Conditions of the Hypopharynx

FOREIGN BODIES Fish, poultry and other bones are often swallowed inadvertently. Usually they will scratch or tear the pharyngeal mucosa before passing down into the stomach. However, they may on occasions lodge in the hypopharynx or oesophagus, where they may lead to perforation, mediastinitis or abscess, or even fatal perforation of the aorta. Children and the mentally disturbed may swallow coins, toys or more bizarre objects (Fig. 38.1) and the elderly may swallow their dentures. MANAGEMENT It may be very difficult for the casualty officer or novice ENT surgeon to decide whether a foreign body has simply caused an abrasion and has passed on, or is impacted.The following routine should be adopted. 1 Take a careful history, noting the nature of the suspected foreign body (is it radio-opaque?) and the time of ingestion. 2 Examine the pharynx and larynx, paying particular attention to the tonsils and valleculae. (Fish bones often stick here.) A foreign body lodged in the cervical oesophagus will cause pain on pressing the larynx against the spine. 3 X-ray the chest and neck (lateral view)—remember that fish bones and plastic are likely to be radiolucent and may not show. 4 If marked dysphagia is present, or a foreign body is seen on X-ray, oesophagoscopy is indicated. 5 If symptoms persist despite normal X-ray appearances, oesophagoscopy is necessary to exclude a foreign body. The potential gravity of an impacted foreign body cannot be overemphasized, and if there is any doubt, expert advice must be sought. Post-cricoid web The Paterson–Brown Kelly syndrome (later described by Plummer and Vinson) usually occurs in middle-aged women but can occur in males, though rarely. It is associated with iron-deficiency anaemia and the development of a postcricoid web.The features of iron deficiency (glossitis, angular stomatitis and microcytic anaemia) will be present and the web will be demonstrated by barium swallow. TREATMENT The iron deficiency is corrected by iron supplements and the web is dilated periodically. A small number of patients with this condition will go on to develop postcricoid carcinoma. PHARYNGEAL POUCH (PHARYNGEAL DIVERTICULUM) The pharyngeal mucosa herniates between the oblique and transverse fibres of the inferior constrictor muscle to produce a persistent pouch (Fig. 38.2). The condition occurs almost exclusively in the elderly and is thought to be due to failure of the cricopharyngeus part of the inferior constrictor to relax during swallowing, thus building up pressure above it. CLINICAL FEATURES 1 Discomfort in the throat initially. 2 Dysphagia as the pouch enlarges. 3 Regurgitation of undigested food. 4 Aspiration pneumonia if untreated. 5 Gurgling noises in the throat on swallowing or pressure on the neck. NB. A pouch almost never causes a palpable neck swelling. INVESTIGATION The pouch is revealed by barium swallow (Fig. 38.3). TREATMENT 1 The early case can be managed by periodic dilatation of the cricopharyngeus. 2 An established pouch causing symptoms will require surgical treatment. Under general anaesthesia, a dilating rigid pharyngoscope is used to demonstrate the party wall between the oesophagus anteriorly and the pouch posteriorly. A staple gun is then used to divide the wall and at the same time staple the cut edges (Fig. 38.2).The patient is usually able to eat the following day and the hospital stay is very short. 3 Only rarely is it now necessary to excise a pouch by external approach through the neck. MALIGNANT DISEASE OF THE HYPOPHARYNX Malignant disease of the hypopharynx occurs in two main forms. 1 Carcinoma of the piriform fossa—predominantly a disease of males (Fig. 38.4). 2 Post-cricoid carcinoma—predominantly a disease of females (Fig. 38.5). This may supervene on long-standing Paterson–Brown Kelly syndrome. CLINICAL FEATURES 1 Increasing dysphagia and weight loss. 2 An enlarged cervical node due to metastasis may be the first complaint of a patient with a small hypopharyngeal cancer not yet large enough to produce dysphagia. 3 Hoarseness may be present from involvement of the recurrent laryngeal nerve or direct spread to the larynx. 4 Referred otalgia is often present, especially on swallowing. 5 Mirror examination may reveal the malignant ulcer, or pooling of saliva in the hypopharynx. Spread occurs locally by direct invasion, but nodal metastases in the neck occur early in the course of the disease. Distant metastases sometimes occur (compare with laryngeal carcinoma). INVESTIGATIONS Every case of dysphagia must be investigated by barium swallow and oesophagoscopy. Even if the X-ray is normal, direct examination must be performed in the presence of dysphagia. TREATMENT 1 Hypopharyngeal cancers are usually treated by pharyngolaryngectomy, a major operation with a definite mortality. Repair of the pharynx is difficult and accomplished either by stomach pull-up or by the use of vascularized skin flaps.The use of a free graft of jejunum with microvascular anastomosis has been shown to be effective and is a less severe operation than stomach pull-up, though with less certain results. The 5-year survival rate is of the order of 35%. 2 Radiotherapy may produce cure or good palliation but the patient will suffer considerable discomfort during the course of treatment and should be warned accordingly. 3 Many cases are unfortunately untreatable when first diagnosed and no effort must be spared to relieve the patient’s misery with analgesics, tranquillizers and devoted nursing care. GLOBUS PHARYNGIS Globus pharyngis is the term applied to the sensation of a lump or discomfort in the throat, probably owing to cricopharyngeal spasm. The discomfort is relieved by eating and there is no interference with the swallowing of food or liquids. The symptoms tend to be aggravated by the patient’s constant action of swallowing, and frequently introspection and anxiety add to the problem.A proportion of patients with globus pharyngis will be found to have reflux oesphagitis or a gastric ulcer and a barium swallow should always be performed, both to find such conditions and to exclude as far as possible organic pathology in the throat. Many cases have a psychological cause and are aggravated by anxiety and introspection. If symptoms persist, oesophagoscopy is essential—a normal barium swallow does not rule out organic disease. If no organic cause for the symptoms exists, most patients improve with reassurance reinforced by adequate examination and investigation. A short course of tranquillizers is often helpful.

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