By Dr Ibrahim Habib Barakat (M.D) (E.N.T) E-mail;salamatuall@yahoo.com (Please vote for this lecture if you see it is good)

2. {‫العاملين‬ ‫ب‬‫ر‬ ‫ض‬‫ر‬‫األ‬ ‫ب‬‫ر‬‫و‬ ‫السموات‬ ‫ب‬‫ر‬ ‫الحمد‬ ‫فلله‬}‫الجاثية‬:36

3. {‫وسلم‬ ‫وصحبه‬ ‫اله‬ ‫وعلى‬ ‫محمد‬ ‫على‬ ‫صلى‬ ‫اللهم‬}

4. {‫يعلمون‬ ‫ال‬ ‫الناس‬ ‫أكثر‬ ‫ولكن‬ ‫الناس‬ ‫خلق‬ ‫من‬ ‫اكبر‬ ‫واألرض‬ ‫السموات‬ ‫لخلق‬}‫غافر‬:57

5. Cancer of the hypopharynx
By
Dr IBRAHIM H. AHMED Barakat
M.D.
Otorhinolaryngology
E-mail: salamatuall@yahoo.com

6. Anatomy of hypopharynx
area extending from :
tip of epiglottis to
lower border of cricoid cartilage .
divided into 3 anatomical subsites :
pyriform fossa ,
posterior pharyngeal wall ,
post cricoid area .

9. Pyriform fossa
Inverted of pharyngeal mucosa .
Superiorly : lateral glosso epiglottic fold .
Apex : meeting of lateral & medial wall inferiorly.
Lateral : Thyroid cartilage. Contiguous with post.
pharyngeal wall.
Medially : Aryepiglottic fold & arytenoid cartilage
contiguous with post cricoid area.

10. Posterior pharyngeal wall
Pharyngeal mucosa
The plane of tip of epiglottis
Down to ;
Cricopharyngeous muscle

11. Post cricoid area
• Mucosa covering the posterior surface of the
cricoid cartilage ,
• extending from the arytenoids superiorly to
lower border of cricoid cartilage inferiorly .

12. The wall of the hypopharynx
• An inner mucosa : stratified squamous
epithelium .
• A fibrous layer : of pharyngeal aponerosis .
• A muscular layer : inferior constrictor of the
pharynx & distal portion of middle constrictor.
• A layer of fascia : buccopharyngeal fascia .

13. Blood supply to hypo pharynx
Ascending pharyngeal branch of external
carotid a.
Ascending palatine & tonssilar braches of
facial a.
Descending pharyngeal &
palatine branches of internal maxillary
a.

14. Lymphatics of hypoharynx
• Upper & mid jugular node .
• Retropharyngeal lymph nodes .
• Node of Rouviere at skull base .
• Prelaryngeal & paratracheal lymph nodes .

15. Cancer of the hypopharynx
epidemiology
•1.1 per 100,000 per year
etiology
Excessive tobacco use &
alcohol consumption .

16. Risk factors
- chronic alcohol and tobacco use
- older age
- family history
- Exposure to polycyclic aromatic hydrocarbons ,
asbestos , & welding fumes.
- Nutritional deficiencies
- Infectious agents especially papilloma virus &
fungi

17. Diseases associated with
hypopharynx ca.
- Plummer Vinson syndrome
- esophageal web
- celiac disease
- scleroderma
- tylosis

18. Field cancerization
Tobacco & alcohol contribute to the
development of multiple carcinoma

19. Superficial spreading carcinoma
Areas of in situ carcinoma
alternating with sections of
micro invasive carcinoma or
with foci of frank invasion over
a large epithelial field .

20. Patterns of local spread
Pyriform sinus :
paraglottic space .
Lateral & post . Pharyngeal wall .
Thyroid gland , cricoid cartilage .
v. c. fixation.
Posterior pharyngeal wall :
tonsillar fossa & oropharynx
Cervical esophagus.
Prevertebral fascia.
Post cricoid area : cricoid cartilage & cervical
esoph,

21. Pattern of lymphatic spread
Post. Pharyngeal wall :
Pyriform sinus :
Post cricoid lesion :
Occult metastasis :
Lymph node groups 60% &
Retropharyngeal L. Ns. 44%
L. N. metastasis 75%
L. N. metastasis 40%
Para tracheal L. N.
50% – 80%

22. Clinical presentation
Early lesions :
No symptoms .
Or vague throat pain .
Advanced lesions :
odynophagia ,
referred otalgia &
dysphagia

23. Clinical presentation
Vague throat pain :
Referred otalgia :
Hemoptysis :
Weight loss :
Ptyalism :
Palpable neck lump
:
Early lesion .
Pyriform fossa tumour .
Large fungating or ulcerated
lesion .
Malnutrition . (circumferential
lesion ) .
Blood tinged ( ulcerated lesion)
Direct extension in soft tissue
neck .

24. Signs of hypopharyneal carcinoma
Palpable lump in the neck , in 2/3 of the
extension in soft tissue neck ) .)patients
Pooling of saliva , edema & erythema especially
near arytenoid . ( apex of pyriform & post
cricoid lesion ) .
Indirect mirror , tumors of posterior pharyngeal
wall & upper pyriform sinus .

25. Clinical evaluation
- complete history of the disease
- weight and weight loss
- performance status
- fiberoptic examination of H&N
mucosa
- neck examination
- drawing of any lesions

26. Complete examination of
the head and neck
Includes examination
• oral cavity,
• pharynx,
• indirect laryngoscopy.
• fiberoptic examination of the larynx and pharynx
.

27. The examination
status of the dentition,
the status of the airway,
vocal cord mobility,
laryngeal crepitus,
tumor extension to:
- the medial, anterior and lateral wall of the pyriform sinus
- the posterior pharyngeal wall or to the post cricoid region.

28. Palpation of the neck bilaterally,
Recording
- the location (Group or Level I - VI),
- size,
- mobility,
- relationship of the node(s) to adjacent
structures.

29. The staging of the primary
and of the cervical lymph
nodes must be documented

30. Imaging Studies:
•Chest radiographs, PA and lateral
To rule out
(1) A synchronous pulmonary tumor,
(2) Acute or chronic pulmonary
disease
(3) Metastatic tumor.

31. imaging
Extent , synchronous tumour .
Thickness , invasion ,
Lymph node metastasis .
Soft tissue details & fat planes ,
Tissue edema & tumor extention .
Viability of a tumor .
Residual , recurrent tumor after
Radiotherapy .
barium swallow
C T scan
M R I
P E T

32. Fig.1
Contrast-enhanced spiral CT images. a. Axial
image during quiet breathing shows subtle soft
tissue thickening in the apex of the right pyriform
sinus (arrow; compare to opposite side); there is
some evidence of subtle infiltration or
displacement of the paraglottic space fat
(arrowhead).
b. Axial image obtained during modified Valsalva
maneuver. The right pyriform sinus expands
somewhat less than the opposite side; the
mucosal irregularity produced by the cancer is
now better visible (arrowheads). Squamous cell
carcinoma.

33. Fig.2
Unenhanced spiral CT images in a patient with a large
laryngohypopharyngeal carcinoma. No contrast medium was
injected because of renal failure. a. Axial image at the level of the
cricoid cartilage. Soft tissue thickening is seen in the retrocricoidal
hypopharynx (arrow) and also beyond the thyroid cartilage, beneath
the thyroid gland (arrowheads). Extensive sclerosis of the cricoid
arch and inferior part of the thyroid lamina is seen at the left side

34. b. Axial image at the glottic level. Thickening of the left vocal cord,
with infiltration of the left paraglottic space (compare to opposite
side). The mass is also seen in the apex of the pyriform sinus
(arrow), extending underneath the pharyngeal constrictor muscle
posterolaterally from the thyroid lamina (arrowheads). Note again
sclerosis of the left thyroid lamina and left arytenoid.

35. c. Axial image through the lower supraglottis. Large
tumour mass in the left pyriform sinus (arrows),
extending into the left paraglottic space (arrowheads).

36. d. Axial image just above the thyroid cartilage. The hypopharyngeal
tumour mass bulges into the soft tissues of the neck (arrows); the
carotid artery (asterisk) has not yet been affected. Infiltration of
the upper paraglottic space (arrowhead). Pathological examination
revealed squamous cell carcinoma and confirmed the described
soft tissue infiltration, but no neoplastic cartilage invasion was
found.

37. Laboratory Tests:
• Preoperative tests according to
institutional guidelines.
• Pulmonary function and arterial blood
gases in the patients with COPD or who
are candidates for partial laryngo-
pharyngectomy.
• Baseline liver function tests (optional).

38. .EXAMINATION UNDER ANESTHESIA AND BIOPSY:
To assess the superior and inferior limits of the
tumor, its relationship to the apex of the pyriform
sinus, the lateral pharyngeal wall, tonsillar fossa, base
of tongue, the postcricoid region, the opposite
pyriform sinus, and direct involvement of the larynx.
To rule out the existence of other primary tumors in
the aerodigestive tract.

39. EXAMINATION UNDER ANESTHESIA AND BIOPSY:
•To assess the mobility of the tumor over the prevertebral
fascia.
•In patients with advanced primary disease and airway
impairment, the examination under anesthesia may
require a tracheostomy to secure the airway. If this is
necessary, the examination may be performed in
conjunction with the definitive surgical procedure.
•Esophagoscopy is performed to evaluate extension into
the post cricoid region or cervical esophagus.
•Bronchoscopy if indicated by clinical or radiographic
findings.

40. Consultations:
•Radiation therapy
In anticipation of possible need for post-operative
radiation therapy or to use radiation therapy as a
definitive primary modality of treatment in early
stage tumors.

41. Consultations:
•Dental
To assess the status of the teeth and make
recommendations considering that radiation
therapy may be indicated. The evaluating dentist
should be versed in the effects of radiotherapy
on dentition. This evaluation should be done with
knowledge of the treatment portals planned for
the radiotherapy.

42. Consultations:
•Speech pathology
For pre-operative counseling regarding possible
post-operative speech and swallowing
rehabilitation.

47. management
Surgery and radiotherapy employed alone or in
combination . Recently , induction
chemotherapy in combination with radiation &
surgery has been used aiming to :
- Increase loco regional control .
- decrease systemic metastasis .
- prolong survival .
- preserving a functioning larynx
.

48. Surgical treatment
1 – partial larygopharyngectomy .
2 – posterior pharyngeal wall resection .
3 – total laryngectomy with partial
pharyngectomy .
4 – total laryngopharyngectomy .
5 – total laryngopharyngoesophagectomy .

49. Surgical procedure Indications
- small pyriform sinus tumour not affecting its
apex or base of tongue , with mobile v.
cords .
- advanced pyriform sinus tumour involves its
apex ,post cricoid mucosa , laryngeal
framework , with paralysed hemi larynx .
- 1ry closure if defect is < 1/3 circumference .
- radial forearm free flap or pectoralis major
myocutanous flap if defect is > 50%
circumference
-partial laryngopharyngectomy :
-total laryngectomy with partial
pharyngectomy :
-Reconstruction :
-:

50. Surgical management continue .
Surgical procedure
-Total larengopharyngectomy :
-Reconstruction :
•Total laryngopharyngoesophagectomy
-Reconstruction :
-Resection of post. Pharyngeal wall ca.
-Reconstruction
indications
- Post cricoid & cervical esophageal lesions .
- A free segment of jejunum ,
- Radial forearm free flap .
- Lesion extends to lower cervical
esophagus ,or
upper thoracic esophagus .
- Mobilization of the stomach &
transposition into the neck .
- A small superficial upper or lower post.
Phary. wall lesion.
- Split thickness skin graft for ( limited
excion ),or
- Radial forearm mictovascular free flap (
(large resection ) .

51. Management of the neck
No neck : elective neck dissection , clearing level
1 , 2 , 3 .
N +ve neck : comprehensive neck dissection .

52. Role of radiotherapy
Radiotherapy is usually utilized
in conjunction with surgery
except :
- Superficial lesions confined to pyriform
sinus with normal vocal cord .
- posterior pharyngeal wall tumours .

53. Multimodality therapy
Induction chemotherapy with 2 to 3 cycle of cisplatin –
based chemotherapy gives complete response rates
of up to 60% with no improvement in survival over
convential treatment of surgery with post operative
radiotherapy .

68. Postoperative Care includes:
•Hospitalization for 7-14 days.
•Intensive care unit, as needed.
•Tube feedings until oral alimentation is reestablished.
•Low pressure suction to the drains.
•Removal of the drains when 24 hour output is less
than 30-50 cc.
•Tracheostomy or stoma care.
•Sutures removed from the neck on the 7-10
postoperative day.
•consult a home-visiting nursing service (optional)
•Speech therapy and physical therapy, as needed

69. Postoperative Care includes:
•For patients undergoing a laryngeal sparing
procedure or partial laryngectomy, a modified
barium swallow may be appropriate prior to
initiating oral alimentation, to rule out significant
aspiration.
•May require discharge with tracheotomy tube and
feeding tube in place. Adequate training of patient
and support personnel is needed before discharge
can safely be effected. Ensure that a portable
suction machine is available to the patient

71. {....‫عظيما‬ ‫عليك‬ ‫هللا‬ ‫فضل‬ ‫وكان‬ ‫تعلم‬ ‫تكن‬ ‫لم‬ ‫ما‬ ‫وعلمك‬}‫النساء‬:113

72. DR , IBRAHIM HABIBThank you