Hypopharyngeal carcinoma
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Hypopharyngeal carcinoma

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ENT head and neck surgery

ENT head and neck surgery

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Hypopharyngeal carcinoma Presentation Transcript

  • 1. Dr. Zaimal Shahan Post-graduate Resident Otolaryngology Department Capital Hospital, Islamabad
  • 2. Oral Preparatory PhaseOral Preparatory Phase Break down foodBreak down food Mix with salivaMix with saliva Prevent premature escape into pharynxPrevent premature escape into pharynx Oral PhaseOral Phase Tongue elevates ant to postTongue elevates ant to post Tongue forms central grooveTongue forms central groove Labial andLabial and buccalbuccal sealseal Begins when tongue moves bolusBegins when tongue moves bolus posteriorlyposteriorly,, and ends when bolus passes anterior pillar ofand ends when bolus passes anterior pillar of faucesfauces Voluntary controlVoluntary control -- ( XII )( XII )
  • 3. Pharyngeal PhasePharyngeal Phase Begins when bolus passes anterior pillar orBegins when bolus passes anterior pillar or faucesfauces Ends when bolus passes through upper oesophageal sphincter intoEnds when bolus passes through upper oesophageal sphincter into oesophagusoesophagus Velum elevates and contracts, closing nasal passage, bolus propeVelum elevates and contracts, closing nasal passage, bolus propelled through pharynx,lled through pharynx, larynx closed and elevated, respiration inhibited, upper oesophalarynx closed and elevated, respiration inhibited, upper oesophageal sphincter relaxesgeal sphincter relaxes Involuntary controlInvoluntary control –– ( IX, X, XII )( IX, X, XII )
  • 4. OesophagealOesophageal PhasePhase Begins when bolus entersBegins when bolus enters oesophagusoesophagus Ends when bolus passes through lowerEnds when bolus passes through lower oesophagealoesophageal sphincter into stomach 8sphincter into stomach 8-- 20 seconds later20 seconds later Sequential peristaltic wave propels bolusSequential peristaltic wave propels bolus Relaxation of lowerRelaxation of lower oesophagealoesophageal sphinctersphincter Involuntary controlInvoluntary control –– ( X )( X )
  • 5. 7
  • 6. Dysphagia is defined as difficulty in swallowing which may affect any part of the swallowing pathway from the mouth to the stomach. Approximately half of the dysphagia patients are seen in ENT clinics.
  • 7. Patients complain that foods or liquids are no longer being swallowed easily and there is a sensation of food sticking. Clinician must try to distinguish oropharyngeal from oesophageal dysphagia
  • 8.  In Oropharyngeal dysphagia, there is difficulty in preparing and transporting the food bolus through the oral cavity as well as initiating the swallow. This may be associated with aspiration or nasopharyngeal regurgitation.  In Oesophageal dysphagia, patients complain of food sticking in their lower throat, neck, retro-sternal discomfort or epigastrium.
  • 9.  Children : Foreign body or congenital malformation  Middle aged patients: Reflux oesophagitis, hiatus hernia, anaemia, achlasia, globus syndrome.  Elderly patients: Malignancy, stricture formation from longstanding reflux, pharyngeal pouch, motility disorders associated with aging and neurological disorders.
  • 10.  1.HISTORY  2.CLINICAL EXAMINATION  3.INVESTIGATIONS  4.ENDOSCOPY
  • 11. Onset. Duration Progression Severity of symptoms Types of food intake that causes problems Alleviating factors
  • 12. Regurgitation Pain on swallowing Hoarseness of voice Otalgia Coughing after eating Frequent chest infections
  • 13.  Complete Head and neck examination  Inspection of oral cavity  Pharynx  IDL  Videolaryngoscopy/ Nasopharyngoscopy  Cranial nerve examination ( tongue, gag and cough reflex, hoarseness, vocal cord mobility)  Neck for lymph nodes, neck masses, thyroid enlargement, loss of laryngeal crepitus and integrity of laryngeal cartilages.
  • 14.  Blood tests to exclude anaemia (? Cause or effect)  ESR raised in chronic inflammatory process  LFT, RFT along with S. Calcium when nutrition is impaired or metastasis is suspected  Thyroid function tests if dysphagia is caused by goiter or malignancy of thyroid
  • 15.  Barium swallow  Chest radiograph  CT scan examination  MRI is indicated when there are neurological causes such as multiple sclerosis, cerebral tx, nasopharyngeal ca.
  • 16.  Rigid endoscopy Direct Laryngoscopy Rigid Esophagoscopy  Flexible endoscopy
  • 17. Abnormality related to the movement of a food bolus from the hypopharynx to the esophagus Arises from disease of the upper esophagus, pharynx, or UES.
  • 18. Typically present with difficulty initiating a swallow and immediately experience coughing, choking, gagging, or nasal regurgitation when attempting to swallow
  • 19. Most commonly caused by disruptions in swallowing secondary to neuromuscular dysfunction These symptoms may be more severe when swallowing liquids  The history and physical examination should focus on neurologic signs and symptoms
  • 20.  Initially, an oro-motor examination of the jaw, lips and tongue will be performed. Any deviations or weaknesses will be noted.  This may be followed by a 3 oz. water swallow test, whereby the patient is given 3 oz. of water in a cup, and told to drink it all without stopping. An abnormal response would be coughing during or after the exam, or a change in vocal quality, to wet or hoarse.
  • 21.  A Modified barium swallow is performed by a Radiologist, a Speech-language Pathologist, and a radiology technician.  Barium sulfate powder is mixed in liquid form.  Thickener is added to make liquids nectar, honey or puree consistency.
  • 22.  Barium paste is used, and spread on cookies.  The test is done in 2 views, Lateral (side), and AP  Anterior-Posterior.
  • 23.  Hypopharynx is a highly important anatomical site since physiologically it is a component of the upper aerodigestive tract.  In its upper part, it represents a common conduit for both respiration and deglutition.
  • 24.  Extends from the oropharynx superiorly to the cervical esophagus inferiorly.  Superior extent at the level of the hyoid bone or at the level of the pharyngoepiglottic folds.  Inferiorly, the hypopharynx tapers to the esophageal introitus at the cricopharyngeus muscle (lower boarder of cricoid cartilage).  Anteriorly bordered by the larynx  Posteriorly by the retropharyngeal space.  Subdivided into 3 regions: the pyriform sinuses, the postcricoid region, and the posterior pharyngeal walls.
  • 25.  4-7% of all cancers of the upper aerodigestive tract.  95% SCC (others include lymphomas, neuroendocrine tumors, adenocarcinomas, and sarcomas)  65-85% of hypopharyngeal carcinomas involve the pyriform sinuses, 10-20% involve the posterior pharyngeal wall, and 5-15% involve the postcricoid area.
  • 26.  Male-to-female ratio of 3:1 (women have a higher incidence of postcricoid cancers related to nutritional deficiencies such as Plummer-Vinson Syndrome)  The mean age at presentation is 65 years.
  • 27.  Tobacco  Alcohol  Gastroesophageal or laryngotracheal reflux (postcricoid)  Diet  Genetic predisposition  A condition specifically associated with postcricoid carcinoma is the Plummer-Vinson or Paterson-Brown-Kelly syndrome, which primarily affects women (85% of the cases).
  • 28.  Full head and neck and GPE  Indirect Laryngoscopy (IDL)  Direct Laryngoscopy (DL)  Particular attention shall be paid to obvious swelling or ulceration and also presence of pooling of secretions in the piriform fossa (Chevalier Jackson’s sign) and oedema of arytenoids.
  • 29. •Pooling in the piriform fossa indicates failure of passage of secretions down the oesophagus, •Whereas oedema of arytenoids may be the only obvious evidence on IDL of a tumour either of the medial wall of piriform fossa or post cricoid space.
  • 30. Following investigations are considered essential:  Full Blood count  Iron Stores  Urea and electrolytes  LFT  Serum Calcium  Thyroid Function
  • 31. Barium Swallow: Extremely useful investigation in these tumours. Objectives include:  To assess tumour length  To rule out synchronus primary tumour of oesophagus  To ascertain presence or absence of aspiration  To assess tumour mobility on vertebral column
  • 32. CT and MRI  To assess the extent of the primary tumour and extensions.  To rule out second primary and distant metastasis  To assess neck  To look for cartilage invasion
  • 33.  Examination of larynx, pharynx,trachea and esophagus  Examination of oral cavity  Biopsy
  • 34. T1: Tumour limited to one subsite of hypopharynx and 2 cm or less in greatest dimension. T2: Tumour invades more than one subsite or measures >2cm but < 4 cm without fixation of hemilarynx. T3: Tumours > 4 cm or with fixation of Hemilarynx T4a: Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophagus, or central compartment of soft tissue (strap mm). b: Tumor invades prevertebral fascia, encases the carotid artery or involves mediastinal structures.
  • 35.  N0: No regional LN  N1: Single ipsilateral LN less or equal to 3cm  N2a: Single ipsilateral LN 3-6cm b: Multiple ipsilateral LNs all less than 6cm c: Bilateral or contralateral LNs all less than 6cm  N3: Any LN more than 6cm
  • 36.  An understanding of the site of initiation and patterns of spread of hypopharyngeal carcinoma is critical in the management of these tumors.  Medial wall pyriform sinus tumors usually spread along the mucosal surface to the aryepiglottic folds and can invade into the larynx by involving the paraglottic space.
  • 37.  Tumors of the lateral wall and apex commonly invade the thyroid cartilage.  Once the tumor penetrates the constrictor muscle, it can spread along the fascial planes to the base of skull.  Because of the abundant lymphatics in the region and the extent of the primary tumor at diagnosis, metastasis to the regional lymph nodes is common.
  • 38. It depends on stage of tumor: T1/T2 Radiotherapy alone (commonly 66-70 Gy) or surgery (possibly with postoperative irradiation, depending on the pathology findings). Larynx preservation therapy is typically possible and is strongly favored.
  • 39. T3/T4 (resectable) Partial or total laryngopharyngectomy, neck dissection, postoperative radiotherapy +/- chemo, or concurrent chemoradiotherapy or participation in prospective clinical trials.
  • 40. Unresectable or medically unstable (1) Radiotherapy alone with altered fractionation or concurrent chemo- radiotherapy (2) participation in prospective clinical trials.
  • 41.  The control of regional metastasis is a critical component of the management of hypopharyngeal and cervical esophageal tumors.  As for other sites, the discussion of neck management can be divided between elective neck dissection (for N0 stage necks) and therapeutic neck dissection (for N+ necks).
  • 42.  For necks with positive nodes, the current management is to treat both necks, either with radiation followed by salvage surgery if necessary or surgery followed by radiation.  For the ipsilateral neck that is staged N0, there is compelling evidence to treat both necks for all but the very early lesions where a unilateral neck dissection alone may be adequate.
  • 43.  Combined chemotherapy and radiation therapy directed at the primary tumor are the most common nonsurgical approaches for advanced tumors.  Best responses are to platinum-based compounds such as cisplatin or carboplatin and/or 5-FU.  Chemo used alone only for palliation.
  • 44.  Close monitoring is required for these patients  Reevaluate the disease status due to high risk of recurrence:  Perform a neck examination and fiberoptic laryngoscopy every 3 months for 2 years after the initial treatment and 2-4 times per year thereafter.
  • 45.  Monitor for second primary cancers (incidence of approximately 3% per y) once or twice per year.
  • 46.  Chest x-ray films for detection of lung cancer or metastases  Hepatic panel to check for liver metastases  Thyroid-stimulating hormone (TSH) levels once or twice per year if neck was radiated
  • 47.  CA Hypopharynx can be treated equally successfully with surgery and radiotherapy if presents at early stage(T1/T2)  Management of CA Hypopharynx requires a multidisciplinary approach.
  • 48. THANK YOU