Malignant Tumors of Hypopharynx
Malignant tumors of the hypopharynx are predominantly of epithelial origin. Squamous cell carcinoma of the root of the tongue presents with pain on swallowing, otalgia, discomfort in the throat, and, finally, difficulty in breathing. The ulcerative, infiltrative form produces early cervical node metastasis, but the proliferative type presents as a bulge on the root of the tongue and is readily visible and easily palpable. These lesions are typically quite advanced before producing symptoms sufficient to bring the patient to the physician. Palpation of the base of the tongue will often permit recogni- tion of a firm mass, even when it is not detectable on basic oral examination. Many of these carcinomas are of the immature or undifferentiated type, explaining their tendency to early metastasis. The tumor may extend into the vallecula and displace the epiglottis toward the laryngeal lumen, causing some hoarseness and, occasionally, difficulty in breathing in the reclining position. Pain on swallowing usually prompts the patient to seek medical advice. On mirror examination, an ulcerative growth may be visible, which is frequently covered with debris and whitish exudate. The tumor may extend into the tonsillar pillars and floor of the mouth. Although usually confined to one side, it may extend across the midline. Grasping and extending the tongue will expose the posterior third of the tongue. Biopsies of the lesion are necessary to obtain a pathologic diagnosis; the method for obtaining the biopsy material varies with the prominent tumor location.
Carcinoma of the piriform fossa is an extrinsic laryngeal lesion. The tumor may arise on the medial wall of the piriform fossa and extend onto the aryepiglottic fold and epiglottis, or it may have its origin on the lateral wall of the piriform fossa and extend onto the lateral wall of the pharynx and down into the mouth of the esophagus. These lesions produce symptoms only in a late stage of the disease. The vocal folds are not compromised, and hoarseness is a relatively late symptom.
Dysphagia may also occur only late in the course because the pathway left free at the opposite piriform fossa is usually adequate for deglutition. The first symptom of the presence of this lesion may be the appearance of a cervical node on the same side of the neck. Diagnosis is best made by mirror examination followed by biopsy, which can be obtained by direct or (most often) indirect laryngoscopy. Tomography of the larynx, especially in the anterior-posterior position, will often show an obliteration of the piriform fossa on the involved side. The lesions are invariably squamous cell carcinomas, with a high percentage of undifferentiated or immature cell types. Irradiation and surgical therapy result in similar rates of control and survival for many head and neck locations. The therapeutic choice depends on the site and surgical accessibility of the lesion, the hoped-for functional outcomes (speech and voice production, swallowing, and airway protection), and the types of morbidity associated with each modality.