ct scan

CT Scan

Infratemporal fossa Cheek (Hondousa Sign)

2015 VARSHNEY LECTURE SERIES 1

CT Scan

Orbit Sphenoid sinus


CT Scan

Middle cranial fossa Pituitary & Cavernous sinus


Computed Tomography


Magnetic Resonance Imaging


Angiography {Digital Subtraction Angiography (D.S.A.) }

Final confirmation of diagnosis

Both diagnostic and a therapeutic

• (preoperative embolization)

Defines the blood supply & identifies anomalous connections between ICA and ECA


External Carotid angiography (Dense-homogenous blush is characteristic of JNA)

Feeding vessel = Internal Maxillary Artery2015 VARSHNEY LECTURE SERIES 9

Angiography - vascular supply


?? Biopsy

contraindicated

• Biopsy under controlled conditions, perhaps after angiography.


Treatment Options

Surgery - Gold standard ; Most widely accepted mode of therapy

Radiation therapy - Reserved for unresectable, life-threatening tumors

Chemotherapy - Recurrent tumors with previous surgery and radiation

Hormone therapy - Estrogens and antiandrogens used to decrease tumor size and vascularity


Pre-op reduction of tumor vascularity

Embolization of feeding arteries: with Gelfoam

Oestrogen therapy: Diethylstilbestrol (2.5 - 5 mg orally t.i.d. for 3 - 6 wk)

Testosterone receptor blocker: Flutamide

Pre-operative radiotherapy

Cryotherapy of tumor


Preoperative embolization

Angiogram showing the typical bloodsupply of the tumor from the internalmaxillary artery (arrow).

After embolization of the internalmaxillary artery

2015 14

Ligation of the major feeding vessels

Reduction of haemorrhage can be obtained by ligation of the ECA or internal maxillary artery.


Surgical Approaches

Endoscopic transnasal

Transpalatal

Denker approach

Midfacial degloving

Lateral Rhinotomy

Weber-Ferguson incision

Infratemporal fossa with or without craniotomy.

16

Trans-palatal approach (Wilson)


Sardana’s approach - Sublabial + Trans palatal approach - large tumour of nose + PNS + nasopharynx


Intranasal endoscopic approach small tumour in nose / PNS / nasopharynx


Transmaxillary approach via:

Extended lateral rhinotomy incision

Midfacial degloving incision

Denker’s extended Caldwell-Luc incision

Le Fort 1 osteotomy approach

Done for extension into pterygopalatine fossa


Lateral rhinotomy approach


Midfacial degloving


Denker’s incision

Caldwell Luc incision extended medially till midline2015 VARSHNEY LECTURE SERIES 25

Le Fort 1 osteotomy


Infratemporal fossa approach (Fisch)-

extension into infratemporal fossa


Anterior subcranial approach intracranial & orbital extension


Surgical specimen


Nasopharyngeal Carcinoma


Nasopharyngeal malignancies

SCCA (nasopharyngeal carcinoma)

Lymphoma

Salivary gland tumors

Sarcomas


Anatomy

Anteriorly -- nasal cavity

Posteriorly -- skull base and vertebral bodies

Inferiorly -- oropharynx and soft palate

Laterally --

• Eustachian tubes and tori• Fossa of Rosenmuller - most common location• Close association with skull base foramen


Epidemiology

Genetic: Chinese native > Chinese immigrant > North American native

Environmental

• Viruses• EBV• HPV • Nitrosamines - salted fish

• Others - polycyclic hydrocarbons, chronic nasal infection, poor hygiene, poor ventilation


Clinical Presentation

Often subtle initial symptoms

• unilateral HL (SOM)• painless, slowly enlarging neck mass

Larger lesions

• nasal obstruction• epistaxis• cranial nerve involvement• DIAGNOSTIC NASAL ENDOSCOPY & Bx



Xerophthalmia - greater sup. petrosal n

Facial pain - Trigeminal n.

Diplopia - CN VI

Ophthalmoplegia - CN III, IV, and VI

• cavernous sinus or superior orbital fissure

Horner’s syndrome - cervical sympathetics

CN’s IX, X, XI, XII - extensive skull base



Nasopharyngeal examination

• Fossa of Rosenmuller most common location• Variable appearance - exophytic, submucosal • NP may appear normal

Regional spread (Lymph nodes)

• Usually ipsilateral first but bilateral not uncommon

Distant spread - rare (<3%), lungs, liver, bones


Radiological evaluation

Contrast CT with bone and soft tissue windows

• imaging tool of choice for NPC

MRI

• soft tissue involvement, recurrences

PET Scan

CXR

Chest CT, bone scans


CT Scan


PET Scan


Treatment

External beam radiation

• Dose: 6500-7000 cGy

Adjuvant brachytherapy

• mainly for residual/recurrent disease


Treatment: Surgical management

Mainly diagnostic - Biopsy

• consider clinic bx if cooperative patient• must obtain large biopsy• clinically normal NP - OR for pan endo and bx

Surgical treatment

• primary lesion • regional failure with local control

Regional disease

• Neck dissection may offer improved survival compared to repeat radiation of the neck


ct scan

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