Anatomy

The pharynx is generally the area we consider as the throat, and the hypopharynx is the lower throat immediately behind the voicebox, and just above the esophagus (the tube that carries the food down to the stomach) (Fig. 1a). The three different subsites of the hypopharynx include: Post-cricoid, Piriform Sinus, and Pharyngeal Wall (Fig. 1b).

	Fig.1a Compartments of the Throat		Fig. 1b Pharyngeal Subsites

he hypopharyngeal tissue coordinate the movement of food down the lower throat, and along with the larynx direct it into the esophagus and down towards the stomach and avoid it by mistake going into the trachea and the lungs.(Fig. 2a to 2d). As a consequence, tumors in this area can interfere with swallowing, breathing and if large enough our voice. By the same token, treatment of tumors in this area has to take into account these important functions, and every effort needs to be made to preserve function.

	Fig2a		Fig2b

	Fig2c		Fig2d

Symptoms

Tumors in the hypopharynx can cause a variety of symptoms, however the symptoms present when the tumors have gotten to be larger (75% present with Stage III or IV tumors).  Symptoms usually include chronic sore throat, one-sided ear pain, swallowing problems, chronic cough and/or blood tinged sputum. A person who has a tumor that is large enough to reach the voice box may have hoarseness as well.  Any of these symptoms present for more than 2 to 3 weeks requires examination by a specialist.  A great majority of the patients are diagnosed after the tumor has spread to the lymph nodes, because they have no throat symptoms.

Risk Factors

Men are more often affected by cancer of the larynx than women. Laryngeal cancer is closely associated with cigarette smoking. Exposure to the chemicals in tobacco as they pass by the structures in the mouth, throat, voice box, and lungs is thought to lead to development of cancer. Tobacco and alcohol use each have been found to increase the risk by many folds (as high 20-30 folds).  However, tobacco and alcohol use together can increase the risk of cancer by 70 folds.

Diagnosis

	Hypopharynx view through the laryngoscope

The diagnosis is made by looking at the throat with a small fiberoptic camera (laryngoscope) during your visit in the office (Fig. 3). This simple procedure takes less than 20 seconds and shows the larynx clearly so that size of the tumor can be assessed. When larger more extensive tumors are found we often perform a CT scan, MRI, or even a PET scan

To confirm the diagnosis a biopsy must be done of the mass. This also is a simple procedure taking only a few minutes. Biopsying a mass in the lower throat involves using a camera and sampling a small piece of the tumor. In a majority of cases, our gag reflex prevents us from being able to have this done in the office.  

	CT Scan Left Pharynx Mass		PET Scan Left Pharynx Mass

Staging

The TNM Staging is a universally used system based on size (T), lymph node involvement (N), and distant spread or metastasis (M).

Treatment

Leukoplakia & Dysplasia

Leukoplakia

The Tumors in the throat usually develop first as a small white plaque on the surface; this small white plaque is called Leukoplakia.These tumors gradually change their character and become more aggressive. In the early stages these tumors are called dysplasia, and in time it becomes moderate dysplasia and then severe dysplasia. These are still pre-cancerous stages. Once the tumor changes and becomes cancer, it is now very aggressive and can destroy the tissue around it, additionally it can it can spread to other parts of the body.

So during this early stage, the tumor is less aggressive and more easily treated, which is why seeing a doctor or specialist immediately soon after symptoms start is very crucial. When a biopsy confirms that the tumor is not cancerous but rather Dysplasia, the treatment involves removing the superficial surface layer only where the lesion (Dysplasia) is and nothing more. This procedure is simple and it is not much more complicated then the biopsy itself.

Cancer

The hypopharynx is a small area with close proximity to vital structures including the voice box, esophagus, and spine.  As such surgery in this area can involve any of the mentioned structures and therefore cause great difficulty for the patient.

T1 & T2 The smaller tumors of the pharynx do not involve the deeper structures; as such they can be readily treated with fair cure rates. The treatment options include radiation therapy (for smaller tumors) or chemo-radiotherapy for larger tumors, or open surgery vs. Transoral endoscopic laser surgery (surgery through the mouth rather than through a cut in the neck) for a select group of patients. Our expert team of doctor’s assesses the patient to determine which treatment option is most appropriate for the patient in terms of cure and swallowing outcomes.  Each patient though is individually evaluated to make sure they receive the best treatment possible

T3 & T4 These larger tumors obviously involve deeper structures of the oropharynx. The treatments of choice are surgery (partial or Total laryngo-pharyngectomy) followed by radiation vs. a combination of chemotherapy and radiation. Both treatment options are involved and rigorous, and require the patient not only to work closely with his/her doctor’s (Head & Neck Surgeon, Oncologist, and Radiation Oncologist), but also have a strong bond with them. These are difficult treatment and our doctors believe that this bond is of an utmost importance in helping to assure success.  Additionally, patients are followed by nutritionist and swallow therapists to make sure they continue to do well.  

Recurrent Tumors

When cancer recurs its best that it be diagnosed early, which is the reason all of our patients are followed closely, at least once every 3 months, if not more closely and with regular imaging studies such as CT, MRI, or PET scans. In a patient that has not been treated with radiation therapy before for their original tumor, then the option of radiation therapy exists. (Generally, radiation therapy can be only used once on each area of the body) Most recurrences are, however, after previous radiation or a combination of chemo-radiation treatments. All patients whom have had a recurrence are considered for Transoral Endoscopic Laser Microsurgery (TLM).  If this approach is not permissible due to the size and location of the tumor than an open surgical procedure is considered. We use a multiple-surgeon approach that makes it possible to both remove the cancer and reconstruct the area.  The criterion to proceed with a transoral approach is, simply put, visibility and therefore accessibility to the entire tumor through the mouth.  This is dictated by the experience of your surgeon and availability of the appropriate equipment. In the hypopharynx because of the nature of its anatomy TLM is less often possible. Our team of expert surgeons will consider each case individually to decide the appropriate course of action.