HYPOPHARYNX

Presented by : Dr. Isha jaiswalModerator: Dr. RAHAT HADIDate: 20 th nov. 2013

ANATOMY OF THE HYPO PHARYNX

• Nasopharynx

• Oropharynx

• Laryngopharynx

(Hypopharynx)

Seen from behind

HYPOPHARYNX

Behind the Larynx (in front of 3rd to 6th Cervical vertebra)

From the tip of epiglottis superiorly to

the lower border of cricoid cartilage

Inferiorly

Communicates:

- Anteriorly with the Larynx

- Superiorly with the oropharynx

- Inferiorly with the esophagus

The hypopharynx does not only

lie behind the larynx BUT also

Projects laterally on each side of the larynx

So it is formed of :- Postcricoid region ( behind the

larynx)- Two pyriform fosse (on each side of

the larynx

Seen from behind

Cross section

PYRIFORM SINUS

Shape : inverted pyramid.

Extent:Superiorly: epiglottis .Lateral: thyroid cartilage Medial: arytenoid cartilage; aryepiglottic fold;. Posteriorly: open & cont. with post pharyngeal wall.Apex: meeting of anterior, lateral &med wall inferiorly.

PYRIFORM SINUS

POST CRICOID REGIONPharynx mucosa covering post. Surface of cricoid

Pharynx become continuous with esophagus at post cricoid region

Extent:•Superior: arytenoids• Inferior: oesophagus

arytenoids

ccoesophagus

POSTERIOR PHARYNGEAL WALL

Cover mid & inf constrictor ms. Seperated from prevertebral fascia by retropharyngeal space.Extent:Superiorly: upper border of epiglottisInferior: lower border of cricoidSideways: apex of one piriform sinus to other.

(

Nerve supply of hypopharynx

sensory:• internal branch of sup. Laryngeal

nerve :vagus; (X)• Glossopharyngeal nerve :(IX)

motor• External branch of sup. Laryngeal

nerve (X)• Recurrent laryngeal nerve (X)• Pharyngel plexus (IX)

LYMPHATIC DRAINAGEDeep cervical lymph node : level 2,3& 4Prelaryngeal & paratracheal lymph nodes: level 6.Retropharyngeal nodeNode of rouviere at skull base

LYMPHATIC DRAINAGE

EXT. CAROTID ARTERY

ASC. PHARYNGEAL

ARTERY

MAXILLARY ARTERY

DESC. PALATINE ARTERY

LINGUAL ARTERY

DORSAL LINGUAL ARTERY

FACIAL ARTERY

TONSILLAR ARTERY

ASC. PALATINE ARTERY

BLOOD SUPPLY

RADIOLOGICAL ANATOMY

LYMPHATIC SUPPLY OF NECKDIVIDED INTO 6 LEVEL-

• level I - IA Submental

• IB Submandibular

• level II – Upper jugular chain

IIA & IIB

• level III – Middle jugular chain

& jugulo-omohyoid

• level IV – Lower jugular chain

virchow node

• level V - Posterior triangle node

• level VI – ant group nodes: pre & para tracheal; precricoid (delphian) parithyroid; prelaryngeal

Submental: Ia

Submandibular:Ib

upper deep cervial: II

Retropharyngeal

Post triangle:level V

PRE TRACHEAL NODE ; LEVEL VI

MID. DEEP CERVICALLEVEL III

POST CERVICAL :LEVEL V

“

”

Pre tracheal node ; Level VI

lower Deep cervical LEVEL IV

Post cervical :LEVEL V

PET SCAN IMAGECT IMAGE

 During spontaneous breathing    Upon phonation

The Pyriform Fossae Views as Seen by Using a direct laryngoscope

Upon forceful nose blowing with the mouth closed

CARCINOMA PYRIFORM FOSSA

Carcinoma hypopharynx

POST CRICOID AREA: 

        

The hypopharynx leading to upper oesopageal sphincter.                    

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Occasionally brisk opening seen apon  laryngeal examinarion (arrow).

  Upper osophageal sphincter opening- upon rigid oesophagoscopy. 

CARCINOMA HYPOPHARYNXConstitute 5.2% of upper aerodigestive tract cancer.

Mostly squamous cell carcinoma of hypopharynx.

Mean age of presentation 65 years

m.C stage of presentation : stage III& IV

POOR PROGNOSIS

INCIDENCE OF HYPOPHARYNX CA.

65-75% •PYRIFORM SINUS CARCINOMA

5-15% • POST CRICOID CARCINOMA

10-20%• POST. PHARYNGEAL WALL

CARCINOMA

RISK FACTORS OF CA .HYPOPHARYNX Age & Sex: CA. PYRIFORM FOSSA : male above 40 years CA .POST CRICOID : females 20 to 40 years CA.POST. PHARYNX WALL : males aove 50 years

Family historyTobaccoAlcoholExposure : polyaromatic compounds ; asbestos & welding fumes

Nutritional deficiency. VIT A.& E. IRON. CRATENODS & FLAVRNOIDS.

RISK FACTORS OF CA .HYPOPHARYNXClick icon to add picture

infectons; HPV (20–25% only postive for hpv dna & Ab against HPV 16 E6 & E7)

Associated diseases: PLUMMER VINSON SYNDROME

GENETIC: P53 & EGFR mutationSynchronous & metachronous malignancy

FIELD CANCERIZATION

Hypopharynx CA occur within field of diseased mucosa

Carcinogens induce dysplastic changes in mucosa of the upper aero digestive tract.

Increased risk of malignancy

CARCINOMA OF PYRIFORM SINUS• Age:40 years

• presentation: late; Metastatic neck nodesSpread: localUpwards: base of tongueDownwards: post cricoid regionMedially: AE fold and ventricleLaterally: thyroid cartilage,

Lymphatic spread: upper and middle group of jugular cervical nodesDistant metastasis: occur late and may be seen in lung, liver, bone

CARCINOMA OF POST CRICOID REGION

Plummer-Vinson syndrome age group of 20-40; female

Progressive dysphagia Voice change Weight loss

Spread: local spread - cervical oesophagus, arytenoids Lymphatic spread - paratracheal nodes, may be bilateral due to midline nature of lesion

CARCINOMA OF POSTERIOR PHARYNGEAL WALL

• Mostly seen in males above 50 years of age

• Clinical features: dysphagia, metastatic neck node

• Spread: local - prevertebral fascia, muscles and vertebrae• Lymphatic: usually bilateral, retropharyngeal and deep cervical nodes involved

CLINICAL PRESENTATION

Throat pain, Sore throatdysphagiaOdynophagiapooling of saliva

Neck mass:metastatic neck

nodeDirect extension

most frequent presenting symptoms include a neck mass (either representing the tumour or nodal metastases -

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Early lesion may result in vague throat painStenotic tumours near the pharyngo-oesophageal junction may result in , dysphagia.Drooling of saliva may occur due to oedema near arytenoids.

MECHANISM OF OTALGIA

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Hoarseness: indicates involvement of the recurrent laryngeal nerve, which runs deep to the anterior wall of the pyriform sinus, or direct invasion of the larynx leading to inflamation of vocal cords.

CLINICAL EVALUATION

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History takingGeneral physical examination Oral hygeine & dentitionAirway statusStatus of speech & swallow.Complete examination of oral cavity , oropharynx. Examinaton of neck nodes.Indirect layngoscopyDirect laryngoscopy

ORAL CAVITY EXAM INATION• Inspect and palpate:• Note condition gums, mucosa, teeth (caries of teeth malocclusion)• Lips: (lumps, lesion, cracking,color) • Tongue: color, moisture, surface characteristics. Check for white patches

• Throat examination• Inspect uvula, palate, tonsils

EXAMINATION OF ORAL CAVITY

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EXAMINATION OF NECK NODESLocationSizenumberMobilityTendernessRelationship with adjacent structure.

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Examination of neck nodes: sub mental(Ia) & submandibular(Ib)

Examination of neck nodes: upper.,middle & lower deep cervical (Ii; iii. iv)

INDIRECT LARYNGOSCOPY

mirror warmed; check temp.Hold tongueIntroduce mirror into the oral cavity facing downwards mirror brought to rest against the uvula do not touch the posterior pharyngeal wall laryngeal inlet is visualized,

structures seen on indirect laryngoscopy (in order):

Base of the tongue ValleculaMedian and lateral glossoepiglottic foldsEpiglottisVestibular foldTrue vocal cordsTracheaLayngeal cartilage

PRE TREATMENT EVALUATION:

To asses extent of tumourRelation with other structureInvolvement of larynxMobillity of vocal cords

Direct laryngoscopyOesophagoscopyBronchoscopyPanendoscopy

Chest x ray :infection; malignancy;mets HRCT : thickness, invasion, L.N metstasisMRI :soft tissue details, tissue oedemaPET :residual or recurrent tumour after RT