Nasopharynx

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Nasopharynx

• By
• Dr Nourizadeh
• Assistant professor of ENT
• MUMS

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SPECIAL CONSIDERATION

• The pharyngeal recess is filled by the levator
  palati muscle and overlies the internal carotid
  artery, which courses at this point against the
  wall of the pharynx.

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Blood Supply

• External carotid artery
• Ascending pharyngeal
• Facial arteries
• Venous drainage
• The pterygoid venous plexus (superiorly)
• The pharyngeal plexus (inferiorly)
• Lymphatic drainage
• The retropharyngeal nodes
• The deep cervical lymph node chain

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Nerve supply

• The trigeminal nerve
• The pharyngeal branch of the sphenopalatine
  ganglion
• Below passavant's ridge the nerve supply is the
  same as for the rest of the pharynx by the
  glossopharyngeal and vagus nerves.

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Physiology Of The Nasopharynx

• Airflow
• Like the nose, it is a noncollapsible structure.
• Usually nasopharyngeal obstruction results in
  reflex use of the oral airway.
• The exception is in neonates, who are regarded as
  obligate nasal breathers.
• Eustachian tube function
• Speech and swallowing
• Bacterial colonization

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Symptoms

• Nasal obstruction
• Severe nasal obstruction at birth suggests
  Bilateral Choanal Atresia
• Onset at age 2 to 3 years is suggestive of
• Adenoidal hypertrophy
• Rhinitis
• Rhinorrhea
• Mouth breathing and snoring
• Posterior epistaxis
• Conductive hearing loss
• Hyper nasal speech or regurgitation

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Physical Examination

• Adenoid facies (nonspecific)
• Open mouth
• Flat midface
• Dark under the eyes
• A dull appearance
• Postnasal mirror
• Fiberoptic flexible endoscopy
• During speech and swallowing maneuvers gives
  functional information about velopharyngeal
  closure
• Rigid endoscope

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Radiology

• Plain radiographs
• Computed tomography(CT)
• The first choice of imaging for
• Choanal atresia
• Disease of the paranasal sinuses
• MRI

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Adenoidal Hypertrophy

• Adenoidal hypertrophy is typically more common in
  children.
• Complications
• Chronic nasal obstruction adenoid facies
• Eustachian tube dysfunction serous or recurrent
  otitis media
• Sleep apnea
• Pulmonary hypertension
• Acute infection is the most common nasopharyngeal
  disease.
• The most common organisms identified are
  Streptococcus pneumoniae, Moraxella catarrhalis,
  and Haemophilus influenzae.

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• Numerous authors have commented on the
  inappropriate use of antibiotics in an attempt to
  treat upper respiratory infections that in fact
  have a viral etiology.
• Estimated that viral upper respiratory infection
  is the most common disease of humans with a
  prevalence rate of six to eight colds per 1,000
  persons per day during the winter months.

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Neoplasms

• The vast majority of tumors of the nasopharynx
  are malignant epithelial neoplasms.
• The second most common malignancy of the
  nasopharynx is malignant lymphoma.
• In children embryonal rhabdomyosarcoma can arise
  in this region.
• A basic distinction is drawn between squamous
  cell carcinomas and lymphoepithelial carcinomas
  (Schmincke tumor).

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Nasopharyngeal Carcinoma

• Symptoms
• Patients may present with significant nasal
  symptoms including nasal obstruction, epistaxis,
  a sensation of sinus fullness, and headache.
• Some patients present with minimal nasal
  symptoms, but complain of otalgia or decreased
  hearing due to eustachian tube obstruction from
  the mass.
• A majority of the patients present with a mass in
  the neck, and in some patients this is the only
  complaint.
• Physical findings
• Nasopharyngeal carcinomas are typically
  erythematous and friable. The tumor arises most
  frequently near the fossa of Rosenmuller.
• Orbital invasion can produce significant
  proptosis or hypertelorism.
• Cranial nerves may be involved at the skull base.
  In particular the trigeminal and abducens nerves
  are at risk and their function should be
  examined.
• Cervical nodes are present in over 70 of
  patients. The nodes are usually involving the
  nodes at the mandibular angle.

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• Any persistent middle ear effusion of long
  duration in an adult patient with no prior
  history of middle ear disease is suspicious for a
  tumor and should be investigated accordingly.
• EBV antibody titer should be determined (this
  shows an elevated IgA, contrasting with the
  elevated IgM/ IgG that is found in infectious
  mononucleosis).

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Pathology

• WHO I tumors are keratinizing squamous cell
  carcinomas. In the United States these tumors
  account for approximately 25 of nasopharyngeal
  carcinomas. In areas of the world where
  nasopharyngeal carcinoma is common, such as
  Southern China, these tumors account for less
  than 5 of nasopharyngeal carcinomas. These
  tumors are not related to EBV infection.
• WHO II tumors are nonkeratinizing squamous cell
  carcinomas. These tumors histologically resemble
  transitional cell bladder cancer, and are also
  called transitional cell carcinoma. These tumors
  are related to EBV infection.
• WHO III tumors are undifferentiated carcinomas
  and include lymphoepithelioma. They account for
  the majority of nasopharyngeal carcinomas in the
  United States and worldwide. These tumors are
  related to EBV infection.

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Diagnosis

• Open neck biopsies should be avoided unless all
  other diagnostic techniques are exhausted.
• Once there is a suspicion of nasopharyngeal
  carcinoma, the suspicious lesion should be
  biopsied. Suspicious cervical nodes can be
  aspirated to aid in the diagnostic workup.
• TREATMENT
• Radiation therapy regardless of stage
• Neck dissection is reserved for persistent or
  recurrent cervical disease
• WHO II and WHO III tumors are more radiosensitive
  than WHO I tumors.

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Juvenile Angiofibroma

• Juvenile angiofibromas are
• Benign neoplasms
• Occur almost exclusively in adolescent males
• These tumors actually arise from the region of
  the sphenopalatine foramen
• Average age 14 (10-18)
• Nasal obstruction and epistaxis (more than 80 )
• CT scanning is used to evaluate the extent of the
  tumor
• Unencapsulated and infiltrate the surrounding
  tissue. The major components are a fibrous stroma
  and intertwined vascular channels. The vessels
  are variable in size, lined by a single layer of
  endothelial cells, and lack elastic fibers in
  their walls.

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• If there is clinical suspicion of an
  angiofibroma, a biopsy should not be performed
  due to the risk of heavy bleeding.
• The primary workup should include MRI or CT with
  IV contrast.

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Treatment

• Surgery
• Radiation therapy
• Electrocoagulation
• Hormonal administration
• Surgery and/or radiation therapy are the current
  main stays of treatment.
• Preoperative angiography with embolization
  (usually the maxillary artery) is recommended.
• Radiation is a viable option, but is best
  reserved for cases with intracranial extension.

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