CASE PRESENTATION

NASOPHARYNGEAL TUMOR

Supervised by:
dr. H. Oscar Djauhari, Sp. THT-KL

Presented by:
Adrienne Trinovia Sulistyo 2011.061.020
Daniela Angeline 2012.061.001

Clinical Rotation
Otolaryngology, Head and Neck Surgery Department
Medical Faculty of Unika Atma Jaya
Syamsudin, S.H. Regional General Hospital, Sukabumi
July 8th, 2013 August 3rd, 2013
 Identity
Name : Mr. T
Age : 60 years old
Occupation : Retired
Weight : 52 kg
Address : Jl. Koperasi no. 45, Sukabumi

Chief complaint : Hearing loss which is getting worse over time

Additional complaint : Bloody discharge from the left nostril and enlarged gland of
the neck since 2 months before admission

History of present illness

Patient came to the hospital since he has a progressive hearing loss, and he forgot
when was the first time he has problems with his hearing. The patient complaint for
the recently frequent bloody discharge from the left nostril which is difficult to stop
and a palpable mass near the side of his neck since 2 months ago. The patient
complain of weight loss up to 5 kg since 2 months ago.
On anamnesis the patient complaint of pain in the left ear. The patient denied the
presence of fever, tinnitus, other palpable mass in the body, difficulty swallowing,
purulent discharge from the mouth, nose or ear, changes in voice,

History of past illness

The patient has no history of high blood pressure, diabetes mellitus, coagulopathies,
mechanic or noise trauma, and infection of the nose, ear and throat before.
The patient never previously had similar complaint as now.

History of family illness

History of tumor (-)
History of hypertension (-), diabetes (-), allergy (-)

Physical Examination

Right ear : External ear : hyperemic (-), deformity(-), laceration (-), mass (-)
Mucuos membrane : hyperemic (-), edema (-), mass (-)
 Secretion (-), laceration (-), cerumen (+)
Tymphanic membrane : intact, retracted (-), light reflex (+) normal
Rinne test (+), no lateralization, normal Schwabach test

Left ear : External ear : hyperemic (-), deformity(-), laceration (-), mass (-)
Mucuos membrane : hyperemic (-), edema (-), mass (-)
Secretion (-), laceration (-), cerumen (+)
Tymphanic membrane : intact, retracted (+), light reflex deviated (+)
Rinne test (-), Lateralization to the left ear, prolonged Schwabach test

Right nose : Mucous membrane : hyperemic (-), edema (-), secretion (-)
mass (-), laceration (-), crust (-)
Concha : non-hypertrophy
Septum : no deviation
Air passage : normal

Left nose : Mucous membrane : hyperemic (+), edema (+), secretion (+)
mass (-), laceration (-), crust (-), blood (+)
Concha : non-hypertrophy
Septum : no deviation
Air passage : normal

Throat : Uvula in the middle

Pharynx : normal pharyngeal arch, hyperemic (-)
Tonsils : T1 / T1, hyperemic (-)

Neck : Lymphadenopathy cervical lymph node (+) with diameter 3cm, hard
consistency, immobile, pain (-), redness (-), lesion (-)

Working diagnosis
Suspect of nasopharynx tumor
Differential diagnosis
- Lymphoma

Workup
- Decompression of the nose, do not swallow the blood, use tampon if possible
- Complete blood count
- EBV titer
- Rhinoscopy posterior
- CT-scan with bone window and MRI if possible

Therapy
- Pro nasoendoscopy and biopsy
 Nasopharyngeal tumor

Nasopharyngeal tumor is the tumor originating from the epithelial cell of the pharynx
which is oftenly found in Indonesia, accounted 60% for the tumor of the head and the neck.
To determine the diagnosis of the tumor is not easy since the location is hidden deep in the
attic of the pharynx and it would not show any sign and symptoms until the size is big enough
to compress the object arounds it. The initial sign is shown when there is a metastasis to the
regional lymph node, resulting in lymphadenopathy.

ANATOMY

Pharynx is divided into 3 parts:

a) 1/3 proximal which is nasopharynx.

b) 2/3 distal is divided with an imaginary line into the oropharynx and the
laryngopharynx
c) The top of the epiglottis is the borderline between the oropharynx and
laryngopharynx.
Meanwhile the nasopharynx is sorrounded by the following borders:

Superior : os Sphenoid Anterior : Posterior of nasal cavity

Inferior : Palatum molle Posterior : 1st and 2nd vertebrae

Lateral : Torus tubarius, meatus tuba eustachius which is 1.5 inch lateral from the choana,
and fossa Rossenmuller

The location of nasopharynx carcinoma is believed to originate from the fossa

Rossenmuller, and later on it will spread to the adjacent borders and manifested according to
the organs affected. The anterior spread will result in nasal obstruction. The lateral spread
will result in the obstruction of the eustachian tube which in turn result in the negative
pressure of the middle ear causing pain and eventually serous secrete accumulation in the
middle ear.

The Sphenoid bone which is located anterior to the pharynx is the floor and the anterior of the
middle cranial fossa which :
 1. Houses the sella tursica
2. Support the cavernous sinuses
3. Seperates the nasopharynx and orbits from the intracranial structures.

The direct spread of tumor is possible due to this anatomical positioning.

ETIOLOGY

The first etiology of the development of this tumor is due to the alleic losses of
chromosomes 3p and 9p. In normal body function, which results in the inactivation of tumor
suppressor genes (p14, 15, p16) causing mild dysplasia. The mechanism is unknown but
consumption of chinese salted fish might contribute to this pathology.
This alone would not result in the development of tumor. With the introduction if
EBV infection, the mild dysplasia will develop into severe dysplasia. Also with the gain of
chromosomes 12, and loss of chromosomes 11q, 13q, 16q result in invasive carcinoma.
Metastasis is due to the mutation of p53 and aberrant expression of cadherin.

PATHOLOGY AND CLASSIFICATION

Nasopharynx carcinoma originates from the epithelial cell and classified into 3 types based
on the histopathological findings :

Type I: Squamous cell carcinoma (SCC) with varying degrees of

differentiation
Type II: Non keratinizing carcinoma
Type III: Undifferentiated carcinoma

CLINICAL MANIFESTATION
Lymphadenopathy (80%) non painful
Epistaxis
Serous otitis media due to the obstruction of the eustachian tube
Unilateral hearing impairment (conductive)
Nasal obstruction
Nerve paralysis as late manifestation
Jacod syndrome : difficulty in facial expression, eye and jaw movement problem
Villaret syndrome : trouble in swallowing, tongue and neck movement problem
Referred ear pain

DIAGNOSIS
The diagnosis is based on the anamnesis, physical findings and biopsy of the mass. The mass
can be seen with the use of posterior rhinoscope, or CT and MRI findings. Enlargement of the
cervical lymph node (the retropharyngeal lymph node) will be the first manifestation of the
tumor.

CANCER STAGING
THERAPY
Radiotherapy
o Eventhough the tumor is not severe, radiotherapy should be the definitive
treatment since it is difficult to define the adequate operative area.
Chemotherapy
o 3 cycles of cisplatin (100mg/m2)
o 3 cycles of cisplatin (80mg/m2) + 5-FU (1000mg/m2) applied after the
radiation therapy.

PROGNOSIS

Grades 5 year disease survival

I 98%
II A & B 95%
III 86%
IV A & B 73%