Abstract

This is a descriptive study to look at nasopharyngeal masses, including malignant ones and benign ones especially angiofibroma in patients admitted in Amir Aalam and Imam Khomeiny Hospitals from 1991 to 1996, in order to analyse different variables including age, sex, sign and symptoms and different pathologies in these kind of tumor.  Two groups of patients consisting of 50 patients with the diagnosis of angiofibroma and 50 suffering from a nasopharyngeal malignancy were screened and the information retrieved from their files were studied and analysed consequently.

Introduction

Nasopharynx is an anatomic cavity which is surrounded by hard walls from sides, above and back. It is connected to nasal cavity from anterior.  It extends from base of skull to soft palate.  It is limited to the body of sphenoid bone and basilar process of occipital bone From above and to cervical spines from back and is parallel to oropharynx from below. The most common benign mass in this area is angiofibroma (1).  Angiofibroma is a common benign mass in head and neck with an incident of 5% to 50%.  The most common age is 12-18 y/o and is more common in male than female (2).  In our study all the 50 cases of angiofibroma were male.  The age range of clinical presentation is from 7-17.  The common clinical manifestations are nasal block, epistaxis, rhinorrhea, conductive hearing loss and serous otitis media (3).  Although it is a benign tumor, due to involvement of the base of skull, brain invasion and recurrence of this tumor, it is a troublesome disease in ENT, head and neck and neurosurgery fields (4,5,6,7).  The other benign tumors include polyps, fibroma, cysts, craniopharyngioma, tratoma, cordoma, papilloma, extracranial menengioma and etc (8). 

Male teenagers are risk groups, so it is important to consider any history of nasal block, nose bleeding and unilateral serous otitis media seriously and examine nasopharynx carefully to rule out any mass (3).

The most common malignant tumor in nasopharynx is nasopharynx carcinoma (NPC) (8).  According to WHO classification malignant tumors include Type I: Keratinzed Squamous Cell Carcinoma, Type II: Non Keratinized Transitional Cell Carcinoma, Type III: Undifferentiated Carcinoma, Lymphoepithelioma, and Anaplastic Carcinoma.  In North America malignant they make 25% of all cancers. According to Ballenger 1992 malignant neoplasm of nasopharynx are 2%of all the head and neck malignancies (9,10,11).  Male to female ratio is 3/1 (3).  The other malignant tumors of nasopharynx include malignant lymphoma, adenocarcinoma, cylindroma, rhabdomyosarcoma, plasmocytoma, chondrosarcoma and etc. 

In terms of clinical manifestations, dependent on the site and extent of involvement, these tumors could present themselves as cervical lymphadenopathy, nose block, epistaxis and malfunction of Eustachian tube (serous otitis media, conductive hearing loss, earache,…) or headache, facial or cervical pain, weight loss, anorexia, nasal discharge, sixth cranial nerve palsy or other cranial nerves palsy and in advance cases base of skull involvement and brain invasion (1,2,3).

Method

103 patients who were referred to and treated in Imam Khomeiny and Amir Aalam Hospitals with the diagnosis of benign (angiofibroma) or malignant nasopharyngeal tumor during the period of 1991 to 1996 were studied in this research.  This is a retrospective, descriptive study.

The objective of this study is to determine the frequency of the clinical manifestations, the most common sign and symptom, the frequency of different pathology findings in nasopharyngeal masses, and age and sex distribution of them. 

The method of data collection was using the patients' files, specifically the pathology results documented in the files.  The patients were referred to ENT, neurosurgery, head and neck surgery and repairing surgery clinics and had undergone operation with the diagnosis of nasopharyngeal mass.  103 patients were studied from which 50 were cases angiofibroma, 3 cases were cordoma and 50 cases were malignant nasopharyngeal tumor.  In the case of angiofibroma patients were 7-23 years old whereas patients suffering from a malignant tumor were 3-80 years old.

Findings

The most common benign tumor of nasopharynx was angiofibroma.  All these cases were male.  From 3 patients with cordoma 1 was a woman and the other 2 were men.  The most common age group in angiofibroma was 16-19 which included 60% of the cases.  32% of the cases were 8-15 years old and there wasn't any case older than 24.  The average of the age was 16 years. 

In terms of clinical manifestations of angiofibroma, nose block was presented in 90% of the cases, epistaxis in 84%, rhinorrhea in 50%, conductive type of hearing loss in 36% and serous otitis media in 30%.  Nose block and epistaxis were the most concomitant manifestations with the incidence of 90% and 34% of the patients had those two symptoms plus rhinorrhea and hearing loss at the same time. 

In 8% of the patients the tumor had invaded the intra cranial cavity and 8% of the cases had base of skull involvement. In terms of cranial nerve involvement facial nerve was involved in 4 of the cases unilaterally,  sensory branches of the 5^th Cranial nerve also in 4 patients and paralysis of 6^th cranial nerve in 3 people which caused external orbital rotation impairment. 

Among 50 malignant cases, 44% were diagnosed pathologically as squamous cell carcinoma including keratinized and non keratinized types, and 24% were undifferentiated carcinoma.  The other malignant cases included 8% congenital rhabdomyosarcoma, 8% large cell malignant lymphoma, and the rest were adenocarcinoma, anaplastic carcinoma, plasmocytoma, and chondrosarcoma.

Sex distribution was male dominant with a rate of 56% comparing to 44% for women. This is shown in details in table 1.

Table 1: The distribution of different types of nasophryngeal malignant tumors in two genders, Imam Khomeini and Amir Aalam Hospitals, 1991-1996

SCC: Squamous cell carcinoma including keratinized and nonkeratinized types, C.: carcinoma.

Age wise, 34% of the patients were between 10 to 39 years old and 56% were 40-69 years old.  The age range was 3-80 and the average was 44 years. 
The relative frequency of clinical manifestations of nasopharyngeal malignant tumor is presented in table 2.

Table 2: the relative frequency of the sign and symptoms of patients with malignant nasopharyngeal carcinoma, Imam Khomeiny and Amir Aalam Hospitals, 1991-1996

Here is the presentation of the 3 cases with nasopharyngeal cordoma which were included in this study.

Case I: It was a 7 years old girl who had presented with chief complaint of mouth breathing, nasal speech and regurgitation of fluid from nose.  In physical examination oronasal fistula, cleft palate and adenoid hypertrophy were detected.  They had detected a gray mass in nasopharynx during adenoidectomy operation which was resected.  The pathology result was in favor of cordoma.  CT scanning from base of skull had showed invasion to this area.

Case II: It was a 9 years old boy who had referred to ENT clinic with fever, pain and tenderness on his maxillary sinuses and bloody-mucoid discharge from nose (PND). In physical examination no cervical lymphadenopathy was detected.  Water's view of sinuses showed radio opacity in left maxillary sinus.  The patient complained of nasal speech from a few months before but didn't have any history of weight loss or change of appetite.  He was treated for acute sinusitis with antibiotics.  In fallow up visits during mirror examination of nasopharynx they noticed a mass in the posterior wall of the patient's nasopharynx.  He was admitted and operated consequently and the pathology result of the mass was cordoma.

Case III: The patient was a 50 years old man, with chief complaint of nose block, mouth breathing, snoring, pain and burning sensation in throat, and voice change.  In nasopharyngeal examination a mass was detected which extended to the side wall of the pharyngeal cavity and had involved the soft palate.  There wasn't any other positive finding in physical examination.  The tumor was resected and was diagnosed as a cordoma after pathologic examination.  In CT scan the base of skull showed to be involved.

Discussion

Table 3 compares the results obtained by other researchers regarding the clinical manifestations of nasopharyngeal tumors with those of this study.  Tables 4 and 5 present the relative frequency of benign nasopharyngeal tumors according to Charles. W. Cummings & John. Fredrickson (1993) and this study, respectively.

Table 3: Comparison of the results of other studies regarding the frequency of clinical manifestations (%) of nasopharyngeal benign tumors with our presented study on the patients admitted in Amir Aalam and Imam Khomeiny Hospitals.

Table 4: Frequency of nasopharyngeal benign tumors in 156 patients according to Charles. W. Cummings & John. M. Fredrickson 1993.

Table 5: Frequency and relative frequency of Benign  nasopharyngeal tumors in the patients admitted in Imam Khomeiny and Amir Aalam Hospitals, 1991-1996.

According to the results of this study and comparing them to the ones obtained from other countries, it seems that the incidence of angiofibroma in our country is more than classic statistics.  Considering that this disease have only been seen in males, it should be at the top of the list of differential diagnosis for any young male who is referred to us with nose and ear block and frequent epistaxis.

Although nasopharyngeal carcinoma is less common in our country especially comparing to Far East countries, considering it usually manifest itself with indirect sign and symptoms like unilateral cervical lymphadenopathy or tinnitus, it is essential to perform biopsy from common sites (even if the tumor mass is not obvious).

References

Published in Tebb-o-Tazkieh Magazine, no. 33, 1999.
By: E. Razmpa, MD; A. Nadimi Tehrani, MD; A. Jabbari, MD