Pharyngeal tumors

1. Pharyngeal tumors Dima Najjar

2. Arterial from the external carotid artery • Ascending pharyngeal • The lingual artery • The facial artery • The maxillary artery • Venous drainage to the internal jugular Retropharyngeal nodes • Deep cervical (jugular) nodesArterial from the external carotid artery • Ascending pharyngeal • The lingual artery • The facial artery • The maxillary artery • Venous drainage to the internal jugular Retropharyngeal nodes • Deep cervical (jugular) nodes

3. Naso>maxillary Oro>>9 Laryngo>>vagus internal laryngeal branch!Naso>maxillary Oro>>9 Laryngo>>vagus internal laryngeal branch!

4. About pharynx funnel shaped tubular structure /12 cm Base of the skull superiorly to the esophageal inlet inferiorly”C6”. nasopharynx, oropharynx, and hypopharynx”laryngopharynx”. superior, middle, and inferior pharyngeal constrictor muscles/Stylo and salpingopharyngeus! Go and read anatomy…!! Behind the ostium of the auditory tube is a deep recess, the pharyngeal recess ( fossa of RosenmüllerBehind the ostium of the auditory tube is a deep recess, the pharyngeal recess ( fossa of Rosenmüller

5. Pharyngeal tumors >>Nasopharynx Benign>>angiofibroma /antrochoanal polyp Malignant>> squamous cell carcinoma >>Oropharynx Benign>> papillomas Malignant>> squamous cell carcinoma >>Hypopharynx Benign>> fibroma /leiomyoma Malignant >> squamous cell carcinoma

6. Smoking or chewing tobacco Alcohol abuse head or neck RADIOTHERAPY Exposure to asbestos or certain industrial chemicals Aging (being 65 years or older) 6

7. Type-Specific Risk Factors >>Nasopharyngeal cancer Chinese or Asian. EBV. >>Oropharyngeal cancer drinking maté (an herbal tea drink common in South America) HPV. 7

8. >>>Hypopharyngeal cancer: Nutritional deficiencies:Iron deficiencies may also be caused by Plummer-Vinson syndrome. Other nutritional deficiencies may be related to a history of alcohol abuse. Plummer-Vinson syndrome??. 8 glossitis, splenomegaly, iron deficiency anemia, esophageal stenosis, and achlorhydria has strong correlation with postcricoid squamous cell carcinomas. This syndrome is seen mainly in Northern European womenglossitis, splenomegaly, iron deficiency anemia, esophageal stenosis, and achlorhydria has strong correlation with postcricoid squamous cell carcinomas. This syndrome is seen mainly in Northern European women

9. Nasopharyngeal Angiofibroma The commenest benign tumor of the nasopharynx At puberty Only males Most probably paraganglioma from the paraganglionic tissue in relation to the terminal part of the maxillary artery The lateral all of the nose behind the middle turbinate.

10. lobulated vascular mass, large sinusoidal vascular spaces with no muscle coat? so bleeding easily Spreading: >Forwards; 1-nasal cavity? pinkish lobulated mass is seen 2-Broadening of the external nose ? proptosis ( Frog face deformity) >Laterally : 1-from the nose? sphenopalatine foramen? ptrygopalatine fossa?Ptrygomaxillary fissure? mass on the cheek 2-Obstruction of ET ? Secretory otitis media

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12. Symptoms : A Male Teen-ager Unilateral nasal obstruction Unilateral severe epistaxis Unilateral impairment of hearing ( Secretory otitis media) Signs - Pallor Pinkish lobulated mass in the nose which bleeds easily on touch Unilateral secretory otitis media Later: Broadening of the external nose & proptosis (Frog Face) Swelling of the cheek

13. CT SCAN Carotid angiography Biopsy ???????? Don’t do it Very Severe bleeding will occur Don’t do it Very Severe bleeding will occur

14. Nasopharyngeal Carcinoma The commonest Malignant tumor of the nasopharynx Commonly above 50 Males > Females Epestein Bar Virus Spread 1-Local - Forewards Lateral Superiorly Inferiorly 2-Lymphatic >>Early & common To Upper deep cervical Lymph Nodes 3-Blood>>Late and Rare To Lung, Liver, Bone , Brain

16. Commonly Male patient above 50 Symptoms - Unilateral Nasal obstruction - Unilateral mild epistaxis - Unilateral hearing loss Why? - Symptoms of pharyngolaryngeal paralysis Why? - Diplopia Why? -Unilateral facial pain Why? - Nasal regurge of fluids -Nasal tone of voice (Rhinolalaia Aperta) -Dysphagia more to fluids -Hoarsness of voice ? ET obstruction ?Sec.OM Due to IX & X cranial nerve paralysis III, IV, VI cranial Nerve paralysis ? V cranial nerve invasion ? ET obstruction ?Sec.OM Due to IX & X cranial nerve paralysis III, IV, VI cranial Nerve paralysis ? V cranial nerve invasion

17. Signs Nasopharyngal examination? Ulcer or fungating mass Oropharyngeal examination - immobilization of the palate - Tongue paralysis : Ear examination ?. Unilateral secretory otitis media Orbital examination? Unilteral Proptosis Unilateral Ophthalmoplegia Facial examination : unilateral anesthesia over the maxilla Cervical Examination: UDCLN, may be the earliest manifestation Rinne’s test : Negative Weber test: sound is lateralized to the diseased ear Rinne’s test : Negative Weber test: sound is lateralized to the diseased ear

18. What is Trotter’s Triad? Unilateral conductive hearing loss Ipsilateral earache & facial pain Ipsilateral immobilization of the soft palate Dagnostic of Nasopharyngeal Carcinoma Dagnostic of Nasopharyngeal Carcinoma

19. >>Diagnosis: 1- CT & MRI 2- Biopsy to confirm the diagnosis 3- Metastatic work-up: Chest X ray Abdominal Ultrasound Bone scan Brain CT scan >>Treatment: Radiotherapy Radical neck dissection in the presence of palpable cervical lymph nodes

20. Oropharyngeal carcinoma The commonest oropharyngeal malignant tumor Commonly elderly Commonly males Commonly the tonsils Excessive smoking & alcohol intake Spread >same as Naso

21. Symptoms Sore throat & referred otalgia Spitting of blood Halitosis Signs -Fungating mass or Ulcer - Enlarged UDCLN

22. Investigations 1- CT scan & MRI : to assess tumor extension & LN involvement 2- Biopsy: To confirm the diagnosis 3- Metastatic work-up: as before

23. Treatment Wide Surgical excision postoperative radiotherapy RND in the presence of palpable cervical LN

24. Pyriform fossa carcinoma Commonly elderly Commonly males Excessive smoking & alcohol intake

25. Spread Local To the postcricoid region To the larynx To the base of the tongue To the esophagus Lymphatic spread& Blood spread : As before

26. Symptoms Early cases Later on - Asymptomatic or - Vague throat discomfort - May present primarily by enlarged cervical lymph nodes

27. Investigations Barium swallow: FILLING DEFECT CT & MRI Biopsy: Metastatic work up: as before

28. Treatment - Surgical - RND -Pharyngolaryngectomy -Reconstruction by: - Stomach pull up - Colon or ileum interposition - Myocutaneous flap

29. Postcricoid Carcinoma

30. AGE Sex Predisposing factor

31. Spread Direct - Forwards to the Larynx - Laterally to the pyriform fossa - Downwards to the esophagus Lymphatic: early & common to UDCLN Blood: late and rare to L, L, B ,B

32. Symptoms Early dysphagia Pain in the throat Hoarseness & stridor Signs By indirect laryngoscopy or endoscopy the tumor is seen Enlarged UDCLN Positive Moure’s sign

35. General considerations nonspecific findings such as otalgia or unilateral otitis media. considerable delay in diagnosis.>common! So>> otalgia but no apparent ear pathology> complete examination of the upper aerodigestive tract, including the larynx>>especially smokers. heterogeneity of nasopharyngeal tumors?? Nasopharyngeal carcinoma is subtyped into three histologic variants: keratinizing (25%), nonkeratinizing (15%), and undifferentiated (about 60%). A prominent non-neoplastic lymphoid component is frequently present, leading to the misnomer “lymphoepithelioma.” Most common site of occurrence of nasopharyngeal carcinoma?? Elevated titers of Epstein- Barr virus (EBV) antibodies >>> undifferentiated and nonkeratinizing types Anatomically, the nasopharynx is connected anteriorly to the nasal cavity through the choanae. Inferiorly, it is bounded by the upper aspect of the soft palate. Superiorly, it is bounded by the base of the skull (occipital bone) and the body of the sphenoid bone. Laterally, each side contains the opening of the eustachian tube posteriorly and a submucosal cartilaginous structure (torus tubarius), behind which is a depression (fossa of Rosenmueller Nasopharyngeal carcinoma arises from the epithelium of the nasopharynx. Nearly all tumors of the nasopharynx are malignant epithelial lesions. The epithelium of the nasopharynx varies from stratified squamous to ciliated columnar. The fossa of Rosenmueller Anatomically, the nasopharynx is connected anteriorly to the nasal cavity through the choanae. Inferiorly, it is bounded by the upper aspect of the soft palate. Superiorly, it is bounded by the base of the skull (occipital bone) and the body of the sphenoid bone. Laterally, each side contains the opening of the eustachian tube posteriorly and a submucosal cartilaginous structure (torus tubarius), behind which is a depression (fossa of Rosenmueller Nasopharyngeal carcinoma arises from the epithelium of the nasopharynx. Nearly all tumors of the nasopharynx are malignant epithelial lesions. The epithelium of the nasopharynx varies from stratified squamous to ciliated columnar. The fossa of Rosenmueller

36. Pyriform sinus lesions are much more common than postcricoid. The most important predisposing factors in hypopharyngeal carcinoma development are tobacco and alcohol use. Alcohol abuse plays a more significant role in hypopharyngeal than endolaryngeal tumor. The hypopharynx includes the pyriform fossae and the posterior and lateral pharyngeal walls . The postcricoid area is immediately behind the larynx superior to the esophageal inlet. The hypopharynx extends from the level of the hyoid bone superiorly to the lower border of the cricoid cartilage inferiorly. Anteriorly, it is bounded by the mucosa on the medial aspect of the posterior thyroid cartilage. The lateral walls attach to the hyoid bone and thyroid cartilage. Medially, it is bounded by the larynx. The pyriform fossa (sinus) is the part of the hypopharynx that extends forward around the sides of the larynx and lies between the thyroid cartilage and the larynx. The hypopharynx includes the pyriform fossae and the posterior and lateral pharyngeal walls . The postcricoid area is immediately behind the larynx superior to the esophageal inlet. The hypopharynx extends from the level of the hyoid bone superiorly to the lower border of the cricoid cartilage inferiorly. Anteriorly, it is bounded by the mucosa on the medial aspect of the posterior thyroid cartilage. The lateral walls attach to the hyoid bone and thyroid cartilage. Medially, it is bounded by the larynx. The pyriform fossa (sinus) is the part of the hypopharynx that extends forward around the sides of the larynx and lies between the thyroid cartilage and the larynx.

37. The hypopharynx has a rich lymphatic drainage/so wt?? . more than 75% of hypopha ryngeal squamous cell carcinomas have cervical lymphatic involvement at the time of diagnosis. Therefore, treatment of the neck is mandatory in these tumors . more than 75% of hypopha ryngeal squamous cell carcinomas have cervical lymphatic involvement at the time of diagnosis. Therefore, treatment of the neck is mandatory in these tumors

38. Patients with hypopharyngeal tumors develop otalgia??? Patients with pharyngeal tumors may complain of ear pain and not mention sore throat, hoarseness, or other pharyngeal symptoms because the 9th and 10th nerves supply the pharynx and also the ear, through Jacobson’s (9th) and Arnold’s (10th) nerves. because the 9th and 10th nerves supply the pharynx and also the ear, through Jacobson’s (9th) and Arnold’s (10th) nerves.

39. Dx History and examination are the most important parts of the diagnostic evaluation. Persistent unilateral otitis media in adults, should raise a strong suspicion of nasopharyngeal carcinoma. unilateral nasal obstruction and/or bleeding. Flexible nasopharyngolaryngoscopy and palpation of the neck should be done if there is any suspicion of nasopharyngeal mass Nasopharyngeal carcinoma >>More than half of patients have a painless neck mass. Other presenting signs and symptoms include serous otitis media, cranial nerve involvement (the 5th and 6th are the most common), epistaxis, and nasal obstruction. Unilateral sore throat is the most common symptom of hypopharyngeal carcinomas. Others include dysphagia, odynophagia, referred otalgia, and hoarseness. Approximately 25% of patients present with otalgia; another 25% present with a neck mass Salivary pooling and asymmetry may indicate a hypopharyngeal mass. Lateral manipulation of the thyroid cartilage normally produces crepitance. With the postcricoid lesions, this sound is usually lost Nasopharyngeal carcinoma >>More than half of patients have a painless neck mass. Other presenting signs and symptoms include serous otitis media, cranial nerve involvement (the 5th and 6th are the most common), epistaxis, and nasal obstruction. Unilateral sore throat is the most common symptom of hypopharyngeal carcinomas. Others include dysphagia, odynophagia, referred otalgia, and hoarseness. Approximately 25% of patients present with otalgia; another 25% present with a neck mass Salivary pooling and asymmetry may indicate a hypopharyngeal mass. Lateral manipulation of the thyroid cartilage normally produces crepitance. With the postcricoid lesions, this sound is usually lost

40. biopsy?? magnetic resonance imaging (MRI) . A computed tomography (CT) scan is the study of choice for determination of invasion of the bony base of the skull. Rigid or flexible laryngopharyngoscopy is used to visualize the hypopharynx. The apex of the pyriform sinus and the postcricoid areas, however, cannot be examined in this fashion. MRI before biopsy!MRI before biopsy!

41. Treatment The treatment of choice for nasopharyngeal carcinoma is high dose radiotherapy (6,500–7,500 cGy) to the nasopharynx and a lesser dose to the neck. Radical neck dissection is indicated for persistent neck disease following radiotherapy. Some surgeons have attempted resection of persistent disease in the nasopharynx, which has proved to be successful for small tumors.

42. Treatment of hypopharyngeal cancers includes operation and postoperative radiotherapy.. Radiotherapy is the primary treatment for the posterior pharyngeal wall tumors. Occasionally, radiation failure can be treated with pharyngectomy. For more advanced lesions, total laryngopharyngectomy and gastric pull-up may be used for ablation and reconstruction. Postcricoid tumors generally require total laryngectomy because of their location.

43. Prognosis younger patients have a better prognosis, partly because the nasopharyngeal carcinoma occurring in younger patients is predominantly of undifferentiated type. Involvement of lymph nodes decreases the overall 5-year survival by 10–20%. Stage and grade.

44. Prognosis Hypopharyngeal squamous cell carcinomas>>>5-year survival rate with early stage is 35–45% and for more advanced stages, 20–25%. Naso>>>response varies according to the histology of the tumor. Keratinizing tumors are not radiosensitive; however, they remain localized without dissemination. Their 5-year survival rate is 10–20%. Nonkeratinizing tumors are variably radiosensitive and have a 5-year survival rate of 35–50%. Undifferentiated tumors are radio responsive with a 5-year survival rate of 55–65%. The treatment of the neck in head and neck cancer remains somewhat controversial. The neck requires treatment if there is adenopathy present or, in the absence of disease, if there is a greater than 20% chance of occult involvement. The neck is treated with irradiation if radiation alone is used for the treatment of the primary lesion. When a combined modality is used for the treatment of the hypopharyngeal disease, a neck dissection and resection of the primary is followed by irradiation. The treatment of the neck in head and neck cancer remains somewhat controversial. The neck requires treatment if there is adenopathy present or, in the absence of disease, if there is a greater than 20% chance of occult involvement. The neck is treated with irradiation if radiation alone is used for the treatment of the primary lesion. When a combined modality is used for the treatment of the hypopharyngeal disease, a neck dissection and resection of the primary is followed by irradiation.

45. FOLLOW-UP close observation for the first 5 years after therapy…why?? 1- local or regional recurrence. 2- considerable risk of developing a second primary tumor in patients who continue to smoke and drink alcohol.

46. What is your diagnosis?