--- title: "Nasopharyngeal Carcinoma - Causes, Symptoms, Spread" description: "ENT notes on Nasopharyngeal Carcinoma - Causes, Pathology, Symptoms, and Spread." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/nasopharyngeal-carcinoma-causes-symptoms-spread" categories: ["Pharynx"] video: "https://www.youtube.com/watch?v=NFzaVMSLP5w" image: "https://media.theentresident.com/og-images/nasopharyngeal-carcinoma-causes-symptoms-spread.png" --- # Nasopharyngeal Carcinoma - Causes, Symptoms, Spread ENT notes on Nasopharyngeal Carcinoma - Causes, Pathology, Symptoms, and Spread. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=NFzaVMSLP5w ## 🎗️ Nasopharyngeal Carcinoma - Causes, Symptoms, Spread ### 🧾 Definition of Nasopharyngeal Carcinoma **Nasopharyngeal carcinoma (NPC)** is a **malignant epithelial neoplasm** of the nasopharynx (a non-lymphomatous **squamous cell carcinoma** of the nasopharyngeal mucosa). It is a **multifactorial disease** with genetic, environmental and viral contributors. --- ### 📊 Epidemiology of Nasopharyngeal Carcinoma - **Age distribution:** **Bimodal** — peak at **15–25 years** (young adult peak) and a second peak at **~50–55 years**. Overall common in 5th–7th decades as well. - **Sex:** **Male predominance** (≈ **3 : 1**). - **Geography:** Very **high incidence** in southern China, Taiwan and Southeast Asia. Relatively uncommon in India (~0.4% of cancers). - **Familial clustering** seen in ~10% → suggests genetic susceptibility. --- ### 🧬 Etiology of Nasopharyngeal Carcinoma Nasopharyngeal Carcinoma arises from interplay between: **1 -Genetic factors** - Familial clustering and retained high incidence in migrant populations suggest genetic predisposition. - **Mechanism:** certain HLA subtypes → impaired immune clearance of EBV → persistent latent infection → premalignant changes. >What are the HLA subtypes associated with increased risk of Nasopharyngeal Carcinoma? >What are the HLA subtypes associated with decreased risk of Nasopharyngeal Carcinoma? **2- Environmental factors** - **Preserved / salted fish, nitrosamine rich diets** (high nitrosamine exposure). - **Smoking** - increases risk (notably in well-differentiated types). - **Burning incense / wood smoke** - polycyclic hydrocarbons exposure. - **Vitamin C deficiency** - less inhibition of nitrosation → higher risk. **3- Viral factor - Epstein–Barr Virus (EBV)** - Nearly all undifferentiated and many non-keratinizing NPCs show EBV association: elevated anti-EBV antibodies, EBV DNA sequences in tumor nuclei. - EBV likely acts with genetic/environmental cofactors to transform mucosal epithelium. --- ### 🧪 Pathology & Classification of Nasopharyngeal Carcinoma - Old WHO classification: Type I (keratinizing), Type II (non-keratinizing), Type III (undifferentiated). - Modern classification: **Keratinizing** vs **Non-keratinizing**; non-keratinizing subdivided into **differentiated** and **undifferentiated**. --- ### 🔬 Macroscopic growth patterns of Nasopharyngeal Carcinoma Nasopharyngeal Carcinoma may present in three macroscopic types with differing common sites & symptoms: 1- **Ulcerative type** - Common origin: **posterior wall** or **fossa of Rosenmüller**. - Often **well differentiated**, destructive to skull base → epistaxis is common. 2- **Infiltrative (polypoidal) type** - Common origin: **lateral wall / around Eustachian tube**. - Grape-like polypoidal mass; can invade anteriorly to pterygopalatine/infratemporal spaces, or superiorly toward orbit → trigeminal (V) involvement possible. 3- **Exophytic type** - Common origin: **roof of nasopharynx**. - Smooth, hemispherical pedunculated mass → early **nasal obstruction** symptoms. >What is Broder's grading? --- ### 🧭 Patterns of spread of Nasopharyngeal Carcinoma Nasopharyngeal Carcinoma spreads **locally**, via **lymphatics** and rarely **hematogenously**. **A. Local (direct) spread** - **Superior / intracranial:** tumor can invade skull base (foramina) or extend through foramina → intracranial extension (via **foramen lacerum** commonly). Intracranial spread → cranial nerve palsies (III, IV, V1/V2, VI), cavernous sinus involvement, optic apparatus in advanced disease. - **Lateral:** through **sinus of Morgagni → parapharyngeal space** (retroparotid route). Parapharyngeal extension → infratemporal fossa, pterygoid muscles, parotid, skull base foramina (foramen ovale), and can cause trismus. - **Anterior:** into nasal cavity, pterygopalatine fossa → infratemporal fossa. - **Inferior:** into oropharynx, soft palate, and further into hypopharynx. - **Posterior:** retro-pharyngeal/prevertebral spread (prevertebral muscles, C1 arch). >What is Linconi's highway? **B. Lymphatic spread** - Retropharyngeal (Node of Rouvière) - Upper jugular (Level II, jugulodigastric) - Nasopharyngeal Carcinoma often gives **bilateral** and **extensive** nodal disease (levels II, V commonly). Spread is typically orderly (superior → inferior); **skip metastases are uncommon**. >What is the first lymph node to be involved in Nasopharyngeal Carcinoma? >What is the first palpable lymph node in Nasopharyngeal Carcinoma? **C. Hematogenous spread (less common)** - Distant mets: **bone (spine, pelvis, skull)**, **liver**, **lungs**. - Bone spread commonly via paravertebral (Batson) venous plexus. >What is the most common site of origin of Nasopharyngeal Carcinoma? --- ### 🩺 Clinical Features of Nasopharyngeal Carcinoma Nasopharyngeal Carcinoma has highly variable presentations - 1. **Cervical lymphadenopathy** (most common) 2. **Otologic** (Eustachian tube dysfunction / OME) 3. **Nasal** (obstruction, epistaxis) 4. **Ophthalmic / orbital** 5. **Neurological / cranial nerve palsies** >What is the most common clinical presentation of Nasopharyngeal Carcinoma? **1- Cervical lymphadenopathy** - **Most commonly involved palpable nodes:** **Level II** (upper jugular). Level V (spinal accessory chain) is also common. - Presentation: painless, firm, often multiple/bilateral nodes. A neck node with unknown primary → always consider Nasopharyngeal Carcinoma. - Pattern: orderly superior → inferior spread >What is Ho's triangle? **2- Nasal symptoms** - Epistaxis / blood-stained postnasal drip (common) - Unilateral nasal obstruction → progressive → bilateral with growth - **Cacosmia** (fetor/odor of blood) from bleeding tumor >Describe the endoscopic appearance of mass in Nasopharyngeal Carcinoma. **3- Otologic symptoms** - **Eustachian tube obstruction → otitis media with effusion / conductive hearing loss** (30–40%). - Persistent/unresolved serous otitis media in an adult should prompt nasopharyngeal evaluation. - Later: ear pain may occur with skull base invasion (referred trigeminal pain). **4- Ophthalmic symptoms** - Diplopia (III/IV/VI palsies), ptosis, proptosis, epiphora, reduced vision — occur with orbital or cavernous sinus involvement. **5- Neurological / cranial nerve palsies** - Signify **advanced disease / skull base invasion**. - Most frequently affected: **VI (abducent)**, **IV**, **V (trigeminal divisions)**; lower cranial nerve palsies (IX–XI) from jugular foramen involvement. - Presentations include facial pain / paresthesia (V2), palatal paralysis (IX/X), dysphagia, hoarseness. Headache localized to vertex/occiput common when skull base involved. **6- Constitutional & systemic** - Weight loss, anorexia, paraneoplastic phenomena (e.g., **dermatomyositis** occasionally associated). --- ### 🧠 Syndromes associated with Nasopharyngeal Carcinoma (Cranial nerve pattern syndromes) - Gradenigo’s syndrome - Trotter’s triad - **Jugular foramen (Vernet) syndrome:** IX, X, XI palsy. - **Collet Sicard syndrome:** IX–XII palsy. - **Garcin syndrome:** unilateral paralysis of multiple cranial nerves (progressive). - **Horner syndrome / orbital apex syndromes** may be seen depending on extension. >What is Trotter’s triad? >What is the triad seen in Gradenigo syndrome? --- ## About This Note This free ENT note on Nasopharyngeal Carcinoma - Causes, Symptoms, Spread was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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