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.
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.