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.
