Carcinomas of the nasopharynx are important on a world scale. In people of Southern Chinese origin they are a very common cancer. They have a lesser, but significant, incidence, in some other races of South-east Asia and North and East Africa. They are strongly associated with the Epstein-Barr virus, but, unlike cancers in other parts of the pharynx, not with either alcohol or tobacco. They are more common in males, and have a peak age incidence between 40 and 50, but are sometimes seen in older children. 90% are carcinomas, and most of the remaining 10% are lymphomas. They spread locally by direct extension, regionally to neighbouring nodes, and distantly in the bloodstream. Distant metastases to the lung, bone, and liver occur more often from the nasopharynx than from any other site in the head and neck.
A patient with carcinoma of his nasopharynx presents with a nasal discharge, nasal speech, a blocked nose, symptoms resulting from a obstruction of his eustachian tube (earache, tinnitus, and hyperacusis), and involvement of his cranial nerves, most commonly his 5th and 6th, but also his 2nd, 3rd, 4th, 7th and 8th (diplopia, facial pain, and numbness, loss of vision, and deafness, etc.). There is an 80% chance that he already has metastases in his cervical lymph nodes when he presents.
CARCINOMA OF THE NASOPHARYNX EXAMINATION. Examine the patient's cranial nerves. Carefully palpate his entire neck for enlarged nodes. Feel particularly for his uppermost internal jugular node, just below the tip of his mastoid process. This is often the first node to be involved when the primary is silent.
Observe his soft palate for asymmetry due to displacement by a tumour. If you are skilled, examine his nasopharynx with a mirror (25.11a).
BLIND BIOPSY is less satisfactory than open biopsy. Give him a general anaesthetic and intubate him orally (nasal intubation will quickly spoil both your access and your view). Push St Bartholomew's or Luc's forceps through his nose, and guide them into his nasopharynx, with a finger behind his soft palate. Grasp a suitable piece of tissue and remove it.
OPEN BIOPSY. Anaesthetize and intubate him orally. Put him into the tonsillectomy position, lying on his back with a pillow under his shoulders and with his head extended. Insert a tonsillectomy (Boyle Davis) gag. Pass a catheter through his nose and out through his mouth. Use this to retract his palate. Using a warmed laryngoscopy mirror, inspect his pharynx and remove suitable pieces for biopsy.
If he has a suspicious node in his neck and you can see no obvious primary (unusual), take specimens from several suspicious-looking areas in his nasopharynx.
X-RAYS may show involvement of the base of his skull.
STAGING is a guide to prognosis.
TIS carcinoma in situ.
T[,1] tumour confined to one site in his nasopharynx, or no tumour visible (positive biopsy only)
T[,2] tumour involving two sites (both posterosuperior and lateral walls).
T[,3] extension of the tumour into his nasal cavity, or oropharynx.
T[,4] tumour invading his skull, or involving his cranial nerves.
TREATMENT. The role of surgery is limited to biopsy. If he has a lymphoma, treat him for it (32.5). It he has a carcinoma, refer him for radiotherapy. There is no established chemotherapy, but methotrexate 150 mg/m['2] with folinic acid and vincristine 1.4 mg/m['2] may help some patients (32.2). Never give this high dose of methotrexate, unless you can also give folinic acid rescue starting 24 hours after the methotrexate. Give him 4 doses of 15 mg of folinic acid orally, intramuscularly, or intravenously at 12 hour intervals, and encourage him to drink plenty of fluid. If he had a sore mouth after the last dose of methotrexate, give him 8 doses. If he fails to respond, don't give more than 3 courses. CAUTION ! This is the high dose range for methotrexate, which is not used with other methods in this manual (the usual dose is 15 mg/m['2], not 150 mg/m['2], as above).
PROGNOSIS. Local control is possible in 60[nd]90% of cases. 5 year survivals range from 27% (squamous cell carcinomas) to 58% (lymphoepitheliomas and lymphomas.
Fig. 32-16 CARCINOMA OF THE NASOPHARYNX. A, the directions of spread of carcinoma from (1) the tonsil, (2) the posterior pharyngeal wall, and (3) the soft palate. B, a 45 year old Masai with cervical metastases and paralysis of his left 2nd, 3rd, 4th, 5th, and 6th cranial nerves. C, a 14 year old Luo boy with enlargement of his left cervical glands, but no cranial nerve lesions. D, a 12 year old Kikuyu boy with severe trismus, ]]bilateral proptosis, ophthalmoplegia and right blindness from an anaplastic carcinoma of his nasopharynx, but without involvement of his cervical glands. A, after Edward M Copeland III, ''Surgical Oncology', p.127, Fig. 5. John Wiley, with kind permission. B, C, D, after Peter Clifford, East African Medical Journal 1965;42:381.