Transcript Nasopharynx - mums.ac.ir

Nasopharynx
By
Dr Nourizadeh
Assistant professor of ENT
MUMS
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.
Blood Supply:
• External carotid artery
• Ascending pharyngeal
• Facial arteries
• Venous drainage
• The pterygoid venous plexus (superiorly)
• The pharyngeal plexus (inferiorly)
• Lymphatic drainage
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.
Pre- Styloid
Lateral
pharyngeal space
Post- Styloid
Parapharyngeal
space
Retropharyngeal
space
Retropharyngeal
nodes
Oral phase
Pharyngeal
phase
• Food is broken down and moistened to form a bolus
• Moved toward the oropharynx
• Voluntary
• Involuntary
• Tongue base receptors
• The velum is elevated to close off the nasopharynx.
• The larynx is also sealed off by elevation of the epiglottis.
• This is accompanied by a reflex adduction of the vocal cords
• Allowing the food to pass through the piriform sinuses toward the
esophagus while bypassing the larynx.
• Fromcranial nerves V3, VII, IX, X, and XII
• Begins with a primary peristaltic wave, which is reflexly initiated in
response to movement of the bolus through the pharynx (cranial nerves IX, X).
Esophageal • Secondary peristalsis is additionally triggered in the esophagus by the
pressure of the bolus against the esophageal wall
phase
• Involuntary
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
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
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
Radiology:
• Plain radiographs
• Computed tomography(CT)
– The first choice of imaging for:
• Choanal atresia
• Disease of the paranasal sinuses
• MRI
Adenoidal Hypertrophy
• Adenoidal hypertrophy is typically more common in
• Complications:
–
–
–
–
Chronic nasal obstruction adenoid facies
Eustachian tube dysfunction serous or recurrent otitis media
Sleep apnea
Pulmonary hypertension
is the most common nasopharyngeal disease.
• The most common organisms identified are Streptococcus
pneumoniae, Moraxella catarrhalis, and Haemophilus
influenzae.
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
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
are at risk and their function should be examined.
and
are present in over 70% of patients. The nodes are usually involving
the nodes at the mandibular angle.
• 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).
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.
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
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.
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
in their walls.
• 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.
Treatment:
–
–
–
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Surgery
Radiation therapy
Electrocoagulation
Hormonal administration
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.