Cancer of Hypopharynx
Head and Neck Tumour Surgery
Cancer of Hypopharynx
Where is Hypopharynx?
The hypopharynx is situated behind the voice box (Fig.1. Coloured green). The upper part communicates with the oropharynx and the lower part forms the entrance of the food pipe (oesophagus). Because the hypopharynx is behind the voice box, the front wall of the hypopharynx is actually the back wall for the voice box covered by mucosa (known as post cricoid area). On either side of the front wall, are the funnel shaped pyriform si-nuses directing food down towards the oesophagus.
Fig.1
Who does it affect?
Incidence of hypopharyngeal cancers is much lower compared to the laryngeal cancers and is nearly always squamous cancers. Approximately 80% of cancers occur in men. This is because smoking and alcohol abuse are common among men.
What symptoms does it cause?
- Unfortunately hypopharyngeal tumours produce few symptoms until they are advanced. They may cause:
- Sore throat
- Ear pain
- Voice change
- Pain or difficulty in swallowing
- Appreacnce of a lump in the neck
- Feeling of food sticking in the throat.
At least 70% of hypopharyngeal cancer cases arise in the pyriform sinus. Diffused local spread is common and is caused by tumour extension underneath the mucosal lining. Abundant lymphatic drainage results in a higher incidence of spread to the lymphnode compared to other head and neck tumours. At presentation, 70-80% of the patients with hypopharyngeal cancers have a lump in the neck; in half of these patients lymphnode metastases is the presenting complaint. Bilateral metastases are seen in only 10% of the patients with pyriform sinus cancers but in 60% of those with postcricoid tumours.
How is it diagnosed?
The hypopharynx will be examined by the ENT surgeon with a help of small mirrors or fbreoptic endoscope. The flexible fibreoptic hypopharyngoscopy can be done as an out patient procedure under local anaesthesia by passing a thin endoscope through the nose into the pharynx.
If something suspicious is seen, then the next step is performing an endoscopy under general anaesthesia. If some area looks abnormal, then a biopsy is taken from that area. If the neck nodes are enlarged, fine needle aspiration is done for cytological examination (FNAC) by the pathologist to rule out metastatic carcinoma. If cancer is found, the doctor will need to know the extent of the disease. This is called staging. In most cases, the most important factor in considering treatment options is the stage of the disease. The stage is based on the size of the tumour, as well as whether or not the cancer has spread (metas-tasized) and where it has spread. To obtain more information about the location and ex-tent of the cancer, the doctor may perform the following investigations.
- CT scan of neck
- PET-CT
How is it treated?
The three main types of treatment for these cancers are surgery, radiation and chemo-therapy. Most of these cancers will need surgery and /or radiotherapy. Chemotherapy is usually given when the cancer has spread too far to be treated with surgery and radio-therapy. It is also given before or along with radiation with the goal of preserving the voice box.
Radiation
Since surgical treatment for hypopharyngeal cancer involves removal of the voice box, radiotherapy has been the ideal treatment for small tumours. Radiotherapy is most com-monly used after surgery in large tumours to kill cancer cells that are not visible during surgery. In some cases when the tumour is extensive and cure is not possible, radiother-apy is given for easing symptoms like pain, bleeding and swallowing.
Surgery
- With small tumours, a number of conservative surgical procedures are available viz
- Partial pharyngectomy
- Partial laryngopharyngectomy
- Near total laryngectomy
- All these procedures are designed to preserve the natural voice by preserving the voice box, fully or partly. With large tumours, surgical removal of the voice box along with the tumour becomes inevitable.
Total laryngopharyngectomy
In this situation, the continuity between the pharynx and oesophagus is lost. This is re-constructed in a number of ways. The latest technique is to use a small portion of the small intestine (Jejunum) (Fig.2). The blood supply to this segment of the transposed intestine is reestablished in the neck by connecting its blood vessels to the blood vessels in the neck using microsurgical techniques.
Fig.2.
In cases where the tumour extends into the food pipe (oesophagus), total laryngopharyn-go oesophagectomy is done. The stomach is brought to neck and connected to the phar-ynx.
When the voice box is removed, the patient will no longer have normal speech. This doesn’t mean that speech is lost and there are ways to talk without a larynx. Further in-formation about Alaryngeal Speech can be obtained in the section about cancer of the larynx.
Questions patients should ask before deciding about the treatment:
- What are my treatment options?
- What are the risks and benefits for each of my treatment options?
- How will treatment affect my everyday activity? How long?
- How often will I need to return?
- Has my doctor explained various surgical options to my satisfaction?
- Has a surgeon who has expertise with removal of cancer, as well as, with reconstruction seen me? Have I seen by a surgeon, radiation oncologist, prosthodontist and dentist?
- Do I know all I need to know about prostheses and prosthetic techniques?
- How often has the surgeon performed the kind of surgery he is recommending?
- What will the surgical site look like after healing?
- Will my appearance and physical capabilities be affected? If so how?
- Should I consider combination therapy (both surgery and radiation therapy)?
The Heart Of Clinic
Dr. C. Rayappa MBBS, DLO, FRCS(Edin)
SENIOR CONSULTANT
+91 44 3315 1105
Dr. C. Rayappa graduated from Madras Medical College, Chennai, India in 1982. He completed his post graduation in Otolaryngology (ENT)
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The Heart Of Clinic
Dr. C. Rayappa MBBS, DLO, FRCS(Edin)
SENIOR CONSULTANT
+91 44 3315 1105
Dr. C. Rayappa graduated from Madras Medical College, Chennai, India in 1982. He completed his post graduation in Otolaryngology (ENT)