Pattern of clinical presentation of hypopharyngeal carcinoma

Objectives: To determine the pattern of clinical presentation of hypopharyngeal carcinoma and pattern of metastases. Methods: This was a cross sectional study with 60 patients. Study was carried out in the Department of Otolaryngology and Head Neck Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka Medical College Hospital and Mitford Hospital during the period of July 2005 to June 2007. This diagnosis was made by detailed history clinical examination and relevant investigation. Analyzed data and presented by various tables, graphs and figures. Result: In this study majority of the patients were within 51-60 years, male female ratio was 7.5:1, majority was smoker (91.66%), 58% patients had habit of tea, 88.32% of the patients chewed betel, Majority of the patients (81.16%) had presented with progressive dysphagia 76.66% and hoarseness of voice (60%), There was neck swelling in 53.3% and haemoptysis in 25% of patients. 63.33% patients had ulcerative lesion, 40% normal laryngeal movements, 63.33% were adequate airway, 65% patient had cervical lympadenopathy. Primary lesion was 75% in pyriform fossa, 20% in post cricoid region and 5% in posterior pharyngeal wall. 46.66% were T3 stage, 53.33% N1 and 48.71% were level IV nodal involvement. Conclusion: Hypophayngeal carcinoma usually presents in advanced state.


Introduction
The hypopharynx is a highly important anatomical site since physiologically it is a component of the upper aero-digestive tract and in its upper part, it represent a common conduit for both respiration and deglutition.Tumour in this resume often present in an advanced stage and key to cure lies in early and in accurate diagnosis and subsequent staging.
Hypopharyngeal carcinoma is an uncommon tumour.The world wide incidence should be below 1 per 1,00,000.High incidence of hypopharyngeal carcinoma in Europe and Asia is in countries like France, Switzerland, Spain, Slovakia, Slovenia and in India in the cities of Bombay and Madras. 1 In the United States, hypopharyngeal cancers are more common in men than in women. 2 This cancer is extremely rare in children. 3,4The principals subsites are divided into three groups.The pyriform fossa growth postpharyngeal and postcricoid growth.Postcricoid carcinoma forms up to 50% of hypopharyngeal carcinoma in the UK and Canada and is uncommon in North America and Australasia.Pyriform fossa growth forms half to two third of the growth and postcricoid up to 40% and posterior pharyngeal wall group up to 10%. 5 Male: Female ratio was 9:1 though in postcricoid growth female was more common.Cases of hypopharyngeal cancer among women are currently more likely to be associated with excessive use of alcohol and tobacco, rather than by deficiency diseases.6,7,8 In the United States and Canada, 65% to 85% of hypopharyngeal carcinoma involve the pyriform sinuses, 10% to 20% involve the posterior pharyngeal wall, and 5% to 15% involve the postcricoid area.9 Pyriform sinus and postcricoid carcinomas are typically flat plaques with raised edges and superficial ulceration.In contrast, posterior hpopharyngeal wall tumors tend to be exophytic and are often large (i.e., 80% > 5 cm) at presentation.10 More than 50% of patients with hypopharyngeal cancer have clinically positive cervical nodes at the time of presentation.In 50% of these individuals, a neck mass is the presenting symptom.11,12 In a retrospective study of 78 cases of hypopharyngeal cancer, other symptoms in addition to dysphagia (46.1%), include a neck mass (25.6%), odynophagia (44.8%), voice change (16.3%), and otalgia (14.2%).13 A voice change due to pyriform sinus or postcricoid lesions is a late symptom that usually indicates invasion into the larynx or the recurrent laryngeal nerve.14 In clinical presentation two principal subsites the pyriform fossa and postcricoid area differ greatly in pattern of occurrence and clinical behavior.5 Regarding occurrence postcricoid carcinoma is the only cancer in buccopheryngeal region more common in women than men with wide geographical distribution.
In a large retrospective study of patients with SCC of the larynx and hypopharynx, 87% of patients with pyriform sinus SCC were found to have stage III or stage IV disease; 82% of patients with SCC of the posterior pharyngeal wall were found to have stage III or stage IV disease. 15As many as 17% of hypopharyngeal SCCs may be associated with distant metastases when clinically diagnosed. 15pophayngeal carcinoma is one of the significant causes of cancer morbidity and mortality in the industrialized and also in developing countries.There is little study on this topics in our country.

Methods
This was a cross-sectional study, carried out from July 2005 to June 2007, Department of Otolaryngology and Head-Neck surgery, Bangabandhu Sheikh Mujib Medical University and Dhaka Medical College Hospital and Sir Salimullah Medical College & Mitford Hospital, Dhaka patients suspected as hypopharyngeal carcinoma were evaluated properly by detailed history, clinical examination and investigations, like fiberoptic laryngoscopy, rigid laryngoscopy with or without oesophagascopy and histopathologically proved cases of hypopharyngeal carcinoma, CT, MRI and punch biopsy.Data were collected in a predesigned data collection sheet and analyzed by using standard statistical methods.

Objectives
To assess the clinical presentation of hypopharyngeal carcinoma and its pattern of metastases.

Results
Analyzed data presented by various tables, graphs and figures.Side by side, 65% (39 patients) had cervical lymph node involvement.Of these 61.66% (37 patients) had their primary lesions in the pyriform fossa.Where as Dailey (1968) showed that 66% of his patients had lymph node involvement, with the primary in the pyriform fossa, posterolateral wall and postcridoid region with frequency of55% and 42%.
In the present series out of 45 cases, pyriform fossa growth 37 persons presented in late stage (Stage III & IV) which is 82.22%.
Out of 45 cases of pyriform fossa lesion 28 was in right sight and 17 was in left site.
Chronic pulmonary and hepatic diseases related to the excessive use of tobacco and alcohol were found in patients with hypopharyngeal cancer.Recognition of these co-morbidities is essential in the formulation of a treatment plan.
There has sufficient lacking in health education over and above the general education level of the population.Poor financial condition of the patients lack of admission facilities in the big hospital along with limited hospital facilities.All the people are not getting proper health care, still a good number of people prefer to attend the private clinics.For all of this reasons this study is surely incomplete but still it can give a little bit of idea about the clinical presentation and management of carcinoma hypopharynx which will be completed later by future extensive studies.

Conclusion
Hypophayngeal carcinoma is one of the significant causes of cancer morbidity and mortality in the industrialized and also in developing countries.There is little study on this topic in our country.Community based study is not available.Here hospital based study was done.

Table - I
Age distribution

Table - VI
State of lymph node involvements.

Table - VII
Level of lymph node involvement