Tumours of the hypopharynx

Benign

Benign tumours of the hypopharynx are very rare, the most common being the fibroma and the leiomyoma. These are polypoid tumours which usually present with dysphagia and are seen on videofluoroscopy or barium swallow. They show a smooth constant mass lying in the lumen of the hypo­pharynx or oesophagus.

Malignant

Malignant tumours of the hypopharynx are almost exclusively squamous cell carcinoma with a predominance of moderate and poor differentiation. The tumours are usually classified according to their anatomical sire of origin from the piriform fossa, postcricoid region or posterior pharyngeal wall but, as mentioned in the section on pharyngeal anatomy, it can be difficult to determine the sire of origin when a tumour has spread to involve one or more of these areas. Even differentiation between laryngeal and hypopharyngeal tumours can be difficult in the advanced disease when the aryepiglorric fold has been replaced or covered by tumours. Marked differences in the incidence of these tumours occur throughout the world in association with factors such as iron deficiency anaemia (see subsection on Sideropenic dysphagia) and they may be associated with marked submucosal spread of 10 mm or more which further complicates their evaluation. Tumours arising from the piriform fossa and posterior pharyngeal wall may spread to upper or lower cervical nodes. Tumours arising in the postcricoid area typically metastasise to paratracheal and para­oesophageal nodes which may not be palpable. As with oropharyngeal tumours, alcohol and tobacco are two principal carcinogens implicated in these tumours. Postcricoid carcinoma, although essentially a rare disease, is more common in women than men. The diagnosis of hypopharyngeal carcinoma should be considered in all patients presenting with dysphagia or hoarseness, particularly if they have a history of iron deficiency and anaemia, smoking or significant alcohol consumption.

On examination indirect laryngoscopy may show only subtle signs of disease such as oedema or pooling of saliva unilaterally in a piriform fossa, or diminution of vocal fold mobility. All regions of the neck must be assessed in a systematic manner. Fine needle aspirate is advocated for suspicious nodes. A suspected primary may require videofluoroscopy or barium swallow study, endoscopy and biopsy, and CT or MRI scanning if available. A chest X-ray should be taken to detect a second primary or metastasis.

Treatment

Squamous carcinoma of the hypopharynx commonly presents late and carries a poor prognosis. Early lesions may be treated with radiotherapy alone, and surgery is generally used for recurrence after radiotherapy or as primary excision in advanced disease. Total pharyngolaryngectomy is commonly required and, for lesions extending into the upper oesophagus, oesophagectomy and total thyroidectomy may additionally be needed.

Reconstruction of the excised pharynx and/or oesophagus may be undertaken by the use of a myocutaneous flap, free jejunal transfer or gastric transposition. These major surgical techniques require excellent preoperative preparation of the patient and surgical teams with a high standard of expertise as they have a potential mortality and a wide variety of complications. Swallowing and voice rehabilitation are necessary to support patients after this major surgery if they are to adjust themselves and maintain some quality of life.

Cytotoxic drugs have not been found to have significant value as an adjunct to surgery or radiotherapy in the treatment of patients with hypopharyngeal squamous carcinoma. It is to be hoped in the future that they will produce better results so that the major surgery and its associated debility can be avoided. Before deciding to give chemotherapy in any form of squamous carcinoma of the head and neck one has to balance the prognosis of the disease against the expected relief and possible toxic side effects. The most commonly used agents are cisplatin, 5-fluorouracil (5FU) and methotraxate. These drugs are best administered by doctors expert in their use and as part of controlled trials until we can evaluate the most suitable method of administration and the best combination of agents.