Definition

Nasopharyngeal carcinoma is a malignant tumor in the upper part of the throat or behind the nose. This condition is relatively common in Southeast Asia, including Indonesia. In these regions, the incidence is approximately 25-30 men and 15-20 women per 100,000 population. Conversely, in other parts of the world, the incidence rate is about 1 per 100,000 population.

Causes

This type of cancer originates from epithelial cells, which are the outermost protective cells of the body's organs and channels. The onset of cancer is triggered by genetic mutations within a cell, resulting from interactions among genetic structure, environmental factors, and Epstein-Barr Virus (EBV) infection. The genetic mutations could cause normal cells to proliferate and divide at an accelerated rate, invading adjacent healthy tissues and potentially spreading to distant organs via the bloodstream.

Risk factor

Several factors can increase the risk of developing nasopharyngeal carcinoma:

• Gender. This type of cancer is more prevalent in men than in women.
• Ethnicity. Nasopharyngeal carcinoma is most common among people from China, Southeast Asia, and North Africa. Additionally, people of Asian descent, regardless of where they live, and the Inuit population in Alaska, who belong to the Mongoloid race, are at higher risk.
• Age. While nasopharyngeal carcinoma can occur at any age, it is most frequently diagnosed in individuals aged 30-50 years.
• Diet of food preserved with salt. Consumption of foods preserved with salt is a significant risk factor. Chemicals released during the cooking of salt-preserved foods, such as fish and vegetables, can enter the nasal cavity and elevate the risk of developing this cancer. Early exposure to these chemicals, starting in childhood, further amplifies the risk.
• Epstein-Barr Virus (EBV). This ubiquitous virus usually causes mild symptoms akin to the common cold. In some cases, it can lead to infectious mononucleosis, characterized by extreme fatigue, fever, sore throat, headache, muscle aches, swollen lymph nodes in the neck and armpits, and an enlarged liver and/or spleen, accompanied by a rash. EBV can also be implicated in the development of several cancers, including nasopharyngeal carcinoma.
• Family History. A family history of nasopharyngeal carcinoma increases the likelihood of developing the disease.
• Alcohol and Tobacco Use. High consumption of alcohol and tobacco significantly raises the risk of nasopharyngeal carcinoma.

Symptoms

The symptoms of nasopharyngeal carcinoma can vary depending on the affected area:

• Nasal symptoms. These may include nasal congestion, nosebleeds or bloody discharge, post-nasal drip (fluid running down the back of the nose), hyponasal speech, and cacosmia (a persistent sensation of smelling a foul odor).
• Otological symptoms. These symptoms arise from blockage in the tube connecting the ear to the nasal cavity and can include decreased hearing, a sensation of fullness in the ear, and tinnitus (ringing in the ear).
• Neurological symptoms. If the cancer spreads to the head, neurological symptoms may occur, depending on the affected nerve. The most common neurological symptom is difficulty moving the eyeball.
• Lymph node symptoms. Enlargement of lymph nodes, particularly in the neck area, is common. If the enlargement extends to the area near the shoulders, it indicates the progression of disease severity.
• Symptoms related to metastasis. The cancer most commonly metastasizes to the lungs and liver.

Diagnosis

Diagnosing nasopharyngeal carcinoma can be challenging and could be missed due to its symptoms resembling other conditions, such as ear infections. Typically, diagnosis occurs when patients present with symptoms related to cervical lymph nodes. Initial steps involve a physical examination to assess the ears, nose, and throat. If a general practitioner suspects nasopharyngeal carcinoma, they will refer the patient to an otolaryngologist for more detailed evaluation and treatment.

To confirm the diagnosis, doctors may conduct basic laboratory tests, including a complete blood count, liver and kidney function tests, and measurement of IgA antibody levels, which are part of the body's immune response. Imaging tests are also essential and are usually available in larger healthcare facilities. These tests may include a computed tomography (CT) scan to check if the cancer has spread to the bones and magnetic resonance imaging (MRI) to detect cancer spread to nearby muscles and lymph nodes. A positron emission tomography (PET) scan can also be used to assess cancer recovery and recurrence, although this procedure is less commonly available in Indonesia.

An endoscopy may also be performed, involving the insertion of a tube with a small camera into the nasal cavity to visualize the tumor and obtain a tissue sample. This sample undergoes histopathological analysis and will be viewed under a microscope, which allows doctors to determine the type, origin, and severity of the cancer cells, thereby guiding appropriate treatment strategies.

Management

The main treatment for nasopharyngeal carcinoma is radiotherapy. Radiotherapy uses high doses of radiation to destroy cancer cells. If the cancer is too advanced, doctors may recommend chemotherapy, which uses specialized drugs to target and destroy cancer cells. Both therapies aim to eliminate cancer cells.

Surgical procedures can be one of the cancer treatment options in the early stages of cancer or for specific considerations. The purpose of the treatment is to remove the affected tissue or lymph nodes filled with cancer cells. Surgery can be combined with radiotherapy.

One of the adverse effects of radiotherapy that could occur is inflammation of mouth mucosa. This can cause pain, chewing and swallowing difficulty. Patients are usually recommended to consume soft foods like milkshakes, mashed potatoes, and chopped meat. Avoid sour, spicy, salty, and rough-textured foods as they can worsen inflammation. As an alternative or in severe cases, a feeding tube may be inserted directly into the stomach to ensure the patient meets their nutritional and caloric needs.

Patients undergoing therapy for nasopharyngeal carcinoma are at high risk of injury if they engage in strenuous activities. It is recommended to limit physical activities, especially those involving physical contact.

Complications

Complications of nasopharyngeal carcinoma can include:

• Cancer invasion to the surrounding cells. In advanced stages, this cancer can invade adjacent healthy tissues, including the lower throat, bones, and brain.
• Cancer metastasis. Nasopharyngeal carcinoma frequently spreads to other parts of the body. It often metastasizes from the nasopharynx to nearby areas, such as the lymph nodes. Common sites of distant metastasis include the bones, lungs, and liver.
• Effusion otitis media. This condition involves inflammation of the middle ear due to fluid buildup. It can occur if cancer tissues obstruct the eustachian tube, which connects the middle ear to the nasal cavity and throat.

Prevention

Preventing nasopharyngeal carcinoma is challenging, but certain measures can reduce your risk. To lower your risk, consider avoiding factors contributing to this cancer's development. For instance, minimize or eliminate consuming foods preserved with salt, alcohol, and tobacco. Additionally, if facilities are available, you may request screening for Epstein-Barr virus.

When to see a doctor?

Early symptoms of nasopharyngeal carcinoma often do not raise significant concern. However, suppose you observe changes in your body, such as nasal congestion, nosebleeds, or persistent ear infections, that do not heal with normal treatment. In that case, it is advisable to consult a doctor. A general practitioner can conduct an initial examination and, if nasopharyngeal carcinoma is suspected, refer you to an otolaryngologist for further evaluation and appropriate therapy.

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