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HYPOPHARYNX ANATOMY & HYPOPHARYNGEAL CANCERS
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HYPOPHARYNX ANATOMY & HYPOPHARYNGEAL CANCERS

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ANATOMY, RADIOLOGY,HYPOPHARYNGEAL CANCERS …

ANATOMY, RADIOLOGY,HYPOPHARYNGEAL CANCERS
CASE PRESENTATION

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  • 1. HYPOPHARYNX Presented by : Dr. Isha jaiswal Moderator: Dr. RAHAT HADI Date: 20 th nov. 2013
  • 2. ANATOMY OF THE HYPO PHARYNX • Nasopharynx • Oropharynx • Laryngopharynx (Hypopharynx) Seen from behind
  • 3. 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
  • 4. 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
  • 5. 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.
  • 6. PYRIFORM SINUS
  • 7. POST CRICOID REGION Pharynx mucosa covering post. Surface of cricoid Pharynx become continuous with esophagus at post cricoid region Extent: • Superior: arytenoids • Inferior: oesophagus arytenoids ccoesophagus
  • 8. POSTERIOR PHARYNGEAL WALL Cover mid & inf constrictor ms.  Seperated from prevertebral fascia by retropharyngeal space. Extent: Superiorly: upper border of epiglottis Inferior: lower border of cricoid Sideways: apex of one piriform sinus to other.
  • 9. ( Nerve supply of hypopharynx • internal branch of sup. Laryngeal nerve :vagus; (X) • Glossopharyngeal nerve :(IX) sensory: • External branch of sup. Laryngeal nerve (X) • Recurrent laryngeal nerve (X) • Pharyngel plexus (IX) motor
  • 10. LYMPHATIC DRAINAGE Deep cervical lymph node : level 2,3& 4 Prelaryngeal & paratracheal lymph nodes: level 6. Retropharyngeal node Node of rouviere at skull base
  • 11. LYMPHATIC DRAINAGE
  • 12. 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
  • 13. RADIOLOGICAL ANATOMY
  • 14. LYMPHATIC SUPPLY OF NECK DIVIDED 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
  • 15. Submental: Ia Submandibular:Ib upper deep cervial: II Retropharyngeal Post triangle:level V
  • 16. PRE TRACHEAL NODE ; LEVEL VI MID. DEEP CERVICAL LEVELIII POST CERVICAL :LEVEL V
  • 17. “ ” Pre tracheal node ; Level VI lower Deep cervical LEVEL IV Post cervical :LEVEL V
  • 18. PET SCAN IMAGECT IMAGE
  • 19. During spontaneous breathing Upon phonation The PyriformFossaeViews as Seen by Usinga direct laryngoscope Upon forceful nose blowing with the mouth closed
  • 20. CARCINOMA PYRIFORM FOSSA Carcinoma hypopharynx
  • 21. POST CRICOID AREA: The hypopharynx leading to upper oesopageal sphincter. Occasionally brisk opening seen apon laryngeal examinarion (arrow). Upper osophageal sphincter opening- upon rigid oesophagoscopy.
  • 22. CARCINOMA HYPOPHARYNX Constitute 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
  • 23. INCIDENCE OF HYPOPHARYNX CA. 65-75% • PYRIFORM SINUS CARCINOMA 5-15% • POST CRICOID CARCINOMA 10-20% • POST. PHARYNGEAL WALL CARCINOMA
  • 24. 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 history Tobacco Alcohol Exposure : polyaromatic compounds ; asbestos & welding fumes Nutritional deficiency. VIT A.& E. IRON. CRATENODS & FLAVRNOIDS.
  • 25. RISK FACTORS OF CA .HYPOPHARYNX infectons; HPV (20–25% only postive for hpv dna & Ab against HPV 16 E6 & E7) Associated diseases: PLUMMER VINSON SYNDROME GENETIC: P53 & EGFR mutation Synchronous & metachronous malignancy
  • 26. 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
  • 27. CARCINOMA OF PYRIFORM SINUS • Age:40 years • presentation: late; Metastatic neck nodes Spread: local Upwards: base of tongue Downwards: post cricoid region Medially: AE fold and ventricle Laterally: thyroid cartilage, Lymphatic spread: upper and middle group of jugular cervical nodes Distant metastasis: occur late and may be seen in lung, liver, bone
  • 28. 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
  • 29. 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
  • 30. CLINICAL PRESENTATION Hoarseness of voice: vocal cord fixation Stridor: masseffect on trachea Weight loss. Anemia malnutrition Throat pain, Sore throat dysphagia Odynophagia pooling of saliva Referred otalgia: cause int. laryngeal nerve (X) Neck mass: metastatic neck node Direct extension
  • 31. most frequent presenting symptoms include a neck mass (either representing the tumour or nodal metastases -
  • 32. Early lesion may result in vague throat pain Stenotic tumours near the pharyngo- oesophageal junction may result in , dysphagia. Drooling of saliva may occur due to oedema near arytenoids.
  • 33. MECHANISM OF OTALGIA
  • 34. 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.
  • 35. CLINICAL EVALUATION History taking General physical examination Oral hygeine & dentition Airway status Status of speech & swallow. Complete examination of oral cavity , oropharynx.  Examinaton of neck nodes. Indirect layngoscopy Direct laryngoscopy
  • 36. ORAL CAVITY EXAMINATION • 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
  • 37. EXAMINATION OF ORAL CAVITY
  • 38. EXAMINATION OF NECK NODES Location Size number Mobility Tenderness Relationship with adjacent structure.
  • 39. Examination of neck nodes: sub mental(Ia) & submandibular(Ib)
  • 40. Examination of neck nodes: upper.,middle & lower deep cervical (Ii; iii. iv)
  • 41. INDIRECT LARYNGOSCOPY mirror warmed; check temp. Hold tongue Introduce 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,
  • 42. structures seen on indirect laryngoscopy (in order): Base of the tongue Vallecula Median and lateral glossoepiglottic folds Epiglottis Vestibular fold True vocal cords Trachea Layngeal cartilage
  • 43. PRE TREATMENT EVALUATION: To asses extent of tumour Relation with other structure Involvement of larynx Mobillity of vocal cords Direct laryngoscopy Oesophagoscopy Bronchoscopy Panendoscopy Chest x ray :infection; malignancy;mets  HRCT : thickness, invasion, L.N metstasis MRI :soft tissue details, tissue oedema PET :residual or recurrent tumour after RT