Tumors of the hypopharynx

ByLt Col Saeed Ullah, MBBS, FCPS

Classified ENT, Head and Neck Surgeon

Anatomy

Anatomy

• Pyriform sinus

• Post cricoid region

• Posterior pharyngeal wall

Aetiology

• Smoking tobacco.• Chewing tobacco.• Heavy alcohol use.• Eating a diet without enough nutrients.• Having Plummer-Vinson syndrome.• There is a significant association with alcohol

and smoking, acting synergistically

Aetiology

• Role of genetic factors- association between tobacco use and p53 mutations is found in a much larger percentage of smokers and drinkers

• The loss of heterozygosity at 9p and abnormalities in chromosome 11 present.

• Mutations in the p21 gene have also been identified.

Aetiology

• The role of human papilloma virus (HPV) as a contributing factor to carcinogenesis in head and neck squamous cell carcinomas.

• Occupational exposures mainly asbestos and welding fumes.

Benign tumors

a) Papillomab) Adenomac) Lipomad) Fibromae) leiomyoma

Malignant tumors

Most of the tumours are squamous cell type with various grades of differentiation

a) Pyriform sinus (60%)b) Post cricoid region (30%)c) Posterior pharyngeal wall (10%)

Carcinoma pyriform sinus

• Mostly affects male above 40 years of age• Growth is either Exophytic, ulcerative and

deeply infiltrative• Because of large size of pyriform sinus growth

of this region remain asymptomatic for long time

• Metastatic neck nodes is the most common presenting symptom

Spread

• Upwards: vallecula and base of tongue• Downwards: post cricoid region• Medially: AE fold and ventricle• Laterally: thyroid cartilage, thyroid gland and may

present as soft tissue mass in neckLymphatic spread: upper and middle group of

jugular cervical nodesDistant metastasis: occur late and may be seen in

lung, liver, bone

Clinical features

• Metastatic neck nodes may be the first sign• Sticking/pricking sensation in throat• Referred otalgia• Odynophagia• Dysphagia• Hoarseness of voice• Stridor

Diagnosis

• Indirect laryngoscopy• Barium swallow• Flexible nasopharyngoscopy• CT scan: helpful to evaluate the extent of

growth and status of nodes• Direct laryngoscopy and biopsy

Barium swallow

CT scan

Endoscopy

Treatment

• Early growth without nodes– radiotherapy (preserves voice)

• Growth limited to pyriform fossa– total laryngectomy and partial

pharyngectomy and pharyngeal reconstruction often combined with neck dissection

Treatment

• Growth extending to post cricoid region– total laryngopharyngectomy with neck

dissection. Pharyngo-oesophageal segment is reconstructed with myocutaneous flap or gastric pull up

• Post operative radiotherapy

Carcinoma post cricoid region

• Constitutes 30% of hypopharyngeal tumours

• Plummer-Vinson syndrome is an important etiological factor (seen in 1/3rd of patients)

Clinical features

• Females are usually affected in the age group of 20-40

• Progressive dysphagia (predominant presenting symptom)

• Voice change• Weight loss

• Spread: local spread to cervical oesophagus, arytenoids, RLN and cricoarytenoid joint

• Lymphatic spread to paratracheal nodes, may be bilateral due to midline nature of lesion

Diagnosis

• laryngeal crepitus will be lost• Indirect laryngoscopy• lateral soft tissue neck x-ray• Barium swallow• CT scan• Direct laryngoscopy and biopsy

Treatment

• Prognosis is poor with irradiation and surgical treatment

• Radiotherapy: preserves laryngeal function• Surgical: laryngo-pharyngo-oesophagectomy

with gastric pull up or colon transposition for reconstruction

Carcinoma post pharyngeal wall• Least common hypopharyngeal malignancy• Mostly seen in males above 50 years of age

Clinical features

• Dysphagia• Metastatic neck node

• Spread: prevertebral fascia, muscles and vertebrae

• Lymphatic: usually bilateral, retropharyngeal and deep cervical nodes involved

Diagnosis

• Indirect laryngoscopy• lateral soft tissue neck x-ray• CT scan• Direct laryngoscopy and biopsy

Treatment • Early lesions radiotherapy early small lesions surgery by lateral

pharyngotomy approach advanced lesions

laryngopharyngectomy with block dissection

Questions

Thank you