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New therapeutic strategy of post-radiation OME in NPC patients

SciTeMed News Center

NPC Etiology

Nasopharyngeal cancer or nasopharyngeal carcinoma (NPC) is a rare type of cancer that grows at the nasopharynx which is precariously located at base of the skull. This type of cancer has unknown origins, however experts believe that it maybe caused by the aberrant establishment of virus latency in epithelial cells that display premalignant genetic changes.

The presence of NPC is mostly evident in Southeast Asian areas which include Guangdong, Taiwan, Hong Kong, and Singapore. Although NPC also occurs in the United States and Western Europe, such incidences are ten times lower than their counterparts in Southeast Asian countries. To minimize the chances of patients from contracting NPC, it is best to avoid eating salt-cured fish as well as meats.

NPC Symptoms and Diagnosis

There are actually plenty of symptoms associated with NPC and the following are some of the most common ones:

  • Lumps within the neck or nose areas
  • Middle ear effusion or otitis media with effusion (OME)
  • Aural fullness
  • Nose bleeds
  • Ringing within the ears
  • Numbness or pain of face
  • Hearing loss

The above mentioned symptoms may also likely occur with other forms of illness or diseases, and is very much dependent on the overall health condition of an individual, which is why it is important to consult a doctor when said symptoms occur. Only a certified physician who specializes in otolaryngology may rule out the presence of a nasopharyngeal cancer.

A detailed examination of nasopharynx must be done to know if cancer has grown within the nasopharynx. Often, a lump in the neck area signifies that the cancer cells may have already spread or metastasize in the lymph nodes. To be more certain, doctors will do a nasopharyngoscopy, where a lighted flexible tube is placed through the nose to give the doctor a better scrutiny of any problems like bleeding or growths in the nasopharynx area.

When abnormal growths are found after the nasopharyngoscopy, usually doctors would suggest a biopsy to determine whether the growth is malignant or benign. A biopsy is a medical technical procedure that removes a minute amount of tissue from any abnormal growth or lump. This procedure is administered without anesthetics.

NPC Remedy and Relevant Otological Complications

Radiotherapy or radiation therapy is the main form of treatment available for NPC. Current technological advances in this kind of treatment have actually minimized the high number of incidence related to complications where radiation is concerned. The downside of radiotherapy or radiation therapy is that the human anatomy adjacent to the nasopharynx area, like the Eustachian tube (a tube that links the nasopharynx to the middle ear), is likewise exposed to radiation whenever the said treatment is administered.

In such cases, the Eustachian tube is damaged, and it usually results in middle ear effusion or OME. OME is clinically described as having fluid behind the eardrum, which is located in the middle ear. OME can materialize even if there is no evident ear infection that is present.

Most patients who have undergone radiotherapy (post irradiation) suffer from recurrent episodes of OME complicated with tinnitus, vertigo, and hearing impairment. The aforementioned complications not only cause a lot of stress but also lower their self-esteem and eventually become a form of psychological burden. Thus, patients become depressed and eventually withdraw from socializing. These issues need to be addressed by clinicians in order to assess efficient management approaches after administering radiation therapy of OME.

New Therapeutic Strategy of Post-radiation OME

Complete and effective treatments of post radiation OME for NPC patients are currently not available. Although physicians or clinicians usually opt for a more conservative approach or treatment, patients often prefer a more aggressive procedure that would provide them a fast form of relief from the physical distress that they are experiencing. Some conventional or traditional treatments preferred by clinicians for OME are: incisional myringotomy, tympanic aspiration, and ventilation tube insertion.

Clinically, there are two forms of OME. It is imperative to distinguish post irradiation pathogenesis from a non-radiation related OME. OME that is not brought about by radiation therapy is caused by the temporary dysfunction of the Eustachian tube, primarily because of poor ventilation. This type of OME can generally be cured by using the conventional or traditional remedies mentioned above. On the other hand, OME that is caused by post irradiation treatments are permanent and cannot be reversed by any form of medical treatment.

In cases where the OME is irreversible, a new therapeutic strategy of post-radiation OME has been proposed: To treat, rather than to cure! The main goal of the strategy is to incorporate a palliative therapy wherein the objective is not to cure the OME, but to control its symptoms and help the patient be more comfortable so that they are still able to manage their respective activities of daily living. The new therapeutic intervention proposed by Kuo et al. is “laser myringotomy followed by intratympanic steroid injection (LMIS) [1].” In their study, immune restoration and epithelial repair of the middle ear mucosa may be achieved by topical steroid administration. In addition, topical steroid administration may delay healing of the eardrum perforation, providing longer-lasting and significant relief of symptoms. In the study, the mean perforation healing time was 6.5 weeks (range 1-24 weeks). Although the 40.9% recurrence rate observed in their research is not inconsequential, it is lower than that in previously published studies (77.8%-88.9%). Importantly, this is balanced by the advantages of using LMIS, i.e. it is a quick, minimally-invasive, office-based technique, allowing for repeated procedures with minimal patient discomfort.

Figure 1. LMIS is a quick, minimally-invasive, office-based technique, allowing for repeated procedures with minimal patient suffering [2]. 

Figure 2. A longer-lasting dry perforation of the eardrum allows for immediate and sustained relief of otologic symptoms [2]. 

Summary

Since there is no permanent treatment available to prevent the onset of otologic problems like OME arising from post radiation therapy of NPC, it is vital that patients be informed of their actual prognosis and the medical treatment that may be available in their particular medical cases. “To treat, rather than to cure!” is a new therapeutic concept for post-irradiation OME in NPC patients. Although the effect of the LMIS treatment is not permanent, LMIS is an option possible to achieve a longer lasting relief of any associated symptoms.

References

  1. Chin-Lung Kuo, Mao-Che Wang, Chia-Huei Chu, An-Suey Shiao. New therapeutic strategy for treating otitis media with effusion in postirradiated nasopharyngeal carcinoma patients. Journal of the Chinese Medical Association. 2012 July;75(7):329-34.
  2. Chin-Lung Kuo and An-Suey Shiao. Strategies for the Management of Post-irradiation Otitis Media with Effusion. Journal of Otolaryngology and Reconstructive Surgery. 2015;1(2):109
  3. Chin-Lung Kuo, An-Suey Shiao.To treat, not to cure! A new therapeutic concept for post-irradiation otitis media with effusion. World Biomedical Frontiers (ISSN: 2328-0166), Cancer Section, 2013 July-24.
  4. Lawrence S. Young and Christopher W. Dawson. Epstein-Barr virus and nasopharyngeal carcinoma. Chin J Cancer. 2014 Dec; 33(12): 581–590. doi:  10.5732/cjc.014.10197