1. By Dr Nourizadeh Assistant professor of ENT MUMS
Nasopharynx By
Dr Nourizadeh
Assistant professor of ENT
MUMS

3. SPECIAL CONSIDERATION
The pharyngeal recess is filled by the levator palati muscle and overlies the internal carotid artery, which courses at this point against the wall of the pharynx.

4. External carotid artery
Blood Supply:
External carotid artery
Ascending pharyngeal
Facial arteries
Venous drainage
The pterygoid venous plexus (superiorly)
The pharyngeal plexus (inferiorly)
Lymphatic drainage
The retropharyngeal nodes
The deep cervical lymph node chain

5. :Nerve supply The trigeminal nerve
The pharyngeal branch of the sphenopalatine ganglion
Below passavant's ridge the nerve supply is the same as for the rest of the pharynx by the glossopharyngeal and vagus nerves.

6. Lateral pharyngeal space Pre- Styloid Post- Styloid
Parapharyngeal space
Lateral pharyngeal space
Pre- Styloid
Post- Styloid
Retropharyngeal space
Retropharyngeal nodes

7. Food is broken down and moistened to form a bolus
Oral phase
Food is broken down and moistened to form a bolus
Moved toward the oropharynx
Voluntary
Pharyngeal phase
Involuntary
Tongue base receptors
The velum is elevated to close off the nasopharynx.
The larynx is also sealed off by elevation of the epiglottis.
This is accompanied by a reflex adduction of the vocal cords
Allowing the food to pass through the piriform sinuses toward the esophagus while bypassing the larynx.
Fromcranial nerves V3, VII, IX, X, and XII
Esophageal phase
Begins with a primary peristaltic wave, which is reflexly initiated in response to movement of the bolus through the pharynx (cranial nerves IX, X).
Secondary peristalsis is additionally triggered in the esophagus by the pressure of the bolus against the esophageal wall

9. Physiology Of The Nasopharynx
Airflow
Like the nose, it is a noncollapsible structure.
Usually nasopharyngeal obstruction results in reflex use of the oral airway.
The exception is in neonates, who are regarded as obligate nasal breathers.
Eustachian tube function
Speech and swallowing
Bacterial colonization

10. Symptoms: Nasal obstruction: Rhinorrhea Mouth breathing and snoring
Severe nasal obstruction at birth suggests Bilateral Choanal Atresia
Onset at age 2 to 3 years is suggestive of:
Adenoidal hypertrophy
Rhinitis
Rhinorrhea
Mouth breathing and snoring
Posterior epistaxis
Conductive hearing loss
Hyper nasal speech or regurgitation

12. Physical Examination:
Adenoid facies: (nonspecific)
Open mouth
Flat midface
Dark under the eyes
A dull appearance
Postnasal mirror
Fiberoptic flexible endoscopy
During speech and swallowing maneuvers gives functional information about velopharyngeal closure
Rigid endoscope

14. Radiology: MRI Plain radiographs Computed tomography(CT)
The first choice of imaging for:
Choanal atresia
Disease of the paranasal sinuses
MRI

15. Adenoidal Hypertrophy
Adenoidal hypertrophy is typically more common in children.
Complications:
Chronic nasal obstruction adenoid facies
Eustachian tube dysfunction serous or recurrent otitis media
Sleep apnea
Pulmonary hypertension
Acute infection is the most common nasopharyngeal disease.
The most common organisms identified are Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae.

16. Numerous authors have commented on the inappropriate use of antibiotics in an attempt to treat upper respiratory infections that in fact have a viral etiology.
Estimated that viral upper respiratory infection is the most common disease of humans with a prevalence rate of six to eight colds per 1,000 persons per day during the winter months.

17. Neoplasms
The vast majority of tumors of the nasopharynx are malignant epithelial neoplasms.
The second most common malignancy of the nasopharynx is malignant lymphoma.
In children embryonal rhabdomyosarcoma can arise in this region.
A basic distinction is drawn between squamous cell carcinomas and lymphoepithelial carcinomas (Schmincke tumor).

18. Nasopharyngeal Carcinoma
Symptoms:
Patients may present with significant nasal symptoms including nasal obstruction, epistaxis, a sensation of sinus fullness, and headache.
Some patients present with minimal nasal symptoms, but complain of otalgia or decreased hearing due to eustachian tube obstruction from the mass.
A majority of the patients present with a mass in the neck, and in some patients this is the only complaint.
Physical findings:
Nasopharyngeal carcinomas are typically erythematous and friable. The tumor arises most frequently near the fossa of Rosenmuller.
Orbital invasion can produce significant proptosis or hypertelorism.
Cranial nerves may be involved at the skull base. In particular the trigeminal and abducens nerves are at risk and their function should be examined.
Cervical nodes are present in over 70% of patients. The nodes are usually involving the nodes at the mandibular angle.

19. Any persistent middle ear effusion of long duration in an adult patient with no prior history of middle ear disease is suspicious for a tumor and should be investigated accordingly.
EBV antibody titer should be determined (this shows an elevated IgA, contrasting with the elevated IgM/ IgG that is found in infectious mononucleosis).

20. Pathology
WHO I tumors are keratinizing squamous cell carcinomas. In the United States these tumors account for approximately 25% of nasopharyngeal carcinomas. In areas of the world where nasopharyngeal carcinoma is common, such as Southern China, these tumors account for less than 5% of nasopharyngeal carcinomas. These tumors are not related to EBV infection.
WHO II tumors are nonkeratinizing squamous cell carcinomas. These tumors histologically resemble transitional cell bladder cancer, and are also called transitional cell carcinoma. These tumors are related to EBV infection.
WHO III tumors are undifferentiated carcinomas and include lymphoepithelioma. They account for the majority of nasopharyngeal carcinomas in the United States and worldwide. These tumors are related to EBV infection.

21. Diagnosis
Open neck biopsies should be avoided unless all other diagnostic techniques are exhausted.
Once there is a suspicion of nasopharyngeal carcinoma, the suspicious lesion should be biopsied. Suspicious cervical nodes can be aspirated to aid in the diagnostic workup.
TREATMENT
Radiation therapy regardless of stage
Neck dissection is reserved for persistent or recurrent cervical disease
WHO II and WHO III tumors are more radiosensitive than WHO I tumors.

23. Juvenile Angiofibroma
Juvenile angiofibromas are:
Benign neoplasms
Occur almost exclusively in adolescent males
These tumors actually arise from the region of the sphenopalatine foramen
Average age = 14 (10-18)
Nasal obstruction and epistaxis (more than 80% )
CT scanning is used to evaluate the extent of the tumor
Unencapsulated and infiltrate the surrounding tissue. The major components are a fibrous stroma and intertwined vascular channels. The vessels are variable in size, lined by a single layer of endothelial cells, and lack elastic fibers in their walls.

24. If there is clinical suspicion of an angiofibroma, a biopsy should not be performed due to the risk of heavy bleeding.
The primary workup should include MRI or CT with IV contrast.

25. Treatment: Surgery Radiation therapy Electrocoagulation
Hormonal administration
Surgery and/or radiation therapy are the current main stays of treatment.
Preoperative angiography with embolization (usually the maxillary artery) is recommended.
Radiation is a viable option, but is best reserved for cases with intracranial extension.