CHAPTER I REVIEW 1.1 Anatomy Nasopharynx is a space or a cube-shaped cavity that lies behind the nose. This cavity is very difficult to see, so in the past so-called "dead-end cavity or hidden cavity". The boundaries of nasopharyngeal cavity at the front is koana (posterior nares). Upper, which is also the roof is cranii base. The back is the mucosal tissue in front of the cervical vertebrae. The lower is the isthmus of the pharynx and soft palate. 1 Figure 1.1. Nasal and Nasopharynx Side Anatomy
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CHAPTER I
REVIEW
1.1 Anatomy
Nasopharynx is a space or a cube-shaped cavity that lies behind the nose. This
cavity is very difficult to see, so in the past so-called "dead-end cavity or hidden
cavity". The boundaries of nasopharyngeal cavity at the front is koana (posterior
nares). Upper, which is also the roof is cranii base. The back is the mucosal tissue
in front of the cervical vertebrae. The lower is the isthmus of the pharynx and soft
palate.1
Figure 1.1. Nasal and Nasopharynx Side Anatomy
Figure 1.2. Nasopharyx Anatomy from the back
Important parts located in the nasopharynx are: 1
1. Adenoid or tonsil Lushka
The building is only found in children aged less than 14 years. In adults
this structure has undergone regression.
2. Nasopharyngeal Fossa
This structure is a small indentation which is predilection of nasopharynx
angiofibroma
3. Torus Tubarius
It is a bulge where the estuary of the Eustachian tube (tubal ostia) .
4. Fossa Rosenmuller
It is a small dent in the rear of tubarius torus. This small dent passed down
behind as a small groove called the sulcus salfingo-pharynx. Rosenmulleri
fossa is the place where the replacement of columnar epithelium/cuboidal
epithelium becomes squamous epitel. This interchange place is considered
a predilection for the occurrence of nasopharyngeal malignancy.
1.2 Definition
Nasopharyngeal carcinoma (NPC) is a tumor arising from the epithelial cells that
cover the surface and line the nasopharynx.2 It involves squamous cell carcinoma,
non-keratinizing carcinoma (differentiated or undifferentiated) and basaloid
squamous cell carcinoma. Adenocarcinoma and salivary gland-type carcinoma are
excluded.3
1.3 Epidemiology
Nasopharyngeal carcinoma is a malignant tumor of the head - neck which most
are found in Indonesia. Nearly 60% of malignant tumors of the head and neck is a
nasopharyngeal carcinoma, followed by malignant tumors of the nose and
paranasal sinuses (18%), larynx (16%), and malignant tumors of the oral cavity,
tonsils, hypopharynx in low percentage.4
Cancer registration data in Indonesia based on histopathology of 2003
showed that the NPC ranks first of all primary malignant tumors in male and the
8th in female. Nasopharyngeal carcinoma can affect all ages, the incidence
increases after age 30 years old and reached the peak at age 40-60 years old.
During 2006-2008 found as many as 45 cases of nasopharyngeal
carcinoma in West Sumatra. Most patients were men, that is 32 cases (71.1%).
WHO subtype-2 and WHO-3 have the same lot number of cases, each 17 cases
(37.8%). 5
1.4 Etiology and Risk Factor
Epstein-Barr virus
The near constant association of EBV with NPC, irrespective of ethnic
background, indicates a probable oncogenic role of the virus in the genesis of this
tumour. The evidence is there is higher levels of antibodies, especially IgA,
against EBV (most commonly viral capsid antigen and early antigen) in most
patients with NPC compared with normal controls and patients with other cancer
types.3
Environmental factors
Diet
In high incidence regions, high levels of volatile nitrosamines in preserved food
have been implicated as the putative carcinogen for NPC development. In the
1960s, it was proposed that the increased incidence of NPC among Hong Kong
boat dwellers compared to house dwellers may have been due to their staple diet
of salted fish.
Several studies found that only the consumption of salted fish during
childhood and weaning is significantly associated with NPC, while consumption
during adulthood is not. Besides the age of consumption the manner of cooking
and the type of fish may also be important, sea salted fish carried a higher risk
than fresh-water fish, as well as steamed fish than fried, grilled or boiled salted
fish.6
Other environmental risk factors
Other purported risk factors include cigarette smoking, occupational exposure to
smoke, chemical fumes and dusts, formaldehyde exposure, and prior radiation
exposure.Busson Matched case-control study reported in Semarang vaporous
formaldehyde exposure and inhalation of smoke that the most likely towards the
NPC. Heavy smokers who smoke 2-4 times a day has more risk than non-
smokers. High alcohol consumption showed no risk in Chinese society, although
in the United States suggest a correlation.
Genetic Factors
Based on the facts that there are significant differences in the frequency among
some ethnic groups, namely the existence of an increased risk in families NPC
patients. In ethnic Chinese, NPC connected with the discovery of HLA type A2
and Bw46. Research in Medan find that the potential gene as the cause of the
onset of NPC susceptibility in Batak is HLA-DRB1.7
1.5 Pathogenesis
EBV plays a role in the pathogenesis of nasopharyngeal carcinoma, which was
originally of infection from this virus causes changes in low-grade dysplasia cells
in the nasopharynx. cell low-grade dysplasia has been caused by predisposing
factors such as diet, genetic sueptibilitas and others. With the infection of EBV
and the influence of chromosomal disorders develop into cancer invasif.
Metastastasis of these tumors is influenced by the presence of p53 mutation and
over-expression of kaderin.8
Figure 1.3. Pathogenesis of Nasopharyngeal Carcinoma9
Figure 1.4. The Microbiologic Changing in Nasopharyngeal Carcinoma9
1.6 Clinical Manifestation
Symptoms or clinical manifestations of nasopharyngeal carcinoma can be divided
into several groups, namely4:
1. Nasal / Nasopharyngeal Symptoms
Nasopharyngeal carcinoma should be suspected when any of these symptoms:
If the patient has a cold a long time, more than 1 month, especially patients
aged over 40 years, currently there are abnormalities in the nasal examination.
If the patient is cold and has thick discharge, foul-smelling, especially if there
is a point or a line of bleeding without abnormalities in the nose or paranasal
sinuses.
In patients over the age of 40 years, frequent bleeding from the nose
(epistaxis), while normal blood pressure and from nasal examination, there is
no abnormalities.
2. Ear Symptoms
Symptoms in the ear are reduced hearing, the ear feels full as filled with water, or
buzzing (tinnitus) and pain (otalgia). Hearing loss that occurs usually in the form
of conductive deafness and occurs when there is an extension to the
nasopharyngeal carcinoma tumor or around the tube, resulting in blockage.
3. Neck Tumor Symptoms
Enlarged neck or neck tumors is the nearest limphogenic spread of
nasopharyngeal carcinoma. This deployment can be unilateral or bilateral. The
specificity of tumor as metastasis of nasopharyngeal carcinoma neck is the
location of the tumor which is at the end of the mastoid process, behind the angle
of the mandible, in the sternocleidomastoid muscle, hard and not easily move.
Suspicions grew when the examination of the oral cavity, tongue, pharynx,
tonsils, hypopharynx and larynx found no abnormality.
4. Eye Symptoms
Patients will complain of reduced vision, but when asked carefully, people will
explain that he saw something in half or double. Clear what is meant is diplopia.
This occurs due to paralysis N.VI located above the foramen laserum lesions due
to tumor expansion. Other circumstances that could give eye symptoms are due to
paralysis N.III and N.IV, causing paralysis of the eye called the ophthalmoplegia.
When the expansion of the tumor on the optic chiasm and N.II then the patient
may experience blindness
.
5. Nerve Symptoms
Prior to the cranial nerve paralysis is usually preceded by some subjective
symptoms are perceived by patients as very disturbing headache or head was
spinning, hipoestesia on the cheek and nose, and often complain of difficulty in
swallowing (dysphagia). Are not uncommon symptoms of trigeminal neuralgia by
a neurologist when there has been no significant complaints. Process of further
carcinoma will make lesion of N.IX, X, XI, and XII when expand through the
jugular foramen. This disorder is called the Jackson syndrome. When the entire
cranial nerve have lesions, it called the unilateral syndrome. Can also be
accompanied by the destruction of the skull and it becomes a worse prognosis.
1.7 Classification
Based on histopathologic pattern, nasopharyngeal carcinoma can be divided into
three types according to the WHO. This division is based on examination by
electron microscopy which nasopharyngeal carcinoma is one variant of
epidermoid carcinoma. This division has supported by more than 70% pathologist
and retained to this day3:
a. WHO Type 1
These include squamous cell carcinoma (SCC). WHO Type 1 has a clear
growth type on the surface of the nasopharyngeal mucosa, differentiated
cancer cells well to moderate and produce quite a lot of keratin both inside and
outside the cell.
b. WHO Type 2
These include non-keratinizing carcinoma (NKC). WHO Type 2 is the most
various type, some tumor has moderately differentiated and the other half has
well differentiated, microscopic finding of this type is similar to transitional
cell carcinoma.
c. WHO Type 3
This type is a Undifferentiation Carcinoma (UDC). The picture of cancer cells
most heterogeneous. The WHO Type 3 includes the formerly called
limfoepitelioma, anaplastic carcinoma, clear cell carcinoma, and spindle
variations.
Type without differentiation and without keratinization in the same nature,
which are radiosensitive, while this type with keratinization not so