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Presentator: Ernest Yoice Yuana

Moderator: dr. Anggoro Eka Raditya


PENDAHULUAN
PENDAHULUAN
Karsinoma nasofarings Keganasan yang cukup
dominan di bidang THT

Karsinoma nasofarings keganasan yang cukup dominan


di Asia Tenggara termasuk Indonesia
PENDAHULUAN
Karsinoma nasofaring undiferensiasi (WHO tipe III)
berada pada deretan jenis keganasan yang cukup sering
ditemukan

Jawa Tengah Yogyakarta


KNF: Peringkat I keganasan pada laki-laki
Peringkat III keganasan pada perempuan

Fachiroh, J, et al. Jounal of Clinical Microbiology. Vol. 46. No. 4. 2008


PENDAHULUAN
Penelitian retrospektif di RSUP Dr. Sardjito
Peningkatan Frek. KNF dari tahun 1992-1994
1992 : 48 kasus
1993 : 59 kasus
1994 : 63 kasus

Selama periode Januari 2002 April 2005


Bag. THT RSUP Dr. Sardjito ditemukan 303 kasus
KNF

Gautama dan Rosmawati, 2010


PENDAHULUAN
Berdasarkan jenis kelamin Pria : wanita = 2:1
Puncak usia sekitar 50-60 tahun, namun 20% dapat
ditemukan pada usia >60 tahun

Faktor etiologi :
Kompleks EBV (Epstein Barr Virus)
Karsinogenik
Genetik
Lain-lain

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


PENDAHULUAN
Gambaran epidemiologi, manifestasi klinis, penanganan,
dan prognosis keganasan ini berbeda dengan keganasan
lain

Penatalaksanaan KNF stadium lanjut dan bagaimana


mengontrol pertumbuhan lokal keganasan serta mencegah
metastase jauh

Farias, TP, et al. Pragnostic Factors and Outcome for Nasopharyngeal Carcinoma. 2003
TINJAUAN PUSTAKA
TINJAUAN PUSTAKA

ANATOMI FARINGS
Saluran berbentuk tabung : 12 - 14 cm
Dasar tengkorak Vertebra servikal ke-6

Terdiri atas:
1. Nasofarings
2. Orofarings
3. Hipofarings

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


ANATOMI FARINGS

Frederich H. Martini. Edwin F. 1997


ANATOMI FARING

Disusun oleh otot-otot


Otot-otot utama:
M. konstriktor faringeal superior
M. konstriktor faringeal media
M. konstriktor faringeal inferior

Otot-otot Tambahan:
M. palatofaringeus
M. salfingofaringeus
M. stilofaringeus

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


NASOFARINGS
Berbentuk Kubus dengan 4 buah dinding
Posterosuperior : Dasar tengkorak dan dasar sinus
sphenoidalis
Inferoposterior : Korpus vert. servikal 2 setinggi uvula
Anterior : Koana yang terbagi oleh septum nasi
Lateral : Lobang pars kartilageus tuba
eustakheus

Ballenger, JJ., 1997


NASOFARINGS

Fossa Rosenmuller merupakan alur sempit yang terletak


di sebelah posterior dari torus tubarius di perbatasan
antara dinding posterior dan dinding lateral nasofarings

Karsinoma nasofarings sering berada pada lokasi ini

Ho-sheng Lin. Malignant Nasopharyngeal Tumor. 2009


NASOFARINGS

Dinding lateral nasofarings selain terdapat muara tuba


eustakheus, juga dibentuk oleh lamina faringobasilaris
dari fasia faringeal dan otot konstriktor faringeus superior

Fasia ini mengandung jaringan fibrokartilago yang


menutupi foramen ovale, foramen jugularis, kanalis
karotis, dan kanalis hipoglossus

Ballenger, JJ, 1997


VASKULARISASI FARINGS

Cabang utama arteri karotis eksterna:


Arteri faringeal ascenden
Cabang dorsal dari arteri lingualis
Cabang tonsilar dari arteri fasialis
Cabang palatina dari arteri maksilaris

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


INERVASI

Persyarafan otot dinding faring:


Nervus vagus (X) melalui pleksus faringeal

Kecuali muskulus stilofaringeus


nervus glosofaringeus (IX)

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


SISTEM LIMFATIK

Nasofaring Kel. limfe retrofaring


Kel. Lateral faring
Kel. limfe jugularis profunda

Orofaring Kel. limfe retrofaring


Kel. limfe jungularis
Kel. limfe servikal superior superfisial

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


SISTEM LIMFATIK

Hipofaring Kelenjar limfe retrofaring


Kel. Lateral faring
Kel. Limfe servikal profunda
Kel. Limfe jugularis

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


HISTOLOGI

Secara histologi dinding nasofarings terdiri atas 3 lapis:


Lapisan epitel
Membran basalis
Lamina propria
Mukosa epitelium kompleks
Daerah sekitar koana dan sekitar atap nasofarings
disusun oleh sel epitel kolumnar bertingkat semu bersilia
Sepanjang daerah posterior dan inferior oleh sel epitel
skumosa berlapis

Ho-sheng Lin. Malignant Nasopharyngeal Tumor. 2009


KARSINOMA NASOFARINGS
DEFINISI

Karsinoma nasofarings merupakan keganasan yang


berasal dari lapisan epitelial nasofarings

Jeyakumar, A, et al. Review of Nasopharyngeal Carcinoma. 2006


ETIOLOGI

EBV (Epstein Barr Virus)


Beberapa penelitian menunjukkan adanya peningkatan
antibodi terhadap EBV pada penderita KNF

Level DNA EBV memiliki korelasi dengan respon terapi


dan berperan sebagai indikator rekurensi serta perkiraan
terhadap prognosis

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


ETIOLOGI

Etiologi karsinoma nasofarings bersifat kompleks dan


melibatkan berbagai proses antara lain:
1. Latar belakang genetik
2. Virus Epstein Barr
3. Faktor komponen karsinogenik

Ho-sheng Lin. Malignant Nasopharyngeal Tumor. 2009


HISTOPATOLOGI

Sel-sel ganas epitel karsinoma nasofarings terdiri dari sel-


sel polygonal besar dengan karakteristik sinsitial yang
artinya terdiri dari sel dengan sitoplasma yang berinti
banyak

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


HISTOPATOLOGI

Klasifikasi histologi yang ditetapkan oleh WHO:


Tipe I
1. Karsinoma sel skuamosa dengan keratinisasi
2. Daerah endemik KNF jumlahnya hanya sekitar 1%
3. Prognosis buruk dengan 5-years survival rate hanya
35%

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


HISTOPATOLOGI

Tipe II
1. Karsinoma epidermoid nonkeratinisasi
2. Menunjukan proses maturasi seperti karsinoma sel
skuamosa namun tidak memiliki keratin.
3. Insidensi paling kecil di antara ketiga tipe karsinoma
nasofarings
4. 5-years survival rate 65%

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


HISTOPATOLOGI
Tipe III
1. Karsinoma tak terdiferensiasi dengan batas sel yang
tidak jelas dan memiliki inti sel yang kromatik
2. Insidensi terjadinya tipe ini pada daerah endemik
dapat mencapai 95%
3. 5-years survival rate 65%

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


HISTOPATOLOGI

Tipe I Usia lanjut


Tipe II dan III Anak dan dewasa muda

Tipe II & III Metastase jauh, namun terkontrol karena


lebih bersifat radiosensitif
Prognosis lebih baik dibandingkan
dengan tipe I

Brennan, B. Nasopharyngeal Carcinoma. 2006


DIAGNOSIS

Diagnosis karsinoma nasofarings diperlukan:


1. Anamnesis
2. Pemeriksaan fisik
3. Penunjang diagnostik

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


ANAMNESIS
ANAMNESIS

Gejala Nasal:
Obstruksi nasal uni/bilateral
Sekret nasalis
Epistaksis
Hiposmia
ANAMNESIS

Gejala pada telinga:


Tinnitus
Pendengaran berkurang
Telinga terasa penuh
Keluar cairan dari telinga

Ketika tumor primer meluas ke arah superior untuk


menginfiltrasi dasar tengkorak, pasien akan merasakan
sakit kepala

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


ANAMNESIS

Keluhan lain :
Pembesaran kelenjar getah bening servikalis akibat
metastasis regional
Tidak nyeri dan seringkali bilateral

Keganasan ini dapat menyebar jauh antara lain ke


tulang, hepar, dan paru-paru

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


ANAMNESIS

Keluhan pasien:
1. Gejala utama massa leher dikeluhkan oleh 76% pasien
2. Keluhan pada telinga sekitar 73%
3. Keluhan akibat gangguan saraf kranial adalah 20%

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


PEMERIKSAAN FISIK

Temuan pemeriksaan fisik tergantung pada stadium


karsinoma nasofarings:
Massa pada leher terutama bagian atas dan seringkali
bilateral dan tidak nyeri
Akumulasi cairan di telinga tengah
Tanda-tanda keterlibatan saraf kranial misalnya
diplopia
Massa di nasofaring

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


PEMERIKSAAN PENUNJANG

Pemeriksaan aspirasi jarum halus terhadap massa leher


Pemeriksaan serologis
CT-Scan
Endoskopi nasofarings
Biopsi

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


STADIUM KLINIS
Klasifikasi stadium karsinoma nasofarings menurut UICC/AJCC 1997

Tumor pada nasofarings (T)


T1 Tumor terletak pada nasofarings
Tumor meluas ke jaringan lunak orofarings dan atau
T2
kavum nasi
T2a Tanpa perluasan ke ruang parafarings
T2b Dengan perluasan ke parafarings
Tumor menyerang struktur tulang dan atau sinus
T3
paranasalis
Tumor meluas ke intrakranial dan atau melibatkan
T4 saraf otak, hipofarings, fossa infratemporal atau
orbita
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
STADIUM KLINIS

Kelenjar Limfe Regional (N)


N0 Tidak ada metastasis limfonodi regional

Metastasis unilateral dengan nodus 6 cm, di atas


N1
fossa supraklavikula

Metastasis bilateral dengan nodus 6 cm, di atas


N2
fossa supraklavikula

Metastasis nodus ukuran > 6 cm, tidak ada


N3a
perluasan ke fossa supraklavikula

Metastasis nodus ukuran > 6 cm, dengan perluasan


N3b
ke fossa supraklavikula
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
STADIUM KLINIS
Metastasis Jauh (M)
M0 Tidak terdapat metastasis jauh
M1 Terdapat metastasis jauh

Pembagian stadium karsinoma nasofarings menurut UICC/AJCC 1997


Stadium Keterangan
I T1N0M0
IIA T2aN0M0
IIB T1-2N1M0 atau T2aN1M0 atau T2bN0-1M0
III T1-2bN2M0 atau T3N0-2M0
IVA T4N0-2M0
IVB T apapun, N3M0
IVC T apapun, N apapun, M1
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
PENATALAKSANAAN

RADIOTERAPI
Karsinoma nasofarings bersifat radiosensitif sehingga
dalam beberapa dekade terakhir telah menjadi terapi
utama bagi keganasan ini

Berbatasan dengan beberapa organ penting


Komplikasi dapat terjadi

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


RADIOTERAPI

Karena seringnya keterlibatan kelenjar limfonodi


regional
radiasi leher juga diperlukan

Dosis radiasi perlu hati-hati

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


RADIOTERAPI

2 cara pemberian radioterapi:


Radiasi internal atau brakiterapi
Tindakan dengan memasukkan suatu alat berupa
implan intertisial atau insersi intrakavitas secara
temporal pada ruang nasofarings
Radiasi eksternal

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


KEMOTERAPI

Bekerja dengan mereduksi sel-sel kanker


Karsinoma nasofarings memberikan respon yang baik
Diberikan pada karsinoma yang mengalami metastasis
Kemoterapi sebagai terapi tambahan ternyata dapat
meningkatkan hasil terapi
Kelemahan sel-sel sehat pun akan tereduksi

Rosmawati, ID. 2010


KEMORADIASI

Pemberian kemoterapi sebelum penyinaran seara induksi


dikenal sebagai neoadjuvant chemotherapy

Sedangkan pemberian kemoterapi sebagai tambahan


setelah penyinaran disebut adjuvant chemotherapy
konkomitan (concurrent)

Rosmawati, ID. 2010


OPERATIF
Pembedahan pada karsinoma nasofarings mengangkat
kelenjar limfonodi regional yang terlibat

Tindakan diseksi leher radikal bila terdapat sisa


pembesaran kelenjar pascaradiasi atau adanya
kekambuhan kelenjar syarat tumor primer telah
dinyatakan sembuh

Tindakan untuk mengangkat tumor primer tidak


dianjurkan lokasi tumor pada daerah dasar tengkorak
& berhubungan dengan banyak organ penting

Cummings, CW et.al., 2005


PROGNOSIS
Dipengaruhi oleh:

Ukuran tumor
Infiltrasi ke organ sekitar
Tipe tumor secara histopatologik
Keterlibatan limfonodi leher
Usia
Jenis kelamin
Teknik terapi yang diberikan

Sheng Lin. Malignant Nasopharyngeal Tumor. 2009


PROGNOSIS

Dengan radioterapi saja:


5 years survival rate untuk KNF stadium I 85-90% dan
stadium II 70-80%
Stadium lebih lanjut (III-IV) rata-rata 5 years survival rate-
nya 37%, namun dapat menjadi 67% bila diberikan
kemoterapi + radioterapi

Sheng Lin. Malignant Nasopharyngeal Tumor. 2009


PROGNOSIS
PROGNOSIS

WHO tipe III prognosis yang baik dengan 5 years


survival rate-nya 60-80% karena bersifat radiosensitif
WHO tipe I prognosis paling buruk dengan 5 years
survival rate-nya 20-40% karena sangat kurang sensitif
terhadap radiasi

Sheng Lin. Malignant Nasopharyngeal Tumor. 2009


LAPORAN KASUS
IDENTITAS
Identitas :
Nama : Tn. S
Usia : 72 tahun
Jenis kelamin : Laki-laki
Alamat : Candimulyo Magelang
No RM : 1.62.51.43
ANAMNESA
Keluhan Utama :
Timbul Benjolan di Leher Kanan dan Kiri
Riwayat penyakit Sekarang :
Pasien mengeluh timbul benjolan dileher kanan
sejak 10 tahun dan leher kiri sejak 1 tahun
terakhir, hidung kanan tersumbat sejak sekitar 1
tahun sebelum berobat ke poliklinik THT RSUP
Dr. Sardjito, pasien mengeluhkan adanya lendir
kuning kental di hidung kanan. Saat berobat
pasien mengeluhkan ada riwayat mimisan hilang
timbul sejak sekitar 4-5 bulan sebelum berobat ke
poliklinik THT RSUP Dr. Sardjito.
Keluhan mimisan timbul terutama setelah makan
dan dapat berhenti sendiri. Saat timbul mimisan,
pasien tidak sedang demam ataupun riwayat
mengorek-ngorek hidung. Pasien juga merasakan
telinga kanan berdenging sejak 7 bulan yang lalu
dan adanya penurunan pendengaran.
Tidak ada keluhan nyeri dan tidak keluar cairan
dari kedua telinga. Sakit kepala, batuk, sesak
nafas, gangguan di tenggorokan disangkal.
Makan dan minum tidak ada gangguan dan tidak
ada keluhan penurunan berat badan. Pasien
merupakan perokok. Pasien sudah periksa ke RS
di Magelang dan sudah dilakukan pemeriksaan
rontgen thorax, AJH serta CT-Scan
Riwayat Penyakit Dahulu :
Riwayat menderita sakit yang sama sebelumnya
disangkal
Riwayat kencing manis disangkal
Riwayat hipertensi disangkal
Riwayat alergi disangkal
Riwayat Penyakit Keluarga :
Riwayat menderita tumor atau kanker disangkal
Riwayat hipertensi disangkal
Riwayat kencing manis disangkal
Riwayat alergi disangkal
RESUME ANAMNESIS
Benjolan di Leher

Hidung tersumbat

Mimisan

Tinnitus
PEMERIKSAAN FISIK
Keadaan Umum:
Tampak sedang, compos mentis, gizi cukup

TandaVital
Tekanan darah : 120/70 mmHg
Nadi : 88 x/menit
RR : 20 x/mnt
Suhu : 37 C
PEMERIKSAAN FISIK
Telinga : tak didapatkan kelainan
Hidung :
Rhinoskopi anterior : Tampak discharge
mukopurulen di cavum nasi dextra.
Rhinoskopi posterior : Tampak massa di nasofaring
dekstra.
PEMERIKSAAN FISIK
Orofarings : Discharge (-)
Laringoskop indirek :Tak didapatkan kelainan
Leher : Teraba massa dan
pembesaran limfonodi cervicalis dextra et sinistra di
regio 2 bilateral dengan ukuran massa kanan :
3cm x 2cm x1cm, massa kiri 3cm x 4cm x 1,5cm
Axilla :Tak teraba massa
PEMERIKSAAN PENUNJANG
PEMERIKSAAN PENUNJANG
PEMERIKSAAN PENUNJANG
PEMERIKSAAN PENUNJANG
PEMERIKSAAN PENUNJANG
PEMERIKSAAN PENUNJANG
PEMERIKSAAN PENUNJANG
PEMERIKSAAN PENUNJANG
DIAGNOSIS

Karsinoma Nasofarings Stadium III


(T3N2M0)
PENATALAKSANAAN
Kemoradioterapi
MASALAH

Etiologi
RENCANA
Edukasi kepada pasien agar mematuhi semua proses
pengobatan karena hal tersebut sangat menentukan
prognosis.
Pasien dianjurkan kontrol kembali
DISKUSI
DISKUSI
Karsinoma nasofarings Keganasan dengan insiden
tertinggi terjadi di Asia Selatan dan Asia Tenggara
termasuk Indonesia.

Puncak kejadian umumnya usia 50-60 tahun, namun


beberapa penelitian menunjukan kejadian pada usia
lebih dari 60 th seperti pada pasien ini.
DISKUSI

Penyebab karsinoma nasofarings beberapa faktor.

Virus Epstein Barr antibodi terhadap virus tersebut


ditemukan pada hampir 95% sampel jaringan massa
karsinoma nasofarings.

Penyebab lain zat yang bersifat karsinogenik, dan


genetik.
DISKUSI
Pasien pada kasus ini belum dapat ditentukan dengan
pasti.

Dalam keluarga pasien tidak ada yang menderita penyakit


keganasan dan pasien perokok aktif
DISKUSI
Pelacakan faktor risiko terhadap kejadian
kanker nasofaring Kemungkinan etiologi
pada pasien ini.

Virus Epstein Barr Pemeriksaan serologis


terhadap sampel jaringan karsinoma pada pasien
ini.
DISKUSI

Diagnosis pada pasien ini :


Anamnesis.
Pemeriksaan fisik.
Pemeriksaan penunjang.
DISKUSI

Anamnesis :
Benjolan di Leher kanan dan kiri
Hidung tersumbat.
Mimisan.
Telinga berdenging.
DISKUSI

Pemeriksaan Fisik :
Discharge mukopurulen di cavum nasi
dekstra..
Kesan massa di nasofaring dekstra.
Dijumpai adanya pembesaran kelenjar
limfonodi di leher.
Tidak dijumpai adanya pembesaran kelenjar
limfonodi di axilla.
DISKUSI

Pemeriksaan Penunjang :
Nasoendoskopi :
Discharge di cavum nasi dextra dan tampak
massa di nasofaring dextra.
DISKUSI

Pemeriksaan Penunjang :
Biopsi :
Undifferentiated carcinoma pada nasofaring
dekstra yang dalam jenis karsinoma
nasofarings termasuk WHO tipe III. Secara
histopatologis, jenis yang paling sering
ditemukan.
DISKUSI
Pemeriksaan Penunjang :
CT Scan :
Tampak lesi isodens di nasofaring terutama dextra, batas
tegas, bentuk amorf, ukuran 4,5 cm x 5,5 cm yang
meluas sampai nares posterior dan sinus sphenoid
dextra.
Torus tubarius dan Fossa Rossenmullers asimetris,
cavum nasi sinistra, sinus maxillaries, ethmoid, sphenoid
sinistra, frontalis normodens.Concha nasalis tidak
membesar.Tampak pembesaran limfonodi cervicalis
dextra.Tak tampak destruksi tulang
DISKUSI

Pemeriksaan Penunjang :
Radiologi thoraks dan bone survey :
Tak tampak adanya metastase

USG Abdomen :
Tidak tampak adanya kelainan dan tanda-tanda
metastase ke organ intra abdominal
STADIUM KLINIS
Klasifikasi stadium karsinoma nasofarings menurut UICC/AJCC 1997

Tumor pada nasofarings (T)


T1 Tumor terletak pada nasofarings
Tumor meluas ke jaringan lunak orofarings dan atau
T2
kavum nasi
T2a Tanpa perluasan ke ruang parafarings
T2b Dengan perluasan ke parafarings
Tumor menyerang struktur tulang dan atau sinus
T3
paranasalis
Tumor meluas ke intrakranial dan atau melibatkan
T4 saraf otak, hipofarings, fossa infratemporal atau
orbita
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
STADIUM KLINIS

Kelenjar Limfe Regional (N)


N0 Tidak ada metastasis limfonodi regional

Metastasis unilateral dengan nodus < 6 cm, di atas


N1
fossa supraklavikula

Metastasis bilateral dengan nodus < 6 cm, di atas


N2
fossa supraklavikula

Metastasis nodus ukuran > 6 cm, tidak ada


N3a
perluasan ke fossa supraklavikula

Metastasis nodus ukuran > 6 cm, dengan perluasan


N3b
ke fossa supraklavikula
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
STADIUM KLINIS
Metastasis Jauh (M)
M0 Tidak terdapat metastasis jauh
M1 Terdapat metastasis jauh

Pembagian stadium karsinoma nasofarings menurut UICC/AJCC 1997


Stadium Keterangan
I T1N0M0
IIA T2aN0M0
IIB T1-2N1M0 atau T2aN1M0 atau T2bN0-1M0
III T1-2bN2M0 atau T3N0-2M0
IVA T4N0-2M0
IVB T apapun, N3M0
IVC T apapun, N apapun, M1
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
DISKUSI

Pasien kemudian didiagnosis dengan Karsinoma


Nasofaring T3N2M0 Stadium III
DISKUSI
Berdasarkan penelitian, pasien dengan karsinoma
nasofaring stadium III mempunyai prognosis yang cukup
baik 5 years survival rate sebesar 65% bila menjalani
program pengobatan sampai selesai.

Edukasi dan motivasi kepada perlu untuk dilakukan.


KESIMPULAN
Dilaporkan pasien laki-laki, berusia 72 tahun dengan
diagnosis karsinoma nasofarings stadium III (T3N2M0).
Pasien ini kemudian direncanakan untuk mendapat
kemoradioterapi. Edukasi dan motivasi untuk
menyelesaikan program pengobatan perlu diberikan guna
tercapainya hasil yang terbaik dari terapi.
TERIMA KASIH
Protokol penanganan KNF yang diajukan oleh Brennan (2003)
sebagai berikut :

Stadium I : Radioterapi dosis tinggi pada tumor primer


dinasofaring dan radiasi profilaktik di daerah leher.
Stadium Il :
1. Kemo-radioterapi, atau
2. Radioterapi dosis tinggi pada tumor primer di nasofaring
dan radiasi profilaktik di leher.
Stadium III:
1. Kemo-radioterapi, atau
2. Radioterapi dosis tinggi / teknik hiperfraksinasi ditujukan
pada tumor primer di nasofaring dan kelenjar leher bilateral
(bila ada)
3. Diseksi leher mungkin dapat dikerjakan misalnya pada
tumor leher persisten atau rekuren asalkan tumor primer di
nasofaring sudah terkontrol.
Stadium IV :
1. Kemo-radioterapi, atau
2. Radioterapi dosis tinggi / teknik hiperfraksinasi ditujukan
pada tumor primer di nasofaring dan kelenjar 30 leher
bilateral (klinis positip)
3. Diseksi leher dapat dikerjakan bila tumor leher persisten
atau rekuren asalkan tumor primer di nasofaring sudah
terkontrol. 4. Kemoterapi untuk KNF stadium IV C
Lymph node distribution of the head and neck area. I = submental and submandibular
nodes; II = upper jugulodigastric group; III = middle jugular nodes draining the
nasopharynx and oropharynx, oral cavity, hypopharynx, and larynx; IV = inferior jugular
nodes draining the hypopharynx, subglottic larynx, thyroid, and esophagus; V = posterior
triangle group; VI = anterior compartment group.
Marur, S et al. Head and Neck Cancer. 2008
Penegakkan Diagnosis

Anamnesis, Pemeriksaan fisik, Pemeriksaan Penunjang

Pemeriksaan fisik :
Massa Colli Massa nasofarings
Keluhan Nasal
Keluhan Telinga AJH Massa Colli
Keluhan akibat infiltrasi Ct-Scan
Biopsi
Bone survey & Ro. Thoraks
Karsinoma Nasofarinf Stadium III (T3N2M0)
GENETIK
1. Delesi kromosum area 14q, 16p, 1p
2. Amplifikasi kromosum 12q and 4q
3. Adanya hubungan antara KNF dengan genotip HLA-
A2 dan HLA-Bsin2 yang banyak ditemukan pada
penduduk China Selatan

Ho-sheng Lin. Malignant Nasopharyngeal Tumor. 2009


EPSTEIN BARR VIRUS
1. It can cause infectious mononucleosis and has also been
found to be associated NPC
2. EBV belongs to the herpes virus family and the EBV-
specific antigens can be grouped into early replicative
antigens, latent phase antigens, and late antigens
3. In patients with NPC, their antibody, immunoglobulin
A (IgA), response to the early antigen (EA) of the first
group, and the viral capsid antigen (VCA) of the third
group has been shown to be of diagnostic value
EPSTEIN BARR VIRUS
The EBV genome is clonal within the tumor suggesting that the tumor
is a clonal proliferation of an EBV infected cell
Within the tumor, the viral infection is latent with expression of the
EBV proteins EBNA1, LMP1, LMP2 and the EBER and BamHI A
RNAs
LMP1 and LMP2 have profound effects on cell growth regulation
LMP2 activates the Akt kinase which inactivates the GSK3 kinase
and induces -catenin regulated expression in epithelial cells
In NPC tumors activated GSK3 and nuclear -catenin are detected
The malignant cells continue to express multiple viral proteins

Nancy Raab-Traub. 2010


EPSTEIN BARR VIRUS

1. Patients with nasopharyngeal carcinoma often have elevated


titers of IgA antibody to EBV structural proteins
2. Measurement of EBV-specific IgA antibodies is useful in
screening patients for early detection of nasopharyngeal
carcinoma in southern China
3. An increase in EBV-specific antibody titers after therapy for
nasopharyngeal carcinoma is associated with a poor prognosis,
whereas a declining or constant level of antibody is associated
with a better prognosis

Cohen. Epstein Barr Virus Infection. 2009


EPSTEIN BARR VIRUS

1. In the oropharynx, EBV directly infects resting B cells or infects


epithelial cells, which in turn infect B cells
2. During primary infection, EBV-infected B cells undergo lytic
infection with production of virus or express the full complement
of latent viral proteins
3. After convalescence, EBV is present in the peripheral blood in
latently infected memory B cells that express latent membrane
protein (LMP) 2 and possibly EBV nuclear antigen (EBNA) 1
4. The latter cells can undergo EBV reactivation and express other
latent viral proteins, resulting in their recognition and
destruction by cytotoxic T cells

Cohen. Epstein Barr Virus Infection. 2009


CARSINOGENIC
NITROSAMINE

1. Most nitrosamines are mutagens and a number are


transplacental carcinogens
2. For instance, dimethylnitrosamine causes liver cancer in
experimental animals, whereas some of the tobacco specific
nitrosamines cause lung cancer
3. Since nitrosamines are metabolized the same in human and
animal tissues, it seems highly likely that humans are
susceptible to the carcinogenic properties of nitrosamines

Scalan,RA. Nitrosamines and cancer. 2000


NITROSAMINE
Nitrosamines in Food, Body Fluids, and Occupational
Exposure :
Fried bacon
Cured meats
Beer
Tobacco products
Rubber products
Metal industries
Pesticide production and use
Certain cosmetics
Certain chemical manufacturing

Scalan,RA. Nitrosamines and cancer. 2000


ROKOK
ROKOK
N-Nitrosamines are a large class of carcinogens
N-Nitrosamines are potent systemic carcinogens that affect
different tissues depending on their structures
Two of the most important N-nitrosamines in cigarette smoke
are the tobacco-specific N-nitrosamines 4 (methylnitrosamino)-
1-(3-pyridyl)-1-butanone (NNK) and N'-nitrosonornicotine
(NNN)
NNK causes lung tumors
NNK can also induce tumors of the pancreas, nasal cavity, and
liver
NNN produces esophageal, nasal tumors, and respiratory tract
tumors

Delvita, et al., 2008


T1N0M0
T2aN0M0
T1-2N1M0 atau T2aN1M0 atau T2bN0-1M0
T1-2bN2M0 atau T3N0-2M0
T4N0-2M0
T apapun, N3M0
T apapun, N apapun, M1
PERLUASAN TUMOR

Infiltrasi sinus kavernosus dan dinding lateralnya


terganggunya saraf kranial III, IV, dan VI diplopia

Perluasan tumor foramen ovale akan mengganggu


saraf kranial V mengakibatkan nyeri pada wajah

Perluasan foramen jungularis dan kanalis hipoglosus


Paralisis saraf cranial IX, X, XI, dan XII

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


KEMOTERAPI

Penderita KNF WHO tipe II (24,2%) dan III (75,8%)

Penderita mendapat 5-fluorouracil (5-FU) 1000


mg/m2/hari diberikan pada hari pertama sampai ke-4
dengan cis-diaminedimino-di-chloro-platium (CDDP atau
cisplatin) 100 mg/m2 pada hari pertama diberikan 3x
siklus setelah 3 minggu selesai radioterapi

91,2% respon lengkap; 4,4% respon sebagian; 4,4%


progresif dan angka respon keseluruhan adalah 95,6%
Rosmawati, ID. 2010
5- FLUOROURACIL
5-Fluorouracil is an S phase specific uracil analogue that
can be activated with two major pathways:
(a) Sequential phosphorylation and incorporation into
RNA
(b) Activation to 5-fluorodeoxyuridine monophosphate,
which blocks both the enzyme thymidylate synthase
and the conversion of uridine into thymidine
compounds
Cells are depleted of thymidine and cannot synthesize
DNA
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
5- FLUOROURACIL
The most important side effects are myelosuppression,
mucositis, diarrhea, dermatitis, and cardiac toxicity
Used as a single-agent intravenous bolus to treat patients
with head and neck cancer
5-Fluorouracil can be substantially more active
administered in a 5-day continuous infusion and clearly
adds to the response rate of cisplatin

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


CISPLATIN
Platinum-containing antineoplastic agent
Its antitumor activity results from intracellular binding of
the activated, positively charged form with a nucleophilic
site on DNA to form bifunctional covalent links that
interfere with normal DNA function

Cisplatin usually is administered over 2 to 6 hours in doses


of 60 to 120 mg/m2, with similar efficacy reported for this
entire dosage range. For single-agent doses ranging from
60 to 120 mg/m2 given every 3 to 4 weeks.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


METHOTREXATE
An antimetabolite that interferes with intracellular folate
metabolism by binding to the enzyme dihydrofolate
reductase.
This inhibits conversion of folic acid to tetrahydrofolate
The result is cellular depletion of reduced folates and
inhibition of DNA synthesis
The side effects can be minimized by supplying reduced
folates in the form of leucovorin within 36 hours after
exposure to the drug
As a single agent, methotrexate usually is given in weekly
doses of 40 to 50 mg/m2
Currently it is not generally used as first-line therapy
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
Brachytherapy

Intracavitary brachytherapy has been used for NPC, both


as a boost of the primary treatment and for persistent or
recurrent disease

The radiation source is inserted directly into the tumor.


The radiation dose is highest at the source and declines
gradually with increasing distance from the tumor.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


Brachytherapy
Radioactive gold grains (198Au) are frequently used asa
brachytherapy source. Gold grains can be implanted either
transnasally or using the split-palate approach (114). The
split-palate approach gives the surgeon a direct view of the
tumor and enables the precise implantation of the desired
number of gold grains permanently into the tumor
When gold grain implants were used to treat persistent
and recurrent tumors after radiotherapy, the reported 5-
year local tumor control rates were 87% and 63%,
respectively, and the corresponding 5-year, disease-free
survival rates were 68% and 60%
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
PHOTODYNAMIC THERAPY
Photodynamic therapy (PDT) is a therapeutic modality
using a photosensitizing drug that selectively localizes in
tumors and that, on being activated by exposure to light,
causes preferential tumor necrosis.
The two components needed for this therapy are a
photosensitizer drug and a laser to activate the drug

The most widely used drug in head and neck has been
porphyrin
Some of the other drugs that have been used as
photosensitizers are tetracyclines, fluorescein, rhodamine,
and more recently sulfonated metallophthalocyanines
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
PHOTODYNAMIC THERAPY

The light source consists of a laser either delivered down a


fiber for surface illumination

An illumination source, which is directed locally or


endoscopically near the tumor, induces cell killing
Complete responses have occurred in small tumors, as has
shrinkage and palliation of symptoms of larger tumors

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


PHOTODYNAMIC THERAPY

The advantages of PDT are that multiple lesions can be


treated at the same time, it has good cosmetic results, and
no anesthesia is required
The disadvantages include lack of predictable response in
more advanced lesions and occasional photosensitivity
The properties required of a photosensitizing agent are:
Selective accumulation or synthesis in target tissue
Generation of reactive oxygen species
Limited cutaneous phototoxicity
Non-mutagenicity and non-toxicity
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
KOMPLIKASI TERAPI
These are the results of radiation on the dose-limiting
organs adjacent to the nasopharynx and neck nodes
These sequelae include neuroendocrine and auditory
complications, xerostomia leading to poor oral and dental
hygiene, radiation-induced soft tissue fibrosis, and carotid
artery stenosis
Debilitating neurologic complications include temporal
lobe necrosis, cranial nerve palsies, and other less obvious
side effects such as memory, and cognitive and
neuropsychological dysfunctions
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
PASCA TERAPI

Complete remission of NPC following treatment can be


monitored with clinical examination, endoscopic
examination with or without biopsy, and imaging studies.
Early detection of locoregional relapses is important
because these tumors are still amenable to salvage when
detected early. In cases of persistent disease, in either the
nasopharynx or neck 10 weeks after completion of the
initial therapy, then salvage treatment should be
considered
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
Persistentor Recurrent Disease
Although concomitant chemoradiation is effective in the
management of NPC, local or regional failure presenting
as persistent or recurrent tumor still occurs
PET (positron emission tomography) is superior to CT and
MRI in detecting persistent or recurrent disease in the
nasopharynx, and any malignancy can usually be
confirmed with biopsy through endoscopic examination
Persistent or recurrent tumor in the neck node after
chemoradiotherapy, is notoriously difficult to confirm,
because only clusters of tumor cells are present in some
lymph nodes
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
Persistent or Recurrent Tumor in Neck
Lymph Nodes

Following combined chemoradiation for NPC, isolated


failure in the neck was reported to be less than 5%

If cancer persists or recurs in the cervical lymph nodes, as


evidenced by fine-needle aspiration cytology, imaging
studies, or progressive enlargement of the lymph nodes,
salvage therapy is indicated

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


Persistent or Recurrent Tumor in the
Nasopharynx
Persistent or recurrent disease in the nasopharynx after
the initial radical dose of radiation can still be managed
with a second course of external radiotherapy with a
larger radiation dose. A salvage rate of 32% has been
reported, although the cumulative incidence of late
sequelae after repeated irradiation was 24%, with a
treatment mortality of 1.8%

The complications arising from the second dose of external


radiotherapy affects significantly the quality of life of these
patients
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
Nasopharyngectomy
When the persistent or recurrent tumor in the
nasopharynx has extended to the paranasopharyngeal
space or is too bulky for brachytherapy to be successful,
the next salvage option is surgery. Nasopharyngectomy is
effective in the eradication of localized disease in selected
patients
In general, as long as the persistent or recurrent tumor can
be resected with a clear margin, the long-term results have
been satisfactory. The 5-year actuarial control of tumors in
the nasopharynx following salvage nasopharyngectomy
has been reported to be approximately 65%, and the 5-
year, disease-free survival rate is approximately 54%
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
Distant Metastasis
The most effective treatment for patients with NPC with
distant metastasis is to use cisplatin-based combination
chemotherapy. Cisplatin and infusional 5FU is currently
the standard treatment, achieving a 66% to 76% response
rate
For the few selected patients with localized metastases to
the lungs, resection of the pulmonary metastases can result
in prolonged tumor control. For patients with localized
metastasis to the mediastinal nodes, the application of
radiotherapy and chemotherapy can also result in more
prolonged tumor control

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


PERFORMANCE STATUS

Karnofsky Score
By Dr. David A. Karnofsky and Dr. Joseph H.
Burchenal; 1949

ECOG / WHO / Zubrod Score


Firstly published by Oken et al, 1982 then by C
Gordon Zubrod

Lansky Score
For Chlidren
KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING
(%) CRITERIA

100 Normal no complaints; no evidence of disease


Able to carry on normal
Able to carry on normal activity; minor signs or
activity and to work; no special 90
symptoms of disease
care needed. Normal activity with effort; some signs or symptoms
80
of disease
Cares for self; unable to carry on normal activity or
70
Unable to work; able to live at to do active work
home and care for more Requires occasional assistance, but is able to care for
60
personal needs; varying amount most of his personal needs
of assistance needed. 50
Requires considerable assistance and frequent
medical care

40 Disabled; requires special care and assistance

Severely disable; hospital admission is indicared


Unable to care foe self. Require 30
although death not imminent
equivalent of institutional or Very sick; hospital admission necessary; active
hospital care; disease may be 20
supportive treatment necessary
progressing rapidly.
10 Moribund; fatal processes progessing rapidly

0 Death
ECOG / WHO / ZUBROD SCORE
0 Asymptomatic (Fully active, able to carry on all predisease
activities without retriction
1 Symptomatic but completely ambulatory (Restricted in
physically strenous activity but ambulatory and able to carry
out work of a light or sedentary nature. For example light
housework, office work)
2 Symptomatic, < 50% in bed during the day (Ambulatory
and capable of all self care but unable to carry out any work
activities. Up and about more than 50% of waking hours)
3 Symptomatic, > 50% in bed, but not bedbound (Capable of
only limited self-care, confined to bed or chair 50%, or more of
waking hours)
4 Bedbound (Completely disable. Cannot carry on any self-
care. Totally confined to bed or chair)
5 Death
LANSKY SCORE (FOR CHLIDREN)
100 Fully active; normal

90 Minor retrictions in sternous physical activity

80 Active, but tired more quickly

70 Greater retriction of play and less time spent in play activity

Up and around, but active play minimal; keep busy to being involved in
60 quiter activities
Lying around much of the day, but get dressed; no active playing
50 participates in all quite play and activities

40 Mainli in bed; participates in quite activities

30 Bedbound; needing assistance even for quite play

20 Sleeping often; play entireli limited to very passive activities

10 Doesnt play; does not get out of bed

0 unresponsive
3rd CRANIAL NERVE (OCCULOMOTORIUS)
Somatic motor
The oculomotor nerve supplies somatic motor impulses
and proprioceptive fibers to the levator palpebrae
superioris, the external ocular muscles (except the superior
oblique and lateral rectus muscles), and all intrinsic
muscles (except the dilator pupillae) of the eye. Fibers of
this nerve emerge from the oculomotor sulcus in the
posterior fossa and pass into the superior orbital fissure
and divide into the superior branch, which supplies the
superior rectus and levator palpebrae superioris muscles,
and the inferior branch, which supplies the medial and
inferior rectus muscles and the inferior oblique muscles.
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
3rd CRANIAL NERVE (OCCULOMOTORIUS)

Visceral motor

Parasympathetic fibers enter the ciliary ganglion to supply


the ciliary muscle of the iris and the pupillary sphincter.
The ciliary ganglion is a parasympathetic ganglion
constrictor lying in the orbit 1 cm anterior to the optic
foramen.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


4th CRANIAL NERVE (TROCHLEAR)
Somatic motor

The trochlear nerve innervates the superior oblique


muscle. The trochlear nucleus is in the midbrain. Fibers
penetrate the dura in the lateral border of the cavernous
sinus. The trochlear nerve enters the orbit through the
superior orbital fissure.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


5th CRANIAL NERVE (TRIGEMINAL)

Branchial motor

The trigeminal nerve innervates muscles of mastication,


mylohyoid, tensor tympani, tensor veli palati, and the
anterior belly of the digastric muscles.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


5th CRANIAL NERVE (TRIGEMINAL)

General sensory

The semilunar ganglion receives the ophthalmic, maxillary,


and mandibular divisions of the trigeminal nerve and
sympathetic fibers from the carotid plexus and sends
branches to the dura. The accessory ganglia of the
trigeminal nerve are small parasympathetic ganglia
anatomically but not functionally associated with the
trigeminal nerve: the ciliary ganglion, pterygopalatine
ganglion, otic ganglion, and submandibular ganglion.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


6th CRANIAL NERVE (ABDUCENS)
Somatic motor

Fibers emerge in the groove between the pons and the end
of the pyramid. The nerve enters the orbit through the
superior orbital fissure.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


7th CRANIAL NERVE (FACIALIS)
Branchial motor
The facial nerve courses through the internal acoustic meatus. At
the lateral internal auditory canal, this nerve enters the bony
fallopian canal. It reaches the medial wall of the tympanic cavity
on the anterosuperior aspect and courses along the medial wall of
the tympanic cavity above the oval window. At the anterosuperior
aspect of the medial wall of the middle ear, there is a sharp
posterior bend. The geniculate ganglion is located in this area.
Posterior to the oval window and inferior to the horizontal
semicircular canal, the nerve turns downward to run vertically
and posteriorly to the bony tympanic anulus. It exits the skull
through the stylomastoid foramen and enters the parotid gland,
where it divides into the temporal, zygomatic, buccal, mandibular,
and cervical branches.
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
7th CRANIAL NERVE (FACIALIS)

Visceral motor

Efferent fibers from the superior salivatory nucleus travel


in the nervus intermedius, where they divide in the facial
canal into two groups to become the greater petrosal nerve
to lacrimal and nasal glands and the chorda tympani to
submandibular and sublingual glands.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


7th CRANIAL NERVE (FACIALIS)

Special sensory

Taste, anterior two-thirds of tongue

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


8th CRANIAL NERVE (VESTIBULOCOCHLEAR)

Special sensory (BALANCE)

The vestibular nerve arises in bipolar cells in the vestibular


ganglion in the upper part of the lateral internal auditory
meatus. Three peripheral branches supply the macula of
the utricle and saccule and cristae of the semicircular
ducts. These fibers travel with the cochlear nerve through
the internal auditory canal and posterior fossa and enter
the medulla.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


8th CRANIAL NERVE (VESTIBULOCOCHLEAR)

Special sensory (HEARING)

The cochlear nerve transmits impulses from the organ of


Corti to the auditory cortex. Hair cells in the organ of
Corti receive impulses and send fibers to the bony
modiolus, where the fibers become myelinated. The cell
bodies are in the spiral ganglion. Central fibers enter the
internal acoustic meatus, where vestibular fibers join the
cochlear fibers. After traversing the internal auditory
canal and meatus, this nerve enters the brainstem in the
cerebellopontine angle.
Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
9th CRANIAL NERVE (GLOSSOPHARYNGEUS)
Branchial motor

The glossopharyngeal nerve emerges from the brainstem


as three to four roots between the olive and inferior
peduncle. It exits the skull through the jugular foramen
and courses between the internal carotid artery and
internal jugular vein following the posterior border of the
stylopharyngeus muscle.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


9th CRANIAL NERVE (GLOSSOPHARYNGEUS)

Visceral motor

The tympanic (Jacobson) nerve provides sensory


innervation for the middle ear and parasympathetic
innervation to the parotid gland through the otic ganglion.
This nerve enters the tympanic plexus and continues as the
lesser petrosal nerve.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


9th CRANIAL NERVE (GLOSSOPHARYNGEUS)

Visceral sensory

Visceral sensation from the carotid body

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


9th CRANIAL NERVE (GLOSSOPHARYNGEUS)

General sensory

General sensation from posterior one-third of the tongue


and internal surface of the tympanic membrane

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


9th CRANIAL NERVE (GLOSSOPHARYNGEUS)

Special sensory

The nerve crosses the stylopharyngeus muscle to penetrate


deeply into pharyngeal terminations. As the nerve leaves
the jugular foramen, there are two gangliathe superior
(jugular) ganglion and the inferior (petrosal)
ganglionthat contain cell bodies for the sensory fibers
of the glossopharyngeal nerve.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


10th CRANIAL NERVE (VAGUS)
Branchial motor

Bilateral corticobulbar fibers descend through the internal


capsule to synapse on motor neurons in the nucleus
ambiguus in the medulla. The lower motor neuron axons
then travel laterally to exit the medulla between the olive
and the pyramid as 8 to 10 rootlets, exiting through the
jugular foramen, and leave as three major branches:
pharyngeal, superior laryngeal, and recurrent laryngeal
nerves.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


10th CRANIAL NERVE (VAGUS)

Visceral motor

Fibers from the dorsal motor nucleus of the vagus nerve


traverse the spinal trigeminal tract and nucleus, emerge
from the lateral surface of the medulla, and continue to
travel with the remaining vagus nerve.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


10th CRANIAL NERVE (VAGUS)

General sensory

The vagus nerve is carried with visceral sensory fibers of


the recurrent laryngeal nerve. It is carried above the vocal
folds by the internal laryngeal nerve to innervate the vocal
folds and the subglottis. Sensory fibers of the ear, auditory
canal, and tympanic membrane are carried in the
auricular branch.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


11th CRANIAL NERVE (ACCESSORY)
Branchial motor

Accessory nucleus postsynaptic fibers emerge to form


rootlets that pass through the foramen magnum to pass
posteriorly and medially to the styloid process to innervate
the sternomastoid and trapezius muscles.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


12th CRANIAL NERVE (HYPOGLOSSUS)
Somatic motor

Axons from the hypoglossal nucleus pass ventrally to the


lateral side of the medial lemniscus to emerge as rootlets
that converge to form the hypoglossal nerve. The nerve
exits through the hypoglossal foramen.

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006


Pseudostratified Columnar Epithelium
Transisional Epithelium
Stratified Squamous Epithelium Keratinizing
Stratified Squamous Epithelium Non-Keratinizing