Familial Nasopharyngeal Carcinoma 6

Natural History, Presenting Symptoms, and Diagnosis of Nasopharyngeal Carcinoma 47regional tumor control and survival. The early presentingsymptoms of NPC can be confused withbenign conditions such as upper respiratory tractinfection, sinusitis, and allergies. As stated above, themost common presenting symptoms is a neck massas a result of cervical nodal metastasis. A good understandingof the epidemiology of NPC and its presentingsymptoms and signs and a high index of suspicionin individuals with high risk of developing NPC arenecessary for a prompt diagnosis. In all patients withsymptoms and signs suspicious for NPC, a very thoroughexamination of nasopharynx is necessary. Ifindicated, a biopsy is necessary to provide pathologicdiagnosis. This should be supplemented with furtherdiagnostic tests including diagnostic imaging studiesand serology test.4.6.1History and Physical ExaminationThe symptoms of NPC can mimic other benign conditionsand can vary tremendously among patients.It is important to inquire about a family history ofNPC. Patients with early stage disease typically presentwith nasal and/or ear symptoms including nasalblockage (speech with nasal twang), blood-stainednasal discharge, postnasal drip, hearing loss, and tinnitus,and they are of greater concern to the physicianif the presentation is unilateral. In more advanceddisease, the above symptoms will become more obviousand there may be presence of cervical nodalmetastasis, cranial nerve involvement, and distantmetastasis. Patients with dermatomyositis should bescreened for NPC in endemic areas. The clinical presentationof NPC has been described in detail in theprevious sections of this chapter.In all patients suspected to have NPC, a full headand neck examination including a nasopharyngoscopyshould be performed. On the general head andneck examination, the neck is carefully palpated todetect any cervical nodal involvement. The levelsinvolved should be carefully documented. It is alsoimportant to document whether the cervical lymphadenopathyis mobile, partially fixed, or fixed. Theoral cavity and oral pharynx should be inspected tolook out for tumor invasion of the oral pharynx andtrismus. The nasal cavity is inspected with a nasalspeculum to detect any tumor extension to the nasalcavity. The cranial nerves and cervical sympatheticnerves should be examined systematically and anydeficit present should be carefully documented.In the clinic, the nasopharynx is best examinedusing a flexible fiberoptic endoscope under local anesthesia.Alternatively, a rigid Hopkins rod endoscopecan be used to visualize the nasopharynx. An indirectmirror examination may be used if an endoscope isnot available. The most important aspect in the detectionof NPC during an endoscopic examination is thefamiliarity with its appearance and usual subsites ofinvolvement. Figure 4.2 shows a normal nasopharynxunder the endoscope. Most NPC arise from the fossaof Rosenmüller. However, owing to the variation of itsanatomy, some early tumors may be obscured. As thetumor progresses, it will encroach on the torus tubaris.Occasionally, NPC may arise from the superior posteriorwall, appearing as a well-circumscribed or anulcerated mass (Woo 1999). Figure 4.3 shows an NPCunder endoscopic view. In more advanced tumors, asa result of more extensive involvement of the nasophar-Fig. 4.2. This is an endoscopic view of a normal nasopharynxFig. 4.3. This is an endoscopic view of a nasopharyngealcarcinoma