why
the disease discovered late.
2. .Symptoms of local invasion: (Trotters triad)
- -Conductive deafness (secretory otitis media).
- -Elevation & fixation of the homolateral soft palate.
- -Pain in the side of the head.
3. .Other symptoms of invasion:
-Internal strabismus (6th CN pulsy).
-Exophthalmos.
-Jugular foramen syndrome (9th, 10th & 11th CN pulsy)
4. .Nasal obstruction in the prolifrative type.
5. .Epistaxis in the ulcerative type.

Diagnosis:

1. .Clinical features & post nasal space examination.
2. .Radiology:
- -Plain x-rays (postnasal space) show soft tissue mass & bone erosion.
- -CT scan shows the size, shape & extension of the mass & any bony erosion.
- -MRI for soft tissue details & intracranial extension.
3. .Biopsy: give the definitive diagnosis.


Treatment:
1. .Radiotherapy is the mainstay treatment for nasopharyngeal CA including the
lymph node metastases.

2. .Surgery:

-Radical neck dissection for radiosensitive nodes & post radiation cervical
metastases.
-Salvage surgery for recurrent tumers.

Tumors of the oropharynx

The oropharynx extends from the level of the hard palate above to the
hyoid bone below & is divided into:
1. .Palatine arch: which include the soft palate& the anterior tonsilar
pillars.
2. .Oropharynx proper:which include the lateral & the posterior
pharyngeal walls,base of the tongue,the
tonsils,posterior pillar & the
valleculae.
The reason for this is that the tumers in the palatine arch (especially
SCC) behave differently (less aggressive & metastases later) than other parts of
the oropharynx, so the treatment is different. The tumers are either benign
(rare & mostly papilloma) or malignant (more common especially in elderly
patient).


Pathology:
The oropharynx has three types of tissues which give rise 3-distinct tumers as
follows:
1. .Sequamous epithelial lining: give rise to SCC which is the commonest type of
tumer about 70% of oropharyngeal tumers.
2. .Tonsils & lymphoid tissue in the base of the tongue: which give
rise to none Hodgkin’s lymphoma (about 25% of oroph. tumers).
3. .Minor salivary glands within the epithelia: give rise to minor
salivary gland tumers(adeno CA ,adenoidcystic CA ,mucoepidermoid
CA)forming about 5% of the tumers.

Sequamous cell carcinoma:

This tumer has 2-clinical types either exophytic (usually follows
leukoplakia with superficial local spread) or ulcerative type (causing deep
invasion of the soft tissues with occasional bleeding). The etiological factors
involved are(reverse smoking in Asia, alcohol, mucosal atrophy associated with
iron deficiency anemia, syphilis,human papilloma virus & elderly patient with
tooth caries).

Lymphoma:

Usually none Hodgkin’s lymphoma, which arises as nodular, swelling in
the tonsil region or base of the tongue, followed by ulceration. In this tumer
we must investigate for a generalized disease (especially for the liver &
spleen) to do proper treatment .The risk factors are (Sjogrens disease,
decreased immunity due to chronic malaria, Epstein-Barr virus EBV & human
T-lymphotrophic virus type 1).


Minor salivary gland tumers:
These are usually malignant tumers (opposite to major salivary gland
tumers, which are usually benign tumers) the tumer is usually smooth
non-ulcerated swelling, it usually arises in the tonsil area & is mostly
adenoidcystic carcinoma. It spread slowly by perineural lymphatics to the lymph
nodes, bone & lung, but it has good prognosis (80%) if discovered early.

Clinical features of oropharyngeal tumers:

1. .Lymph node metastases in the neck (60%).
2. .Sore throat.
3. .Referred otalgia.
4. .Dysphagia & odenophagia.
5. .Plummy voice.
6. .Trismus.
7. .Bleeding.
8. .Fixation of the tongue.

Investigations:

1. .FNA fine needle aspiration cytology:
This investigation is easy to do & used for the neck mass to differentiate
between reactive & carcinomatous lymph node & also between branchial cyst &
metastatic lymph node.
2. Radiology: chest x-ray if lymphoma is suspected.
CT scan for the tumer, neck, chest, abdomen & pelvis.
MRI.
3.Ultrasound: for the lymph nodes & as a guide for FNA.
4. Biopsy: is the definitive diagnostic test.
5. Blood investigation: CBP & ESR with blood film.
6. Bone morrow aspiration & biopsy to diagnose lymphoma.


Treatment:
Sequamous cell carcinoma:
1. .Radiotherapy: usually used in SCC & localized lymphoma.
2. .Surgery: very difficult & destructive procedure called:commando
operation (combined neck dissection,mandibulectomy & resection

of the oropharynx).

3.Surgery & radiotherapy: it gives the best results because of occasional
failure of radiotherapy.
4.Chemotherapy: has a limited role in SCC & used as adjuvant to
radiotherapy & palliative in advanced tumers.
5.Cryosurgery: it decreases bleeding & pain during surgery usually
used in small recurrent tumers & benign tumers.
6. Laser surgery: used in patient who cannot undergo reconstructive
surgery.
7. Reconstruction after surgery: used to restore the shape & function
of the area operated upon , many types of flaps can be used (local,
axial,myocutanuous & free vascularised flaps.

Non-Hodgkin’s lymphoma:

1. .Localized: radiotherapy followed by chemotherapy.
2. .Disseminated: systemic chemotherapy.


Minor salivary gland tumers:
1. .Benign: local excision.
2. .Malignant: radical wide excision.
3. .No place for radiotherapy except for palliation.

Tumors of the hypopharynx

The hypopharynx extend from the level of the hyoid bone above to the level
of the lower border of the cricoid cartilage below, its lined by sequamous
epithelia & have a rich submucosal lymphatic vessels (that’s why submucosal
spread is very common to the esophagus & hence poor prognosis). It has 3-areas:
Pyriform fossa: it’s a funnel shape channels on each side of the larynx
bounded laterally by the thyroid cartilage & medially by the aryepiglottic fold.
Post cricoid area: it consists of the mucosa covering the cricoid cartilage
in the posterior part of the larynx, to the level of the inferior border of the
cricoid cartilage.
Posterior pharyngeal wall: connecting the 2-pyriform fossae.
Pathology:
Benign tumers: Non-epithelial tumers (fibroma, lieomyoma).
Epithelial tumers (minor salivary gland tumers
treated by local excision.
Malignant tumers: Epithelial tumers mostly SCC, tumers are minor salivary
gland tumers.


Etiology:
1. .Female in post cricoid CA.
2. .Elderly patient.
3. .Precipitating factors: alcohol, smoking & radiotherapy.
4. .Risk factors: tea, low serum cholesterol, vitamin-A deficiency & iron
deficiency.

Clinical features of hypopharyngeal tumers:

1. .Dysphagia: is the commonest symptom, which is constant & progressive,
starting for solid & then for liquid food.
2. . Pain: usually referred otalgia or odenophagia.
3. . Hemoptysis: unusual & occurs in pyriform fossa tumer.
4. . Hoarseness of voice: due to involvement of the larynx.
5. . Neck mass: either the lymph node or the tumer invading the neck.
6. . Weight loss: is very fast in these tumers.

Investigations:

1. .Full blood count.
2. .Serum iron study: especially in females.
3. . Radiology: -plain x-ray (lateral of the neck & chest x-ray).
-CT & MRI.
-Contrast study for dysphagia.
4. .Endoscopy:
5. . Biopsy: for the tumer & FNA for the metastatic lymph node.


Treatment:
1.Pyriform fossa tumers: small tumers by radiotherapy with or
without radical neck dissection , large tumers treated by a massive
operation called: total laryngopharyngoesophagectomy with
stomach pull-up.
2.post-cricoid tumer: small tumers (<5 cm) treated by radiotherapy or
partial surgery with preservation of the larynx. Large tumers if the
anterior spinal ligament is not involved treated by total
laryngopharyngoesophagectomy with stomach pull-up.
3.Neck:
N0 radiotherapy
N1 (<3cm) radiotherapy & surgery for recurrent lymph node
N2 N3 surgery & post operative radiotherapy.

4.Reconstruction after surgery:

Most common method is gastric transposition (stomach pull-up). The colon &
jejunum can be used also.
Paterson-Brown-Kelly syndrome: (Plummer-Vinson synd.)

Disease of the postcricoid area of unknown etiology, which may be immune in

origin & is a major predisposing factor for post cricoid CA.
Clinical features:
1. .Progressive dysphagia: due to a web in the post cricoid area.
2. .Iron deficiency anemia with oral manifestation of anemia (angular
stomatitis, glossitis, and cheilosis).
3. .Common in females (30-50 yr.).
4. .Associated with mucosal atrophy of the GIT.


Diagnosis:
By clinical features & investigations (CBP, serum iron study & Ba-swallow
showing filling defect in the post cricoid area).

Treatment:

1. .Iron supplement.
2. .Esophagoscopy: to excise the web or to dilate the esophagus.