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ANATOMY, RADIOLOGY,HYPOPHARYNGEAL CANCERS CASE PRESENTATION
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HYPOPHARYNX
Presented by : Dr. Isha jaiswalModerator: Dr. RAHAT HADIDate: 20 th nov. 2013
ANATOMY OF THE HYPO PHARYNX
• Nasopharynx
• Oropharynx
• Laryngopharynx
(Hypopharynx)
Seen from behind
HYPOPHARYNX
Behind the Larynx (in front of 3rd to 6th Cervical vertebra)
From the tip of epiglottis superiorly to
the lower border of cricoid cartilage
Inferiorly
Communicates:
- Anteriorly with the Larynx
- Superiorly with the oropharynx
- Inferiorly with the esophagus
The hypopharynx does not only
lie behind the larynx BUT also
Projects laterally on each side of the larynx
So it is formed of :- Postcricoid region ( behind the
larynx)- Two pyriform fosse (on each side of
the larynx
Seen from behind
Cross section
PYRIFORM SINUS
Shape : inverted pyramid.
Extent:Superiorly: epiglottis .Lateral: thyroid cartilage Medial: arytenoid cartilage; aryepiglottic fold;. Posteriorly: open & cont. with post pharyngeal wall.Apex: meeting of anterior, lateral &med wall inferiorly.
PYRIFORM SINUS
POST CRICOID REGIONPharynx mucosa covering post. Surface of cricoid
Pharynx become continuous with esophagus at post cricoid region
Extent:•Superior: arytenoids• Inferior: oesophagus
arytenoids
ccoesophagus
POSTERIOR PHARYNGEAL WALL
Cover mid & inf constrictor ms. Seperated from prevertebral fascia by retropharyngeal space.Extent:Superiorly: upper border of epiglottisInferior: lower border of cricoidSideways: apex of one piriform sinus to other.
(
Nerve supply of hypopharynx
sensory:• internal branch of sup. Laryngeal
nerve :vagus; (X)• Glossopharyngeal nerve :(IX)
motor• External branch of sup. Laryngeal
nerve (X)• Recurrent laryngeal nerve (X)• Pharyngel plexus (IX)
LYMPHATIC DRAINAGEDeep cervical lymph node : level 2,3& 4Prelaryngeal & paratracheal lymph nodes: level 6.Retropharyngeal nodeNode of rouviere at skull base
LYMPHATIC DRAINAGE
EXT. CAROTID ARTERY
ASC. PHARYNGEAL
ARTERY
MAXILLARY ARTERY
DESC. PALATINE ARTERY
LINGUAL ARTERY
DORSAL LINGUAL ARTERY
FACIAL ARTERY
TONSILLAR ARTERY
ASC. PALATINE ARTERY
BLOOD SUPPLY
RADIOLOGICAL ANATOMY
LYMPHATIC SUPPLY OF NECKDIVIDED INTO 6 LEVEL-
• level I - IA Submental
• IB Submandibular
• level II – Upper jugular chain
IIA & IIB
• level III – Middle jugular chain
& jugulo-omohyoid
• level IV – Lower jugular chain
virchow node
• level V - Posterior triangle node
• level VI – ant group nodes: pre & para tracheal; precricoid (delphian) parithyroid; prelaryngeal
Submental: Ia
Submandibular:Ib
upper deep cervial: II
Retropharyngeal
Post triangle:level V
PRE TRACHEAL NODE ; LEVEL VI
MID. DEEP CERVICALLEVEL III
POST CERVICAL :LEVEL V
“
”
Pre tracheal node ; Level VI
lower Deep cervical LEVEL IV
Post cervical :LEVEL V
PET SCAN IMAGECT IMAGE
During spontaneous breathing Upon phonation
The Pyriform Fossae Views as Seen by Using a direct laryngoscope
Upon forceful nose blowing with the mouth closed
CARCINOMA PYRIFORM FOSSA
Carcinoma hypopharynx
POST CRICOID AREA:
The hypopharynx leading to upper oesopageal sphincter.
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Occasionally brisk opening seen apon laryngeal examinarion (arrow).
Upper osophageal sphincter opening- upon rigid oesophagoscopy.
CARCINOMA HYPOPHARYNXConstitute 5.2% of upper aerodigestive tract cancer.
Mostly squamous cell carcinoma of hypopharynx.
Mean age of presentation 65 years
m.C stage of presentation : stage III& IV
POOR PROGNOSIS
INCIDENCE OF HYPOPHARYNX CA.
65-75% •PYRIFORM SINUS CARCINOMA
5-15% • POST CRICOID CARCINOMA
10-20%• POST. PHARYNGEAL WALL
CARCINOMA
RISK FACTORS OF CA .HYPOPHARYNX Age & Sex: CA. PYRIFORM FOSSA : male above 40 years CA .POST CRICOID : females 20 to 40 years CA.POST. PHARYNX WALL : males aove 50 years
Family historyTobaccoAlcoholExposure : polyaromatic compounds ; asbestos & welding fumes
Nutritional deficiency. VIT A.& E. IRON. CRATENODS & FLAVRNOIDS.
RISK FACTORS OF CA .HYPOPHARYNXClick icon to add picture
infectons; HPV (20–25% only postive for hpv dna & Ab against HPV 16 E6 & E7)
Associated diseases: PLUMMER VINSON SYNDROME
GENETIC: P53 & EGFR mutationSynchronous & metachronous malignancy
FIELD CANCERIZATION
Hypopharynx CA occur within field of diseased mucosa
Carcinogens induce dysplastic changes in mucosa of the upper aero digestive tract.
Increased risk of malignancy
CARCINOMA OF PYRIFORM SINUS• Age:40 years
• presentation: late; Metastatic neck nodesSpread: localUpwards: base of tongueDownwards: post cricoid regionMedially: AE fold and ventricleLaterally: thyroid cartilage,
Lymphatic spread: upper and middle group of jugular cervical nodesDistant metastasis: occur late and may be seen in lung, liver, bone
CARCINOMA OF POST CRICOID REGION
Plummer-Vinson syndrome age group of 20-40; female
Progressive dysphagia Voice change Weight loss
Spread: local spread - cervical oesophagus, arytenoids Lymphatic spread - paratracheal nodes, may be bilateral due to midline nature of lesion
CARCINOMA OF POSTERIOR PHARYNGEAL WALL
• Mostly seen in males above 50 years of age
• Clinical features: dysphagia, metastatic neck node
• Spread: local - prevertebral fascia, muscles and vertebrae• Lymphatic: usually bilateral, retropharyngeal and deep cervical nodes involved
CLINICAL PRESENTATION
Throat pain, Sore throatdysphagiaOdynophagiapooling of saliva
Neck mass:metastatic neck
nodeDirect extension
most frequent presenting symptoms include a neck mass (either representing the tumour or nodal metastases -
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Early lesion may result in vague throat painStenotic tumours near the pharyngo-oesophageal junction may result in , dysphagia.Drooling of saliva may occur due to oedema near arytenoids.
MECHANISM OF OTALGIA
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Hoarseness: indicates involvement of the recurrent laryngeal nerve, which runs deep to the anterior wall of the pyriform sinus, or direct invasion of the larynx leading to inflamation of vocal cords.
CLINICAL EVALUATION
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History takingGeneral physical examination Oral hygeine & dentitionAirway statusStatus of speech & swallow.Complete examination of oral cavity , oropharynx. Examinaton of neck nodes.Indirect layngoscopyDirect laryngoscopy
ORAL CAVITY EXAM INATION• Inspect and palpate:• Note condition gums, mucosa, teeth (caries of teeth malocclusion)• Lips: (lumps, lesion, cracking,color) • Tongue: color, moisture, surface characteristics. Check for white patches
• Throat examination• Inspect uvula, palate, tonsils
EXAMINATION OF ORAL CAVITY
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EXAMINATION OF NECK NODESLocationSizenumberMobilityTendernessRelationship with adjacent structure.
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Examination of neck nodes: sub mental(Ia) & submandibular(Ib)
Examination of neck nodes: upper.,middle & lower deep cervical (Ii; iii. iv)
INDIRECT LARYNGOSCOPY
mirror warmed; check temp.Hold tongueIntroduce mirror into the oral cavity facing downwards mirror brought to rest against the uvula do not touch the posterior pharyngeal wall laryngeal inlet is visualized,
structures seen on indirect laryngoscopy (in order):
Base of the tongue ValleculaMedian and lateral glossoepiglottic foldsEpiglottisVestibular foldTrue vocal cordsTracheaLayngeal cartilage
PRE TREATMENT EVALUATION:
To asses extent of tumourRelation with other structureInvolvement of larynxMobillity of vocal cords
Direct laryngoscopyOesophagoscopyBronchoscopyPanendoscopy
Chest x ray :infection; malignancy;mets HRCT : thickness, invasion, L.N metstasisMRI :soft tissue details, tissue oedemaPET :residual or recurrent tumour after RT