Dr. Zaimal Shahan
Capital Hospital, Islamabad
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 )
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 )
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 )
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.
Patients complain that foods or
liquids are no longer being swallowed
easily and there is a sensation of food
Clinician must try to distinguish
oropharyngeal from oesophageal
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.
Children : Foreign body or congenital
Middle aged patients: Reflux oesophagitis,
hiatus hernia, anaemia, achlasia, globus
Elderly patients: Malignancy, stricture
formation from longstanding reflux,
pharyngeal pouch, motility disorders
associated with aging and neurological
Severity of symptoms
Types of food intake that causes
Pain on swallowing
Hoarseness of voice
Coughing after eating
Frequent chest infections
Complete Head and neck examination
Inspection of oral cavity
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.
Blood tests to exclude anaemia (? Cause or
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
CT scan examination
MRI is indicated when there are neurological
causes such as multiple sclerosis, cerebral tx,
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.
Typically present with difficulty
initiating a swallow and
coughing, choking, gagging, or
nasal regurgitation when
attempting to swallow
Most commonly caused by
disruptions in swallowing
secondary to neuromuscular
These symptoms may be more
severe when swallowing liquids
The history and physical
examination should focus on
neurologic signs and symptoms
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
A Modified barium swallow is performed by a
Radiologist, a Speech-language Pathologist,
and a radiology technician.
Barium sulfate powder is mixed in liquid
Thickener is added to make liquids nectar,
honey or puree consistency.
Barium paste is used, and spread on cookies.
The test is done in 2 views, Lateral (side),
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.
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
4-7% of all cancers of the upper
95% SCC (others include lymphomas,
neuroendocrine tumors, adenocarcinomas,
65-85% of hypopharyngeal carcinomas involve
the pyriform sinuses, 10-20% involve the
posterior pharyngeal wall, and 5-15% involve
the postcricoid area.
Male-to-female ratio of 3:1 (women have a
higher incidence of postcricoid cancers
related to nutritional deficiencies such as
The mean age at presentation is 65 years.
Gastroesophageal or laryngotracheal reflux
A condition specifically associated with
postcricoid carcinoma is the Plummer-Vinson
or Paterson-Brown-Kelly syndrome, which
primarily affects women (85% of the cases).
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
•Pooling in the piriform fossa
indicates failure of passage of
secretions down the
•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
Following investigations are considered
Full Blood count
Urea and electrolytes
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
To assess tumour mobility on
CT and MRI
To assess the extent of the primary tumour
To rule out second primary and distant
To assess neck
To look for cartilage invasion
Examination of larynx, pharynx,trachea and
Examination of oral cavity
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
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.
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
c: Bilateral or contralateral LNs all
less than 6cm
N3: Any LN more than 6cm
An understanding of the site of initiation and
patterns of spread of hypopharyngeal
carcinoma is critical in the management of
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.
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.
It depends on stage of tumor:
Radiotherapy alone (commonly 66-70 Gy) or
(possibly with postoperative irradiation,
depending on the pathology findings).
Larynx preservation therapy is typically
possible and is strongly favored.
Partial or total laryngopharyngectomy, neck
dissection, postoperative radiotherapy +/-
chemo, or concurrent chemoradiotherapy or
participation in prospective clinical trials.
Unresectable or medically unstable
(1) Radiotherapy alone with altered
fractionation or concurrent chemo-
(2) participation in prospective clinical
The control of regional metastasis is a
critical component of the management of
hypopharyngeal and cervical esophageal
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).
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
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.
Combined chemotherapy and radiation
therapy directed at the primary tumor are
the most common nonsurgical approaches for
Best responses are to platinum-based
compounds such as cisplatin or carboplatin
Chemo used alone only for palliation.
Close monitoring is required for these
Reevaluate the disease status due to high risk
Perform a neck examination and fiberoptic
laryngoscopy every 3 months for 2 years after the
initial treatment and 2-4 times per year
Monitor for second primary cancers
(incidence of approximately 3% per y) once
or twice per year.
Chest x-ray films for detection of lung cancer
Hepatic panel to check for liver metastases
Thyroid-stimulating hormone (TSH) levels
once or twice per year if neck was radiated
CA Hypopharynx can be treated equally
successfully with surgery and radiotherapy if
presents at early stage(T1/T2)
Management of CA Hypopharynx requires a