CA HYPOPHARYNX UG TEACHING CASE SHEET

1. • A 65 YEAR OLD MALE CAME WITH COMPLAINTS OF DIFFICULTY IN
SWALLOWING SINCE 6 MONTHS
• HOPI:
PATIENT WAS APPARENTLY NORMAL BEFORE 3 MONTHS THEN HE DEVELOPED
DIFFICULTY IN SWALLOWING WHICH IS ACUTE IN ONSET,INITIALLY HE HAD
DIFFICULTY IN SWALLOWING SOLIDS WHICH PROGRESSED TO SEMI SOLIDS
AND NOW PATIENT IS ABLE TO SWALLOW ONLY SIPS OF FLUIDS.
H/O NECK SWELLING PRESENTSINCE 2 MONTHS WHICH WAS INITIALLY SIZE OF
A PEA NOW IT HAS REACHED SIZE OF A ORANGE
NO H/O EAR ACHE
NO H/O VOICE CHANGE
NO H/O DIFFICULTY IN BREATHING
H/O LOW+
H/O LOA +

2. • PAST H/O: NOT SIGNIFICANT
• PERSONAL H/O: BEEDI SMOKER 15/DAY SINCE 20 YRS
ALCOHOLIC-600 ML/DAY SINCE PAST 30 YRS
• FAMILY H/O:
• GENERAL EXAMINATION:
CONSCIOUS,ORIENTED,COHERANT,COOPERATIVE
THINLY BUILT,THINLY NOURISHED
LEVEL 2 LYMPHADENOPATHY PRESENT

3. • Vitals :-Temp :- Afebrile, PR :- 66/bpm,BP :- 130/90 mm hg,RR :- 16/min
• Systemic Examination :
• Cranial nerve examination :- Normal
• ENT EXAMINATION :
• ORAL CAVITY :
• Mouth opening – full and adequate ,Angle of mouth – Normal ,Lips – Normal ,Gingivo Labial sulcus –Normal
• Gingivo Buccal Sulcus – Normal ,Gums- Nicotine stained
• Teeth – Normal , No loose tooth seen ,Anterior 2/3rd of Tongue – Normal
• Buccal Mucosa – Hyperpigmentation +,Hard Palate – Normal.
• Retro Molar Trigones – Normal

4. • OROPHARYNX : Normal
• IDL : Ulcero - Proliferative growth with irregular
surface seen involving left aryepiglottic fold and
left pyriform fossa. Pooling of saliva present. Right
Pyriform fossa Normal
• Base of tongue Normal
• Epiglottis Normal
• Vallecula Normal
• Vocal cords normal in mobility. Glottic chink
adequate.

5. Neck :
• Left level 2 lymphadenopathy :-
• A Single, Irregular, 5*3 cms with normal surface, hard in consistency, immobile, fixed to underlying structures,
skin over the swelling is pinchable. On contracting left SCM becoming less prominent.
• Trachea – central in position
• Laryngeal Framework – Normal
• Laryngeal Crepitus – Present
• No Laryngeal Tenderness
• Carotids – Palpable

6. • NOSE :
• Anterior Rhinoscopy ; Normal
• Posterior Rhinoscopy : Normal
• Ear : Normal
• PROVISIONAL DIAGNOSIS :
• Malignancy hypopharynx with secondaries in neck ( Left Pyriform fossa malignancy )