short brief of tumors of hypopharyns

1. TUMORS OF HYPOPHARYNX
BY DR.M.V.HARIKA

2. Applied Anatomy
• Hypopharynx is the lowest part of the pharynx and
lies behind and partly on the sides of the larynx. Its
superior limit is the plane passing from the body of
hyoid bone to the posterior pharyngeal wall, while
the inferior limit is lower border of cricoid cartilage
where hypopharynx becomes continuous with
oesophagus. Hypopharynx lies opposite the third,
fourth, fifth, sixth cervical vertebrae. Clinically, it is
subdivided into three regions—the pyriform sinus,
postcricoid region and the posterior pharyngeal
wall.

3. • Pyriform sinus (fossa). It lies on either side of the
larynx and extends from pharyngoepiglottic fold
to the upper end of oesophagus.
It is bounded laterally by the thyrohyoid
membrane and the thyroid cartilage and medially
by the aryepi- glottic fold, posterolateral surfaces
of arytenoid and cri- coid cartilages . It forms the
lateral channel for food. Foreign bodies may
lodge in the pyriform fossa. Internal laryngeal
nerve runs submucosally in the lateral wall of the
sinus and thus is easily accessible for local
anaesthesia. It is also through this nerve that pain
is referred to the ear in carcinoma of the pyriform
sinus.

4. • Postcricoid region. It is the part of the
anterior wall of laryngopharynx between the
upper and lower borders of cricoid lamina. It
is a common site for carcinoma in females
suffering from Plummer–Vinson syndrome.
• Posterior pharyngeal wall. It extends from
the level of hyoid bone to the level of
cricoarytenoid joint.

6. • Benign tumours. They are exceptionally uncommon and
include papilloma, adenoma, lipoma, fibroma and
leiomyoma. They present as smooth well-defined masses
which are sometimes pedunculated and mobile.
• Malignant tumours. Carcinoma of the hypopharynx is
very common in India. Practically, most of the tumours are
squamous cell type with various grades of differentia- tion.
The various subsites involved are:
I. pyriform sinus,
II. postcricoid region and
III. posterior pharyngeal wall, in that order of frequency.

7. CARCINOMA PYRIFORM SINUS
• It constitutes 60% of all hypopharyngeal
cancers, mostly affecting males above 40
years of age. Growth is either exophytic or
ulcerative and deeply infiltrative. Because of
the large size of the pyriform sinus, growths of
this region remain asymptomatic for a long
time. Metastatic neck nodes may be the first
to attract attention.

8. Spread
• Locally, the growth may spread upwards to the val-
lecula and base of tongue; downwards to postcricoid
region; medially to aryepiglottic folds and ventricles. It
may infiltrate into the thyroid cartilage, thyroid gland
or may present as a soft tissue mass in the neck.
• Lymphatic spread occurs early. Pyriform fossa has a
rich lymphatic network. Seventy five percent of the
patients have cervical nodal metastases when first
seen, with half of them having bilateral involvement.
Upper and middle group of jugular cervical nodes are
often involved. Sometimes, nodes make their
appearance long after the primary has been
eradicated.
• Distant metastases often occur late and may be seen
in lung, liver and bones.

9. Clinical Features
• Early symptoms are few. Something sticking in
the throat and “pricking sensation” on
swallowing may be the earliest symptoms.
Referred otalgia, pain on swallowing and
increasing dysphagia may follow. A mass of
lymph nodes high up in the neck may be the
first sign. Hoarseness and laryngeal
obstruction indicate laryngeal oedema or
spread of disease to the larynx.

10. Diagnosis
• Growth and its extent can often be seen on
mirror examination. Sometimes, pooling of
secretions obstructs the view.
• Barium swallow and CT scan are helpful to
evaluate the extent of growth and status of
lymph nodes.
• Endoscopic examination is necessary for biopsy
and accurate assessment of the extent of growth
and also to find out any synchronous primary at
any other site.

11. Treatment
• Early growth without nodes can be cured by
radio- therapy with the advantage of
preserving the laryngeal function.
• If growth is limited to pyriform fossa and does
not extend to postcricoid region, total
laryngectomy and partial pharyngectomy is
done. Remaining pharynx can be primarily
closed. This is often combined with elective or
prophylactic block dissection of lymph nodes.

12. • If growth extends to postcricoid region, total
laryngectomy and pharyngectomy is done
along with block dissection. Pharyngo-
oesophageal segment is reconstructed with
myocutaneous flaps or stomach pull-up.
• Planned postoperative radiotherapy can be
given routinely to all cases. Patients with no
palpable nodes (N0 neck) can also be given
radiotherapy avoiding block dissection.

13. CARCINOMA POSTCRICOID REGION
• This constitutes 30% of laryngopharyngeal
malignancies. Paterson–Brown–Kelly
(Plummer–Vinson) syndrome characterized by
hypochromic microcytic anaemia is an
important aetiological factor as one-third of
patients of postcricoid carcinoma may be
suffering from it.

14. Spread
• Usually an ulcerative type of lesion arises from
postcricoid region. Local spread often occurs in
an annular fashion causing marked dysphagia.
Growths may invade cervical oesophagus,
arytenoids or recurrent laryngeal nerve at
cricoarytenoid joint.
• Lymphatic spread involves paratracheal lymph
nodes and may be bilateral due to the midline
nature of lesions. They may not be clinically
palpable.

15. Clinical Features
• Females are usually affected, sometimes in
the early age group of twenties and thirties.
Progressive dysphagia is the predominant
presenting symptom. This may cause
progressive malnutrition and weight loss.
Sometimes, voice change and aphonia may be
produced due to infiltration of recurrent
laryngeal nerve or posterior cricoarytenoid
muscles affecting vocal cord mobility.

16. Diagnosis
• Postcricoid growths may not be visible on indirect
laryngoscopy. Oedema and erythema of the
postcricoid region and pooling of secretions in
the hypopharynx are suggestive of growth.
Laryngeal crepitus, felt normally while moving
larynx over the cervical spine, may be lost.
• Lateral soft tissue radiograph of the neck may
show an increased prevertebral shadow. Barium
swallow is essential to find the lower extent of
the disease. Endoscopy is always done to take
biopsy and assess the extent of lesion.

17. Treatment
• Prognosis is poor both with irradiation and
surgical treatment. Some prefer to give
radiotherapy initially. It has the advantage of
preserving laryngeal function. Failed cases are
subjected to laryngo-pharyngo-
oesophagectomy with stomach pull-up or
colon transposition to reconstruct pharyngo-
oesophageal segment. Many feel that initial
surgery, if feasible, gives better results.

18. CARCINOMA POSTERIOR
PHARYNGEAL WALL
• This is the least common of laryngopharyngeal
malignancy constituting only 10% of them.
They are mostly seen in males above 50 years
of age.

19. Spread
• Growth is usually exophytic but may be
ulcerative. It remains localized until late and
then spreads to the prevertebral fascia,
muscles and vertebrae.
• Lymphatic spread is usually bilateral due to
midline nature of the lesion. Fifty per cent of
the patients with cancer of posterior
pharyngeal wall have nodal metastasis on
their initial examination. Retropharyngeal
nodes, though not clinically palpable, may also
be involved.

20. Clinical Features
• Dysphagia or spitting of blood may be the
presenting symptom. Some may present with
a palpable mass of nodes in the neck without
any symptoms pointing to the primary
tumour.

21. Diagnosis
• Indirect mirror examination often reveals the
tumour. Lateral soft tissue radiography may
show vertical extent and thickness of the
tumour and any involvement of cervical
vertebrae. Endoscopy is essential for biopsy
and accurate assessment of the tumour and to
find any synchronous primary at any other
site.

22. Treatment
• Early lesions, particularly exophytic, can be
treated by radiotherapy with preservation of
laryngeal function. Early small lesions can also
be excised surgically via lateral pharyngotomy
and primary repair with equally good results.
Advanced lesions may require
laryngopharyngectomy and block dissection of
neck with repair of the food channel. Gross 5-
year cure rate is only 19%.

23. PHARYNGEAL POUCH

24. Hypopharyn- geal mucosa herniates through the
Killian’s dehiscence—a weak area between two
parts of inferior constrictor muscle.

25. • Also called hypopharyngeal diverticulum or
Zenker’s diverticulum, it is a pulsion
diverticulum where pharyngeal mucosa
herniates through the Killian’s dehiscence— a
weak area between two parts of the inferior
constrictor.

26. AETIOLOGY
• Exact cause is not known. It is probably due to
spasm of cricopharyngeal sphincter or its
incoordinated contractions during the act of
deglutition. It is usually seen after 60 years of
age.

27. PATHOLOGY
• Herniation of pouch starts in the midline. It is
at first behind the oesophagus and then
comes to lie on its left. Mouth of the sac is
wider than the opening of oesophagus and
food preferentially enters the sac.

28. CLINICAL FEATURES
• Dysphagia is the prominent feature. It appears
after a few swallows when the pouch gets filled
with food, and presses on the oesophagus.
Gurgling sound is produced on swallowing.
Undigested food may regurgitate at night,
• when patient is recumbent, causing cough and
aspiration pneumonia. Patient is often
malnourished due to dysphagia. Patients with
pharyngeal pouch may have associated hiatus
hernia. Rarely carcinoma can develop in long-
standing cases of pharyngeal pouch.

29. DIAGNOSIS
• Barium swallow will show the sac and its size.

30. TREATMENT
1. Excision of pouch and cricopharyngeal
myotomy. This is done through cervical
approach.
2. Dohlman’s procedure. The partition wall
between the oesophagus and the pouch is
divided by diathermy through an endoscope.
This is done in poor risk debilitated patients.
3. Endoscopic laser treatment. It is similar to Dohl-
man’s procedure. Partition between the pouch
and oesophagus is divided by CO2 laser using
operating microscope.

31. PLUMMER-VINSON (PATTERSON BROWN-KELLY)
SYNDROME
Plummer- Vinsson (PV) syndrome predominantly affects middle
aged females.It consists of atrophy of the mucous membrane of
the alimentary tract, subepithelial fibrosis in lower part of
laryngopharynx and iron deficiency anemia.
Clinical Features:
Dyspagia immediately after trying to swallow food
Iron- Deficiency anemia
Glossitis
Angular Stomatitis
Kollonychias ( Spooning of nails)
Achlorhydria

32. Potential of Malignant Conversion :
The PV syndrome may be associated with carcinoma of the tounge,
buccal mucosa, pharynx, esophagus or stomach. About 10% of the
patients devlop postcricoid carcinoma.
Diagnosis :
Barium Swallow and esophagoscopy: A hypopharyngeal web
(subepithelial fibrosis) can be seen in the postcricoid region.
Treatment :
Oral or parenteral iron:For correcting anemia. Serum level of
iron is more important than hemoglobin.
 Vitamins B12 and B6.
Esophagoscopy and dilatation of webbed area with bougies.

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