HYPOPHARYNX ANATOMY & HYPOPHARYNGEAL CANCERS
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Transcript of HYPOPHARYNX ANATOMY & HYPOPHARYNGEAL CANCERS
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HYPOPHARYNX
Presented by : Dr. Isha jaiswalModerator: Dr. RAHAT HADIDate: 20 th nov. 2013
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ANATOMY OF THE HYPO PHARYNX
• Nasopharynx
• Oropharynx
• Laryngopharynx
(Hypopharynx)
Seen from behind
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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
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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
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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.
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PYRIFORM SINUS
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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
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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.
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(
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)
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LYMPHATIC DRAINAGEDeep cervical lymph node : level 2,3& 4Prelaryngeal & paratracheal lymph nodes: level 6.Retropharyngeal nodeNode of rouviere at skull base
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LYMPHATIC DRAINAGE
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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
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RADIOLOGICAL ANATOMY
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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
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Submental: Ia
Submandibular:Ib
upper deep cervial: II
Retropharyngeal
Post triangle:level V
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PRE TRACHEAL NODE ; LEVEL VI
MID. DEEP CERVICALLEVEL III
POST CERVICAL :LEVEL V
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“
”
Pre tracheal node ; Level VI
lower Deep cervical LEVEL IV
Post cervical :LEVEL V
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PET SCAN IMAGECT IMAGE
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During spontaneous breathing Upon phonation
The Pyriform Fossae Views as Seen by Using a direct laryngoscope
Upon forceful nose blowing with the mouth closed
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CARCINOMA PYRIFORM FOSSA
Carcinoma hypopharynx
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POST CRICOID AREA:
The hypopharynx leading to upper oesopageal sphincter.
Click icon to add picture
Occasionally brisk opening seen apon laryngeal examinarion (arrow).
Upper osophageal sphincter opening- upon rigid oesophagoscopy.
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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
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INCIDENCE OF HYPOPHARYNX CA.
65-75% •PYRIFORM SINUS CARCINOMA
5-15% • POST CRICOID CARCINOMA
10-20%• POST. PHARYNGEAL WALL
CARCINOMA
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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.
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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
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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
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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
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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
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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
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CLINICAL PRESENTATION
Throat pain, Sore throatdysphagiaOdynophagiapooling of saliva
Neck mass:metastatic neck
nodeDirect extension
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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.
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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.
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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
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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
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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)
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Examination of neck nodes: upper.,middle & lower deep cervical (Ii; iii. iv)
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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,
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structures seen on indirect laryngoscopy (in order):
Base of the tongue ValleculaMedian and lateral glossoepiglottic foldsEpiglottisVestibular foldTrue vocal cordsTracheaLayngeal cartilage
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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
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