HYPOPHARYNGEAL CARCINOMA

Dr. Zaimal Shahan

Post-graduate Resident

Otolaryngology Department

Capital Hospital, Islamabad

WHAT ARE THE STAGES OF SWALLOWING?

Oral Preparatory PhaseOral Preparatory Phase

Break down foodBreak down foodMix with salivaMix with salivaPrevent premature escape into pharynxPrevent premature escape into pharynx

Oral PhaseOral PhaseTongue elevates ant to postTongue elevates ant to post

Tongue forms central grooveTongue forms central grooveLabial 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 control Voluntary control -- ( XII )( XII )

Pharyngeal PhasePharyngeal Phase

Begins when bolus passes anterior pillar or Begins when bolus passes anterior pillar or faucesfaucesEnds when bolus passes through upper oesophageal sphincter into Ends when bolus passes through upper oesophageal sphincter into oesophagusoesophagusVelum 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 control Involuntary control –– ( IX, X, XII )( IX, X, XII )

OesophagealOesophageal PhasePhase

Begins when bolus enters Begins when bolus enters oesophagusoesophagusEnds when bolus passes through lower Ends when bolus passes through lower oesophageal oesophageal sphincter into stomach 8sphincter into stomach 8--20 seconds later20 seconds laterSequential peristaltic wave propels bolus Sequential peristaltic wave propels bolus Relaxation of lower Relaxation of lower oesophageal oesophageal sphinctersphincter

Involuntary control Involuntary control –– ( X )( X )

VIEW OF NORMAL SWALLOW

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DEFINITION

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.

HISTORY AND EXAMINATION

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

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.

COMMON CAUSES:

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.

HOW TO APPROACH A PATIENT PRESENTING WITH DYSPHAGIA 1.HISTORY 2.CLINICAL EXAMINATION 3.INVESTIGATIONS 4.ENDOSCOPY

HISTORY

Onset. Duration Progression Severity of symptoms Types of food intake that causes

problems Alleviating factors

ASSOCIATED SYMPTOMS

Regurgitation Pain on swallowing Hoarseness of voice Otalgia Coughing after eating Frequent chest infections

CLINICAL EXAMINATION

Complete Head and neck examination Inspection of oral cavityPharynx IDLVideolaryngoscopy/ NasopharyngoscopyCranial 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.

INVESTIGATIONS

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

SPECIAL INVESTIGATIONS

Barium swallow Chest radiograph CT scan examination MRI is indicated when there are

neurological causes such as multiple sclerosis, cerebral tx, nasopharyngeal ca.

ENDOSCOPY Rigid endoscopy Direct Laryngoscopy Rigid Esophagoscopy Flexible endoscopy

OROPHARYNGEAL DYSPHAGIA

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 immediately experience coughing, choking, gagging, or nasal regurgitation when attempting to swallow

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

CLINICAL SWALLOW EVALUATIONS 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.

MODIFIED BARIUM SWALLOW - MBS

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.

Barium paste is used, and spread on cookies.

The test is done in 2 views, Lateral (side), and AP

Anterior-Posterior.

HYPOPHARYNGEAL CARCINOMA 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.

ANATOMY 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.

EPIDEMIOLOGY 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.

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.

ETIOLOGY 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).

PRESENTATION

EXAMINATION 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.

•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.

LABORATORY INVESTIGATIONS

Following investigations are considered essential:

Full Blood count Iron Stores Urea and electrolytes LFT Serum Calcium Thyroid Function

RADIOLOGICAL ASSESSMENTBarium 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

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

ENDOSCOPY

Examination of larynx, pharynx,trachea and esophagus

Examination of oral cavity Biopsy

STAGING

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.

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

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.

TUMOR SPREAD 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.

TREATMENTIt 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.

T3/T4 (resectable)

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-radiotherapy

(2) participation in prospective clinical trials.

MANAGEMENT OF THE NECK 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).

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.

NON-SURGICAL MANAGEMENT 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.

FOLLOW-UP 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.

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 or metastases

Hepatic panel to check for liver metastases

Thyroid-stimulating hormone (TSH)

levels once or twice per year if neck was radiated

CONCLUSIONS 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.

THANK YOU