Case Presentation

Supervisor:
dr. H. Oscar Djauhari, Sp. THT
Presented by:
FK UAJ and FKUMJ
A 60-years-old male came to ENT clinic with a complaint of
sensation of blocked right nose and bloody discharge from
the nose since 7 days ago
Name : Mr. M
Gender : Male
Age : 60 years old
Occupation : Industrial worker
Race : Javanese
Address : Sukabumi
Weight : 55 kg
Height : 170 cm

Chief Complaint : sensation of blocked right nose and
bloody nasal discharge since 7 past days.

Additional Complaint : right ear fullness, hearing
loss, neck mass since 2 months ago, weight lost

A 60-years-old male came to ENT clinic with a chief
complaint of sensation of blocked right nose and bloody
nasal discharge since 7 past days. The bloody discharge
was intermittent and in a small amount. The discharge was
only in the right nose. He also felt right ear fullness and
hearing loss.
He also noticed a mass at his right upper neck since
2 months ago. The mass was single, round, not enlarging
in the past 7 days, and painless. In the past 6 months, he
lost weight dramatically despite of regular meal
He has a history of hard smoker. History of fever and
malaise was denied. He didnt have any other ear or eye
complaint. There was no ear discharge, ear pain, or
tinnitus. Complaint of swallowing pain and cough were also
denied
History of Past Illness
History of previous illness was denied

History of Family Illness
History of family illness was denied

General condition : Appear calm
Body weight : 55 kg
Height : 170 cm
Blood pressure : 110/80 mmHg
Pulse : 88 beat per minute
Respiratory rate : 20 times per minute
Temperature : 36,9
o
C
Ear
Right ear
Auricle : normal
External auditory canal:
hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) ,
cerumen
Tymphanic membrane:
Intact, hyperemic (-),bulging (+), light reflex

Left ear
Auricle : normal
External auditory canal:
hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) ,
cerumen (-)
Tymphanic membrane:
Intact, bulging (-), light reflex (+)

Nose
Right nose
Mucous membrane:
hyperemic (-), edema (-), blood-stained discharge (+),mass (-
), laceration (-), crust (-)
Inferior conchae : eurtrophy
Septum : no deviation
Air passage : decreased

Left nose
Mucous membrane:
hyperemic (-), edema (-),secretion (-), mass (-), laceration (-),
crust (-)
Inferior conchae : eurtrophy
Septum : no deviation
Air passage :normal

Oropharynx
Posterior pharynx : hyperemic (-)
Palatine tonsils : T1 / T1, hyperemic (-),
detritus (-)
Uvula : symmetrical
Dental : no abnormatlities
Maxillofacial : symmetrical
Neck : single right upper jugular
lymphadenopathy, diameter of 2
cm, painless


Working Diagnosis
Suspect of nasopharyngeal carcinoma

Differential Diagnosis
Nasal polyp
Turbinate hypertrophy

Laboratory:
Complete blood count
Liver function test
Head and neck CT-scan
Nasopharyngoscopy + biopsy
Radiotherapy chemotherapy
NPC is a relatively rare disease in the west, but is
endemic in the Far East
The highest incidence reported is from the Guangdong
Province of Southern China, where it is the third most
common malignancy among men, with an incidence rate
of between 15 to 50 per 100,000
Latent infection by the Ebstein-Barr virus (EBV) is crucial
in the progression to severe dysplasia, and gains on
chromosome 12 and allelic losses on 11q, 13q, and 16q
lead eventually to invasive carcinoma
Dietary factors have focussed mainly on
preserved foods, and salted fish, in
particular, has been found to have a strong
relation to the development of NPC. There
is also an increased risk with diets deficient
in fresh fruits, carotene, or fiber intake;
vegetables do not provide protection
against NPC
Three histopathologic types are described in the World
Health Organization (WHO) classification:


Type I: Squamous cell carcinoma (SCC) with varying
degrees of
differentiation
Type II: Non keratinizing carcinoma
Type III: Undifferentiated carcinoma

Three histopathologic types are described
in the World Health Organization (WHO)
classification:


Type I: Squamous cell carcinoma (SCC)
with varying degrees of
differentiation
Type II: Non keratinizing carcinoma
Type III: Undifferentiated carcinoma
Three histopathologic types are described
in the World Health Organization (WHO)
classification:


Type I: Squamous cell carcinoma (SCC)
with varying degrees of
differentiation
Type II: Non keratinizing carcinoma
Type III: Undifferentiated carcinoma
Second decade of life
Peaks in the forth and fifth decades of life
Male:female ratio = 3:1
Cervical lymphadenopathy 50% - 90% of patients
Blood-stained nasal discharge
Unilateral nasal obstruction
Unilateral hearing loss, although tinnitus and otalgia may
occasionally be present
Neurologic symptoms, cranial nerve paralysis &
headaches
Detailed history and clinical examination
Visualization Nasopharyngoscopy
Biopsy
FNAC (Fine Needle Aspiration Cytology)
MRI
w
/ gadolinium and fat suppression = imaging
modality of choice
CT better definition bone involvement & cervical
lymphadenopathy

Surgery
Chemotherapy
Radiotherapy
confined to the treatment of residual or recurrent disease
for postradiation residual or recurrent nodal disease
important considerations are tumor extent, access for
exposure, and control of the internal carotid artery
advanced disease (stage III and IV)
Single and combination chemotherapy adjunct

inaccessible location
tumor has extended beyond the confines of the
nasopharynx
tumors are particularly radiosensitive
Locoregional recurrences without distant metastases