Trotters triad is seen in -
• Nasopharyngeal cancer is most common in China particularly in southern states and Taiwan.
• People in Southern China, Taiwan and Indonesia are more prone to this cancer.
• MC tumor to produce cervical LN metastasis
• MC tumor responsible for secondaries in the neck with no obvious primary malignancy
• Burning of incense or wood (Polycyclic hydrocarbon), use of preserved salted fish (Nitosamines) along with vitamin C deficient diet (vitamin C blocks nitrosification of amines and is thus protective) may be other factors operative in China.
Etiology
• Exact etiology is not known. The factors responsible are:
−− Genetic: Chinese
−− Viral: Epstein-Barr virus
−− Environmental: Air pollution, smoking of tobacco and opium, nitrosamines from dry salted fish, smoke from burning of incense and wood
Pathology
• Squamous cell carcinoma in various grades of its differentiation or its variants as transitional cell carcinoma and lymphoepithelioma, is the most common.
• MC site of origin: Fossa of Rosenmuller in the lateral wall of Nasopharynx.
• LN involvement is common because of rich lymphatic network in the nasopharynx.
Clinical features
• Age: It is mostly seen in fifth to seventh decades but may involve younger age groups.
• Sex: Males are three times more prone than females.
• Cervical lymphadenopathy is MC presenting symptom (60-90%).
• Nasal: Nasal obstruction, nasal discharge, denasal speech (rhinolalia clausa) and epistaxis.
• Otologic: Due to obstruction of Eustachian tube , there is conductive hearing loss, serous or suppurative otitis media.
• Presence of unilateral serous otitis media in an adult should raise suspicion of nasopharyngeal growth.
• Involvement of IX , X and XI cranial nerves may occur, constituting jugular foramen syndrome.
• Can cause conductive deafness (Eustachian tube blockage), ipsilateral temporoparietal neuralgia (involvement of CN V) and palatal paralysis (CN X)-collectively called Trotter’s triad.
• Cervical nodal metastases may be the only manifestation of nasopharyngeal cancer.
• Nodal metastases are seen in 75% of the patients, when first seen, about half of them with bilateral nodes.
• Distant metastases involve bone, lung, liver and other sites.
• Jaccods’s triad: Ipsilateral ophthalmoplegia + Amaurosis + Ipsilateral neuralgia
Diagnosis
• CT scan: Demonstrate erosion of bone at the base of skull and the extent of tumor.
• Biopsy is essential to show the exact histology of the malignancy.
• In absence of nasopharyngeal lesion but with strong suspicion of malignancy, nasopharynx is exposed by transpalatal approach and a strip of mucosa and submucosa from the region of fossa of Rosenmuller should be taken and subjected to histology.
Treatment
• Irradiation is treatment of choice.
• Chemo therapy for stage III and IV cancers
Angiofibroma
Nasopharyngeal carcinoma
Laryngeal carcinoma
Growth in fossa of Rosenmuller