Diseases of the nasopharynx

Dr. Mohamed Talaat ELGhonemy

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ADENOIDS
 Hypertrophy of the lymphoid tissue of the
nasopharynx sufficient to produce symptoms.
 Commonest nasopharyngeal swelling.
 Children between 3 to 8 years due to
repeated upper respiratory tract infections.
 No capsule and is covered by respiratory
epithelium.
Clinical picture:
1- Symptoms of hypertrophy
2- Symptoms of recurrent infection
3- General symptoms
4- Reflex symptoms
 1-Symptoms of hypertrophy:
A) Bilateral nasal obstruction:
-Snoring and sleep apnea.
-Difficult suckling in infants.
-Nasal tone of voice.
-Anterior nasal discharge (Bilateral).
B) Eustachian tube obstruction:
-Conductive hearing loss due to secretory otitis media.

C) Adenoid facies: (idiot look)

-Narrow pinched nostrils. Inactive atrophied alae nasi
-The mouth is opened and the upper lip is short.
-Overcrowded protruding incisors.
-High arched palate.
-Receding mandible and enlarged lower lip.
Adenoid facies

High arched palate

Receding mandible

Opened mouth –short upper lip

enlarged lower lip

Overcrowded protruding
incisors
2- Symptoms of recurrent infection:
-Rhinitis and sinusitis.
-Otitis media.
-Pharyngitis, laryngitis and bronchitis.
3- General symptoms:
School retardation ( deafness + interrupted sleep).
4- Reflex symptoms:
-Nocturnal enuresis.
-Laryngismus stridulus.
-Reflex cough.
X-ray lateral view nasopharynx : narrowing of air column.

Normal
Endoscopy

Adenoid
Adenoid (A)
Treatment:
Adenoidectomy (± tonsillectomy if indicated)
 TUMOURS OF THE NASOPHARYNX

 Benign tumours : fibroma, papilloma, adenoma

and mixed salivary tumours

 Malignant tumours : Squamous cell carcinoma

is the most common.
Lymphoepithelioma and sarcoma are rare.
 Nasopharyngeal fibroma
(Juvenile Nasopharyngeal Angiofibroma)

 Benign, highly vascular, locally aggressive

tumour.
 Tendency to bleed because there is no muscle
coat in its vessels.
 Young males below the age of 18 years with
spontaneous regression at sexual maturity.
 Behavior: Either spontaneous regression
(rare) at sexual maturity or extension to the
surrounding structures.
Pathology

-Origin: Superior margin of sphenopalatine

foramen.
-Gross picture: Firm, lobulated, pinkish tumour,
has no true capsule.
-Vascular supply: most commonly from the
internal maxillary artery.
Also: internal carotid, external carotid, common
carotid, ascending pharyngeal arteries.
Origin : Sphenopalatine foramen
(Posterior part of lateral nasal wall)
Sphenopalatine foramen
Site of origin
Arises in posterior nasal cavity, near superior
border of sphenopalatine foramen
Microscopic picture:

-Angio = vascular spaces without musculosa.

-Fibroma = collagen bundles and fibroblasts.

Low power view shows highly vascular growth of benign fibromyoblasts.

 Clinical picture:

Nasal: Nasal obstruction, recurrent severe epistaxis.

Aural: Conductive deafness due to Eustachian tube
obstruction.
Signs:
A smooth, lobulated, firm, easily bleeding mass.
a) Is seen in the nose.
b) Depresses the palate and appears behind it.
Extension of the tumour causes:
a) Widening of the nasal bones.
b) Proptosis and frog-face deformity.
c) Swelling of the cheek and zygoma.
Facial swelling (frog-face deformity)
Differential diagnosis: Unilateral nasal mass
N.B. Young boy with unilateral nasal
obstruction and epistaxis = Angiofibroma
until proved otherwise
Characteristic Presentation
 Teenage or young adult male

 Recurrent epistaxis

 Nasal obstruction
Juvenile angiofibroma
Investigations:
1. C.T scan:
-Detects extension to orbit, sphenoid sinus and
pterygopalatine fossa.
-Bowing of posterior wall of maxilla (Holman-Miller
Sign).
-Widening of sphenopalatine foramen.
2. Carotid angiography: to see feeding vessel, and
to do preoperative embolization.
3. MRI: to detect intracranial extension.
4. Biopsy is contraindicated (bleeding), and not
needed.
Coronal CT scan
 Widening of left
sphenopalatine
foramen

 Lesion fills left nasal

cavity

 Extends into
sphenoid sinus
Axial CT scan with Contrast
 Homogenous
enhancement

 Widening of left
sphenopalatine
foramen

 Extension into
 Nasopharynx
 Pterygopalatine fossa

Bowing of posterior wall of maxilla (Holman-Miller Sign)

Bowing of posterior wall of maxilla (Holman-Miller Sign)
CT scan & MRI

Bowing of posterior wall of maxilla (Holman-Miller Sign)

External carotid angiography

Feeding vessel = Internal Maxillary Artery

External carotid angiography
Treatment:
1)Surgical: Surgical excision with preoperative
embolizaiton.
a-Endoscopic transnasal.
b-Transpalatal: if the tumour is small localized to
nasopharynx.
b-Lateral rhinotomy: if it extends to the nasal cavity
or pterygopalatine fossa.
C- Craniotomy may be needed if there is intracranial
extension.
Embolization
Endoscopic transnasal approach
Endoscopic Transnasal

 Sphenopalatine artery ligation

 Tumor resection from pterygopalatine fossa
Trans-palatal approach
Trans-palatal approach
Trans-palatal approach
Transpalatal
Lateral rhinotomy

 Wide anterior antrostomy

 Removal of ascending process of maxilla
 Removal of inferior half of lateral nasal wall
Lateral rhinotomy approach
Lateral rhinotomy approach
2)Hormonal:
Combination of estrogen + testosterone 
maturation of fibrous tissue and reduce
vascularity.

3)Radiotherapy:
Not done nowadays as it is carcinogenic except in
recurrent cases or if there is intracranial extension.
 Nasopharyngeal Carcinoma

Age: Old above 60 years.

Sex: More in males.
Predisposing factors:
- Epstein Barr virus infection.
- Smoking.
- Irradiation.
Gross picture:
Shape : ulcer, cauliflower mass or nodular or infiltrative.
Site : Fossa of Rosenmuller is the commonest site.
Metastatic cervical Lymphadenopathy may be the
presenting symptom.
Spread:
1) Direct: to the surrounding structures.
2) Lymphatic spread: Retropharyngeal then to
upper deep cervical LNs.
N.B. Nasopharynx is midline structure, so bilateral
nodal metastasis is common.
3) Blood spread: Lung, Liver, Bone, Brain.
Prognosis:
bad as nasopharynx is a silent area, and midline.
Clinical Picture:

Aural manifestations:
 Unilateral Secretory Otitis Media: due to
obstruction of Eustachian tube
 Referred pain in the ear through 9th nerve.
Nasal manifestations:
 Nasal obstruction (unilateral or bilateral).
 Nasal discharge (unilateral or bilateral).
 Epistaxis.
Nodal manifestations:
 Upper deep cervical LNs may appear before primary.
 Incidence of metastasis = 70%.

Neurological manifestations:
Cranial nerve palsies: in this order of frequency:
 5th: unilateral facial pain, numbness then loss of
sensation.
 Ocular(3rd, 4th, 6th): squint, diolopia and
ophthalmoplegia.
 lower 4 cranial nerves: 9th, 10th, 11th, 12th
(compression by retropharyngeal LNs at skull base):
Cancer nasopharynx
Trotter's triad :
(diagnostic for nasopharyngeal carcinoma)

1) Unilateral facial pain (trigeminal nerve).

2) Unilateral palatal immobility ( vagus nerve).
3) Unilateral conductive deafness ( S.O.M).
Investigations:

1. CT: to detect site, size and extensions of the

tumor, and retropharyngeal LNs enlargement
(which is not clinically palpable).
2. MRI: to detect intracranial extension.
3. Biopsy by :Nasal endoscopy (local anesthesia).
4. Metastatic work up.
Carcinoma of the nasopharynx
Endoscopic view of nasopharynx
Ct scan nasopharynx
Treatment:

1. Radiotherapy: to 1ry tumor in the nasopharynx and to

neck (for LNs) in both sides.

2. Surgery: has no place as a primary treatment, it is

done only (radical neck dissection) for persistent or
recurrent LNs (after failure of radiotherapy).
Thank you