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Full text of "Diseases Of The Nose Throat And Ear"

236           THE LARYNX, BRONCHI AND OESOPHAGUS

lateral wall of the pyriform fossa often present as a mass in the neck—either a
metastatic gland or an extension of the tumour outside the laryngopharynx.
If the tumour is primarily on the medial wall it will involve the larynx and
cause hoarseness. Any tumour of the pyriform fossa may extend up to the
tongue or downwards into the cervical oesophagus.

Most tumours diagnosed as postcricoid are either cervical oesophageal
tumours 'coming up* or pyriform fossa tumours 'going down*. Because the
oesophagus is involved the incidence of 'skip lesions' due to wide dissemina-
tion in the submucosal lymphatics is high. About 20 per cent of these patients
have a metastatic gland when first seen. In this tumour spread also occurs to the
paratracheal nodes and mediastinal nodes.

Tumours of the posterior pharyngeal wall are usually midline and exo-
phytic. They are confined to the posterior wall until late in the disease and
about 50 per cent of patients have a metastatic node when first seen.

Although squamous carcinoma is the commonest tumour, various
sarcomas may occur. The carcinosarcoma or spindle-cell carcinoma is a
polypoidal tumour usually arising from the posterior pharyngeal wall. It is
slow growing and relatively benign. Similarly the leiomyosarcoma is a
polypoidal non-aggressive tumour which does well with merely wide local
removal.

Benign tumours such as leiomyoma, lipoma and fibrolipoma are also
found.

HISTORY. The clinical picture of the large hypopharyngeal tumour is
unmistakable. The patient has dysphagia at first for solids and then for
fluids with resultant aspiration and lung infections. There is weight loss of
several stones and biochemical evidence of dehydration, protein and electro-
lyte deprivation and starvation. As the surrounding structures are involved,
the patient will have dysphonia either due to direct invasion of the larynx or
to vocal cord paralysis consequent to recurrent laryngeal nerve involvement.
The diagnosis of the early case presents some difficulty, however. These
patients will complain of a feeling of 'something' in the throat around the
level of the cricoid. Unfortunately, so too will many thousands of other
patients with oesophagitis or anxiety neurosis in the globus hystericus type of
picture. Every patient with this symptom must have a barium swallow and
meal but to pass an oesophagoscope in every one of these people would be an
impossible task. Two symptoms help in sorting out patients with this symptom
and a normal barium swallow; first, if they have ever had food sticking and
secondly if they have a constant feeling of a crumb in the throat. Such cases
must have an oesophagoscopy,

Although it is not pre-malignant, a surprisingly high proportion of these
cases give a past history of the Paterson-Brown Kelly syndrome (see Chapter
43). What is more significant, however, are those patients who give a history
of irradiation for thyrotoxicosis 25-30 years before.

EXAMINATION. Indirect laryngoscopy may show the presence of a frank
tumour in the pyriform fossa or the posterior pharyngeal wall. It will not,
however, show up a cervical oesophageal or a postcricoid tumour—these will
manifest themselves by oedema of the arytenoids, or by pooling of saliva in
the pyriform fossae. If the recurrent laryngeal nerves have been involved one
or both vocal cords will not move. In palpating the neck it is vital to differenti-
ate the mass which is a direct extension of a pyriform fossa tumour from a