# Nasopharyngeal Pathology

> Nasopharyngeal pathology for MBBS Pathology: nasopharyngeal carcinoma WHO types, EBV association, neck node presentation and the Northeast India belt.

- Canonical URL: https://prepelephant.com/topics/mbbs/pathology/nasopharynx-pathology
- Exam / course: MBBS · Subject: Pathology
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-02
- Last updated: 2026-10-02
- How to cite: "Nasopharyngeal Pathology", PrepElephant, https://prepelephant.com/topics/mbbs/pathology/nasopharynx-pathology

## Direct answer

Undifferentiated carcinoma of the nasopharynx is the tumour that behaves like an infection and spreads like a cancer: Epstein-Barr virus-driven carcinoma arising in the lateral wall (fossa of Rosenmüller), presenting with a neck node rather than nasal complaints, serous otitis media from Eustachian obstruction, or cranial nerve palsies through the foramen lacerum. The WHO classifies it into keratinising squamous (type I), non-keratinising differentiated (type II) and undifferentiated (type III) carcinoma — types II and III are EBV-associated, radiotherapy-sensitive and dominate high-incidence populations. In India, the Northeast — Nagaland, Mizoram, Manipur — records incidence rates comparable to southern China among its Mongoloid-origin populations, a geography-plus-genetics story (HLA-linked susceptibility) that examiners from the region expect candidates to know.

## What you must remember

- **Anatomy decides presentation:** the nasopharynx sits behind the nasal cavity, around the Eustachian cushions and fossa of Rosenmüller; tumours there cause blood-stained nasal discharge, unilateral secretory otitis media (blocked Eustachian tube) and nasal obstruction late.
- **The neck node first:** up to three-quarters of patients present with a cervical lymph node — classically a level V (posterior triangle) or upper deep cervical mass — because nasopharyngeal carcinoma metastasises early and bilaterally to retropharyngeal and cervical chains.
- **WHO typing:** type I keratinising squamous carcinoma (EBV-linked less consistently, radioresistant, worse local control); type II non-keratinising differentiated; type III undifferentinated carcinoma with lymphoepithelioma pattern — syncytial sheets of malignant epithelial cells densely infiltrated by lymphocytes (the old Schmincke-Regaud lymphoepithelioma).
- **EBV markers:** clonal episomal EBV DNA in the tumour cells, elevated IgA antibodies to viral capsid antigen and early antigen for screening and follow-up in endemic areas, and EBV-encoded small RNAs (EBER) on in-situ hybridisation as the diagnostic stain.
- **Cranial nerve route:** spread through the foramen lacerum to the cavernous sinus affects cranial nerves III, IV, V and VI — diplopia and facial numbness are ominous presenting features; the petrous apex adds VI palsy (Gradenigo-like picture).
- **Geography and India:** highest incidence in southern Chinese, Inuit and Southeast Asian populations; within India, Nagaland and neighbouring Northeast states carry rates of the same order, attributed to HLA-related genetic susceptibility plus preserved-fish and wood-smoke exposures interacting with EBV.
- **Non-neoplastic conditions:** adenoids (nasopharyngeal tonsillar hyperplasia) in children with snoring; Thornwaldt cyst from notochordal remnant; angiofibroma — see below.

## A juvenile male with epistaxis, worked through

A 15-year-old boy has recurrent unilateral epistaxis and progressive nasal obstruction without cervical nodes: that combination in an adolescent male is juvenile nasopharyngeal angiofibroma, a benign but locally aggressive, hormone-sensitive tumour of vascular channels and fibrous stroma arising in the sphenopalatine foramen. The steps are characteristic — avoid biopsy (bleeding can be torrential); confirm with contrast computed tomography or angiography showing a vascular mass extending to the pterygopalatine fossa with Holman-Miller sign (anterior bowing of the posterior maxillary wall); embolise then resect. Contrast this with a 45-year-old Northeast Indian man with a level V neck node and a silent nasopharynx: here the biopsy comes from the nasopharynx itself or the node (EBER-positive undifferentiated carcinoma), staging includes magnetic resonance imaging of the skull base, and treatment is concurrent chemoradiotherapy with cisplatin — high cure rates in type III disease, and EBV DNA titres track response. Two masses, same site, opposite biopsy rules — a contrast examiners relish.

## Where students slip

The reflex error is to approach every neck lump with fine-needle aspiration first and treat the nasopharynx as an afterthought; for an undiagnosed upper-neck or posterior-triangle node, the nasopharynx is part of the primary survey, especially in patients from high-incidence regions. Second, candidates misclassify the lymphoepithelioma as a lymphoma because the histology is sheeted with lymphocytes — the malignant cells are epithelial, cytokeratin-positive, EBER-positive, and lymphoma markers are negative; this immunohistochemistry panel is a standing viva question. Third, students forget that unilateral serous otitis media in an adult is nasopharyngeal carcinoma until scoped — the Eustachian catheter question is old, the principle is not.

## Frequently asked questions

### Which virus drives nasopharyngeal carcinoma and which antibody is followed?

Epstein-Barr virus; IgA antibodies to viral capsid antigen and early antigen are used for screening and monitoring, while EBER in-situ hybridisation confirms the diagnosis on tissue.

### What are the WHO histological types?

Type I keratinising squamous carcinoma, type II non-keratinising differentiated carcinoma, and type III undifferentiated carcinoma with the lymphoepithelioma pattern.

### Why does nasopharyngeal carcinoma present with a neck node?

The nasopharyngeal mucosa has rich lymphatic drainage to retropharyngeal and cervical chains, so ipsilateral and bilateral node metastases occur early, often before local symptoms.

### Which tumour must never be biopsied transnasally?

Juvenile nasopharyngeal angiofibroma in adolescent males — a highly vascular tumour requiring imaging diagnosis, preoperative embolisation and surgical excision.

### Why is nasopharyngeal carcinoma common in Northeast India?

Mongoloid-origin populations carry HLA-linked susceptibility, compounded by dietary and environmental exposures, yielding incidence rates comparable to southern China, particularly in Nagaland and Mizoram.