CASE PRESENTATION

NASOPHARYNGEAL
CARCINOMA
Supervisor:
dr. Oscar Djauhari, Sp.THT-KL

Presented by:
Michael (2014061107)
Vanessa A Thomas (2014061109)

Clerkship of Ear Nose Throat – Head and Neck Department

Regional Hospital R. Syamsudin SH
IDENTITY OF PATIENT

• Name : Mr. Y
• Age : 60 years old
• Occupation : Retired
• Weight : 50 kg
• Address : Jl. Koperasi , Sukabumi
 ANAMNESIS

• Chief complaint: Bloody nasal discharge

• Additional complaint : fullness in the left ear, weight
loss, enlarged gland in the neck
 ANAMNESIS (2)
• History of present illness
• A 65 years old, male, came to ENT clinic with a chief
complaint of bloody nasal discharge since 7 past days.
The bloody discharge was intermitten and in a small
amount. The discharge was from his left nostril. He also felt
his left ear fullness and he felt hearing loss gradually.
• He also notice and feel a mass in the left neck, the mass
was single, round, and painless. He also feel have a weight
loss dramatically more than 10 % in a month.
• The patients were a heavy smoker.
• The patient denied the presence of fever, ear pain,
tinnitus, other palpable mass in the body, difficulty
swallowing, purulent discharge from the mouth, nose or
ear, changes in voice. Complaint of swallowing pain and
cough were also denied.
 ANAMNESIS (3)
• 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

• General condition : Appear calm

• Body Weight : 50 kg
• Blood Preassure : 130/80 mmHg
• Pulse : 90 beat per minute
• Respiratory rate : 18 times per minute
• Temperature : 36,8 0C
 PHYSICAL EXAMINATION (EAR)
• Right ear :
• Auricle : normal
• External ear : hyperemic (-), deformity(-), laceration (-),
mass (-) hyperemic (-), edema (-), mass (-)Secretion (-
), laceration (-), cerumen (+)
• Tymphanic membrane: intact, retracted (-), light reflex
(+)
• Rinne test (+), no lateralization, normal Schwabach test
 PHYSICAL EXAMINATION ( EAR )

• Left ear :
• Auricle : normal
• External ear : hyperemic (-), deformity(-),
laceration (-), mass (-) hyperemic (-), edema (-),
mass (-) Secretion (-), cerumen (+)
• Tymphanic membrane: intact, retracted (+),
light reflex deviated (↓)
• Rinne test (-), Lateralization to the left ear
 PHYSICAL EXAMINATION (NOSE)
• Right nose : Mucous membrane : hyperemic (-),
edema (-), secretion (-)
: mass (-), laceration (-), crust (-)
: Concha : eutrophy
: Septum : no deviation
Air passage : normal

• Left nose : Mucous membrane : hyperemic (-),

edema (-), secretion (-)
: mass (-), laceration (-), crust (-), blood-
stained discharge (+)
: Concha : eutrophy
: Septum : no deviation
: Air passage :decreased
 PHYSICAL EXAMINATION (THROAT
AND NECK)
• Throat : Uvula in the middle
: Pharynx : normal pharyngeal arch,
hyperemic (-)
: Tonsils : T1 / T1, hyperemic (-)
• Neck : single Lymphadenopathy with diameter
± 4cm, hard consistency, immobile, pain (-),
redness (-), lesion (-) in upper jugular neck
 DIAGNOSIS, WORKUP, THERAPY
• Working diagnosis
Suspect of nasopharynx tumor (malignant)

• Differential diagnosis
Lymphoma

• Workup
• Decompression of the nose, tampon if possible
• Complete blood count
• EBV titer
• Rhinoscopy posterior or nasoensoscpy wth biopsy
• CT-scan with bone window and MRI if possible

• Therapy
if positive nasopharingeal carcinoma  radiotheraphy and/or
chemoteraphy
ANATOMY
 DEFINITION
• Squamous cell carcinoma (SCC)
• Arising from epithelial lining of
nasopharynx, frequently from lateral wall
(rosenmuller fossa)
 CLASSIFICATION

• Type I: keratinizing
• Type II: non-keratinizing
• Type III: undifferentiated
 EPIDEMIOLOGY

• Endemic (Type II, III)

• Predominantly in southern province of China, Southeast Asia

• Sporadic (Type I)
• Related to tobacco and alcohol use

• Peak incidence : 5th – 6th decades of life

• 20% of NPC develops in patients younger than 30 years old
(Type III)
ETIOLOGIC FACTORS + RISK FACTORS

• Frequent consumption of salted fish

(Nitrosamin)
• Epstein Barr Virus (EBV)
• Genetics
• Tobacco + alcohol consumption
 SYMPTOMS

• Nasal symptoms
• Nasal obstruction & Discharge
• Epistaxis

• Ear symptoms
• Unilateral deafness
• Otalgia
• Tinnitus

• Neck Symptoms
• Painless neck mass

• Cranial nerve palsy

• Diplopia
• Facial pain & numbness
 SUPPORTING
MODALITIES
• Serology: IgA anti-EBV, EBV viral DNA
• Imaging: CT, MRI
• Endoscopy + Biopsy
IMAGING (CT)
IMAGING (CT)
IMAGING (MRI)
IMAGING (MRI)
ENDOSCOPY
ENDOSCOPY
ENDOSCOPY
STAGING (AJCC 5 TH

EDITION)
STAGING (AJCC 5TH EDITION)
 PRIMARY DISEASE

• Radiotherapy
• NPC sensitive with radiotherapy
• Several way :
• External beam : most commontly
• Conventional
• 3DCRT
• Chemotherapy
• Single or combine therapy
• Most widely use : cisplatin/5-florouracil
 RECURRENT DISEASE

• Radiotherapy
• Combine with radiotherapy and chemotherapy
• Surgery
• Neck dissection postradiation residual or reccurent nodal
disease
• Variety aproaches to nasopharynx :
• Transpalatal
• Transmaxillary
• Transcervical
• Lateral infratemporal
• Anterolateral / maxillary swing
 COMPLICATION

• Late toxicity :
• Xerostomia
• Hipotiroidism
• Fibrosis of neck with loss of ROM
• Trismus
• Endocrinopathies  panhypopituitarism
• Sensorineural hearing loss
• Renal toxicity
• Caries and poor dental hygiene
• Second malignancy
• myelities
 PROGNOSIS

• Long term survival rate : 50-80%

• 5 years survival rate
• Radiotherapy alone : 42 %
• Combine radiotherapy and chemotherapy : 58%