Pharynx - nasopharynx

Question 1

Adenoids

Answer 1

Hypertrophy of the nasopharyngeal tonsil sufficient to produce symptoms.
Normally it start to diminish in size at the age of 7-8 years and disappears in adult hood.
Etiology (Causes of hypertrophy) :
1- Physiological : commonest cause, usually occurs at the age of 3-8 years and usually occurs in association with hypertrophy of the palatine tonsils.
2- Repeated attacks of upper respiratory tract infection.
3- General factors : bad hygiene, crowding.

Clinical picture :
a- Symptoms due to size.
b- Symptoms due to infection.
c- General symptoms.
d- Reflex symptoms.

A- Symptoms due to size : (enlargement)
I- Nasal obstruction :
* In infancy and early childhood :
1- Difficult suckling.
2- Noisy breathing, snoring and may be sleep apnea.
3- Nasal tone of voice (Rhinolalia clausa).
* In late childhood (due to prolonged nasal obstruction)
1- Adenoid face :
- Open mouth and thick lips.
- Atrophy of alae nasi with slit-like opening.
- Absence of the nasolabial fold with smooth expressionless face due to disuse atrophy of orbicularis oris.
- High-arched palate due to loss of moulding and adaptation of the palate over the tongue during palatal growth.
- Crowded teeth with prominent incisors.
- Receding back lower jaw due to loss of negative intrabuccal pressure.
2- Chest deformities : as a result of nasal breathing against resistance because nasal breathing is instinct :
- Pigeon chest.
- Harrison’s sulcus.
- Retraction of lower end of sternum.
3- Retarded growth.

II- Eustachian tube obstruction : Leading to secretory otitis media with
conductive deafness.

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B- Symptoms due to infection :
1- Nose : Rhinitis and sinusitis.
2- Ear : otitis media (suppurative or non-suppurative).
3- Nasopharynx : chronic nasopharyngitis with post-nasal discharge (gummy egg white).
4- Digestive symptoms as loss of appetite, indigestion and morning vomiting due to swallowed mucous.

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C- General symptoms :
Mental dullness as a result of :
1- Lack of concentration due to conductive deafness.
2- Hypoxia during sleep due to airway obstruction.
3- Recurrent illness e.g.rhinitis, bronchitis.

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D- Reflex symptoms :
1- Nocturnal enuresis and nightmares due to hypoxia.
2- Nervous symptoms as chorea, convulsions and tics.
3- Respiratory symptoms as reflex cough, asthma, laryngismus stridulus and bronchitis.
4- Obstructive sleep apnea.

Investigations :
* X-ray nasopharynx, lateral view (soft tissue shadow narrowing the airway).
* Nasopharyngoscope (Flexible).
* Audiogram and tympanogram.
Treatment :
* Conservative : For infant or with mild symptoms :
- Diet rich in calcium.
- Decongestant nasal drops.
* Surgical removal : Adenoidectomy.

Question 2

ADENOIDECTOMY

Answer 2

Indications :
* Enlarged adenoid causing symptoms.
* If it is done alone (without tonsillectomy). It can be done as early as one year of age.

Contraindication :
As tonsillectomy, but it is contraindicated also in cases of cleft palate to avoid velopharyngeal incompetence because the adenoid mass assists in nasopharyngeal closure.

Operation :
* General anaesthesia with an endotracheal tube.
* The adenoids are shaved by adenoid curette inserted behind the soft palate in the nasopharynx.
* A pack is put in the nasopharynx for few minutes to stop bleeding.
* Recently endoscopic microdebrider and coblator are used

Complications :
* Hemorrhage :
- Most commonly due to incomplete removal or excess removal during operation (1ry hemorrhage).
- Reactionary or secondary hemorrhage is rare and is treated by post-nasal pack.
* Injury :
- To Eustachian tube leading to conductive deafness.
- To prevertebral muscles leading to torticollis.
- To the palate leading to nasal tone and regurgitation of fluids from the nose.

• Recurrence :
• This is mostly due to incomplete removal due to a blunt curette or movements of the pharynx (light anesthesia), hence the necessity for complete relaxation during curettage of the adenoid.
• However, the lymphoid tissue, in some patients, has a high tendency to hypertrophy, thus even after complete removal of the adenoids, it recurs and the child may need another operation.
• Pulmonary complications : Lung abscess or atelectasis due to inhalation of blood clots, adenoid tissue or vomitus.

Question 3

NASOPHARYNGEAL TUMOURS (Benign)

Answer 3

Fibroma, papilloma, adenoma, chondroma and mixed salivary tumours.
Nasopharyngeal fibroma :
* It is the most common benign tumour of the nasopharynx.
* It is histologically benign but clinically it is an aggressive tumour.

Pathogenesis :
a- Most probably hormonal (oestrogen-androgen imbalance) because :
* It is mainly a disease of male (juvenile fibroma).
* It is limited to the age group 10-20 years (age group undergoing endocrine changes).
* It may regress after the age of 25 years.
b- It may be hamartoma of vascular erectile tissue or paraganglioma of maxillary artery.
Pathology :
* Firm, lobulated swelling arise from periosteum of the sphenopalatine foramen.
* Histologically : (a) fibrous tissue, fibroblasts; (b) blood vessels of 2 types :
- Vascular spaces without a muscle coat and are the cause of severe bleeding.
- Feeding vessel : mainly from maxillary artery.

Clinical picture :
* Unilateral nasal obstruction with foeted discharge.
* Recurrent attacks of severe epistaxis (anaemic patient).
* Nasal tone (rhinolalia clausa).
* Anterior and posterior rhinoscopy : will show lobulated pink mass which bleeds on touch.
* Signs due to extensions (late) :
- To the nose leading to broadening of the nasal bridge, to the cheek leading to facial swelling and to the orbit leading to proptosis (frog-face deformity).
- To the Eustachian tube leading to secretory otitis media.

Investigations :
* CT scan to detect site, size and extension
* Angiography to show feeding blood vessel to do preoperative embolization.
* Biopsy : contraindicated due to severe bleeding.

Treatment :
Surgical excision : Is the treatment of choice for operable cases.
Endoscopic excision is now the main option with other approaches left for large tumours.
* Lateral rhinotomy approach, if the tumour extends to the nose and sinuses.
* Preoperative embolization of the feeding vessels to decrease bleeding during operation.
* Gamma knife radiotherapy for inoperable cases.

Question 4

NASOPHARYNGEAL TUMOURS (Malignant)

Answer 4

(B) Malignant :
* Squamous cell carcinoma is the most common tumour of nasopharynx.
* Other rare tumours are lymphoepithelioma, lymphoma, adenocarcinoma and mixed salivary tumours.

Squamous cell carcinoma :
Etiology :
* Tobacco smoking and wood dust.
* Genetic : common in China.
* Epstein-Barr virus infection.

Pathology :
* The fossa of Rosenmuller (just above and behind the Eustachian tube orifice) is the commonest site of origin.

Clinical picture :
* Enlarged cervical lymph nodes (from metastases) in old male patient is often the presenting sign.
* Nasal symptoms :
- Nasal obstruction and discharge.
- Epistaxis (slight, intermittent).
* Aural symptoms : Unilateral secretory otitis media in old age is suspicious.
* Symptoms of cranial nerve involvement :
-3rd, 4th, 6th cause ophthalmoplegia.
-5th causes trigeminal neuralgia.
- 10th causes vocal cord paralysis.
-11th causes paralysis of the palate.
- 12th causes paralysis of the tongue.
*** Trotter’s triad :
The 3 main symptoms due to local invasion by nasopharyngeal carcinoma :
- Unilateral facial pain (Trigeminal nerve).
- Unilateral conductive deafness (Eustachian tube).
- Unilateral palatal immobility.

Diagnosis :
* CT scan of the nasopharynx and skull base to detected tumour extension and bone erosion, MRI to detect intracranial extension.
* Biopsy is essential.

Treatment :
* Radiotherapy is the treatment of choice as the tumours are radiosensitive.
* For recurrence after irradiation, surgery for the tumor(endoscopic nasopharyngectomy ) and radical neck dissection for the lymph nodes .
* Permanent ventilation tube insertion in the middle ear on the side of the lesion.