Anatomical subdivision of the pharynx: Hypopharynx naso ...
Transcript of Anatomical subdivision of the pharynx: Hypopharynx naso ...
Hypopharynx: anatomy and pathologies
Bernhard Schuknecht Medical Radiological Institute Zurich/CH
European Course in Head and Neck NeuradiologyMarch 25 – 11:20-11:50
COI Disclosure
• no actual or potential conflict of interest regarding this presentation
Pa viewSobotta Becher 2nd ed. U&S 1972
NasopharynxSkull base
soft palate
Oropharynxsoft palate
pharyngo-epiglottic fold
Hypopharynxhyoid/pharyngo-epiglottic fold
cricopharyngeus m.
= part of upper esophageal spincter UES
Anatomical subdivision of the pharynx:naso-, oro-, and hypopharynx
Hypopharynx visceral spaceHarnsberger ED. Diagnostic Imaging Head and neck 2nd edition Amirsys 2011
Visceral space = continuation of suprahyoid pharyngeal mucosal space upper mediastinum
middle layer of deep cervical fascia (ML-DCF)alar fascia separates RPS and danger space, prevertebral fascia
piriform sinus= anterolateral recessesinverted pyramid with base from pharyngoepiglottic fold to inferior tip (PS apex) at level of true cord
posterior wall = continuation of post. oropharyngeal wall, level of hyoid to inf. cricoid cartilage/ cricopharyngeus m.
postcricoid region= anterior wall of lower hypopharynxfrom cricoarytenoid joints to lower edge of cricoid lamina
Hypopharynx 3 subsites:
• aryepiglottic fold anteromedially
• paraglottic space anteriorly
• thyroid cartilage/thyrohyoid membrane lat.
• carotid space laterally
• crico-arytenoid cartilage anteriorly
• post. wall ML-DCF alar + prevertebral fascia
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Hypopharynx :
Anatomic relationship
HHypopharynx :
Anatomic relationship
• aryepiglottic fold anteromedially
• paraglottic space anteriorly
• thyroid cartilage/thyrohyoid membrane lat.
• carotid space laterally
• crico-arytenoid cartilage anteriorly
• post. wall ML-DCF prevertebral fascia
Mucosa: stratified squamous epithelium and lymphocytes
Submucosa: loose stroma contains fat, serous and mucinous glandssubmucosal infiltration clinically undetactable imagingrich lymphatic drainage - nodes,(retropharyngeal
Muscles: inferior constrictor m. - cricopharyngeus muscleinnervation: motor X, sensory IX, communication with Arnolds nerve (X)
Killians triangle- between thyropharyngeal comp. and cricopharyngeus m. diverticulum
Hypopharynx wall:
Zenker diverticulum
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Posterior hypopharyngeal saccular mucosal herniation above cricopharyngeal muscle
DD: Killian-Jamieson diverticum = antero-lateral esophageal pouch below cp muscle; rare, smallerEsophageal webs = 1-2mm mucosal filling defect along anterior wall; esophageal strictures - longer
Risks: aspiration pneumonia (30%), diverticulitis, carcinoma (0.3%), perforation
piriform sinus upper aspect of left thyroidlocalized thyroiditis
4th branchial cleft anomaly
3% of head and neck malignancies.SCC: 95% , majority are environmentally related (alcohol, tobacco)
squamous cell: conventionalsquamous cell variant: adeno- and basosquamous, papillary, spindle, verrucous
other: lymphoepithelial like, neuroendocrine (4%) and composite (SCC- neuroendocrine) Ca`s
minor salivary gland tu (adenoidcystic ca )
worst prognosis of all subsites of head and neck neoplasmssurvival poor, < 50% at 3 y after txrecurrence distant metastasis < 2 years
locoregional
Facts: hypopharynx carcinoma Hypopharynx carcinoma
• piriform sinus 60% moderately –poorly differentiated
• postcricoid region 25% usually well differentiated
• posterior wall 15% usually large and exophytic
• prognosis: piriform > posterior wall > postcricoid
• 50-75% malignant adenopathy at presentation, 15-20% contralateral
• 10% synchronic/ 25% metachronic additional 1ary Ca!
Staging of hypopharynx carcinoma
• T1 one subsite , < 2cm
• T2 > one subsite, 2-4cm
• T3: > 4cm or fixation of hemi-larynx
invasion of esophagus
• T4a: invas. thyroid/ cricoid cartilagethyroid gland- central c. soft tissue
• T4b: invas. prevertebral fascia, ICA, mediastinum
N-Staging in HPV- neoplasms
N0 no regional lymph node metastases
N1 single ipsilateral LN 3cm
N2a single ipsilateral LN > 3cm, < 6cm
single < 3cm ENE+
N2b multiple ipsilateral LN < 6cm
N2c bilateral or contralateral LN < 6cm
N3a single > 6cm, ENE –
N3b single ipsi >3cm ENE+, or multiple ENE+ ipsi-/contralat.
LN level-classification in the neck
Level I: superior to hyoidIA: submental, IB: submandibular
Level II: internal jugular -superior to hyoidIIA: anteror to SCM, IIB: medial to SCM
Level III: int. jugular (inferior hyoid-inf. cricoid)midthird vascular chain – SCM
Level IV: internal jug- inf cricoid- supraclavicularlower vascular chain – SCM
Level V: posterior cervical space – supraclavicularVA : above inf. cricoid level VB: below inf. cricoid
Level VI: prelaryngeal: hyoid- jugulum
Level: VII: jugulum -aortic arch+ retropharyngeal, parotid, facial LN
tends to present in an advanced stage !
Hypopharynx carcinoma
Difficulties in early diagnosis due to • underlying anatomy extended growth from pharyngoepiglottic fold- esophagus
• symptoms of early stage (globus, sore throat) gastroesophageal reflux
• depth of piriform sinus difficult to visualize w office based fiberoptic laryngoscopy
• limited accuracy of routine imaging studies such as CT.
Hypopharynx carcinoma: piriform sinusMR more sensitive primary tu location
cartilage invasionrelation of LN to vessels
w 300/ c100
w 1700/ c600
Piriform sinus most common location = 65%
Hypopharynx carcinoma: piriform sinus
Questions:origin,relation to aryepiglottic fold, paraglottic space, extrapharyngeal extensioncartilage: thyroid/ arytenoid/cricoid ?lymph nodes ?
Anterior wall
Hypopharynx carcinoma: piriform sinus
Cartilage signal :Signal T1 low lowSignal T2 ~ signal tumor > signal tumorSignal T1 Gd ~ signal tumor > signal tumor
Cartilage : invasion inflammation
AnteriorT1
Invasion of thyroid cartilage, + central compartment soft tissue
T2
T1gd
cor STIR
T4a
Hypopharynx carcinoma: posterior wall well defined anterior surface
survival
Extension ?oropharynxesophagusextrapharyngealif yes, vessels/ICA? T4bmediastinum –T4b
Prevertebral fasciainfiltration: T4b
Internal carotid artery encasement = T4b
Interruption of :posterior pharynx muscle +retropharyngeal fat line(T2w >>> T1gd)Muscle = longus colli medial
longus capitis lateral
Hypopharynx carcinoma: posterior wall
Prevertebral fascia infiltration ? T4b?
Hypopharynx carcinoma: postcricoidpostcricoid well defined surfacepoorest prognosis 5-year survival = 30%
Tendency for submucosaloften T3: hemilarynx fixation
or T4 a: cricoid cartilage invas.
cricoid cartilage infiltration
Predisposition:Plummer Vinson syndrome= sideropenic dysphagia16% of pats postcricoid ca
Hypopharynx carcinoma: postcricoid
posterior wall well defined!
Infiltration ofTrachea !!
thyroid gland,
upper esophageal sphincter
= T4a
Hypopharynx carcinoma: piriform sinus
HPV associated hypopharynx carcinoma (6% - 16%) OPSCC >70%pats younger, no risk factors
small tumours w large (commonly cystic) LN
29y female
Sahovaler A et al. Survival outcomes in Human papillomavirus–Associated Nonoropharyngeal Squamous Cell Carcinomas. A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2020;146(12):1158-1166. doi:10.1001/jamaoto.2020.3382
“In this meta-analysis of 24 studies, HPV was associated with OS in laryngeal and hypopharyngeal locations but not in the oral cavity and the nasopharynx. “
HPV status vs survival outcome in hypopharynx carcinoma ?
improved survival and quality-of-life outcome of pats with HPV+ OPSCC!- true for hypopharynx ? Pre-treatment Posttx : laser resection and RT
Hypopharynx carcinoma:treatment evaluation- morphology /DWI
Vp
Ktrans
high pre-treatment permeability (Ktrans) and Vp are linked to favorable treatment outcomeinverse correlation between Ktrans , Ve and proliferation (KI 67)
Ve
pre-treatment post-laser and RT Perfusion
Permeability and MVD*histo:*CD31 antigen staining
Proliferation /gradinghisto:* ki 67 stainingVe ~ vessel diameter > cell count
Hypopharynx carcinoma:treatment evaluation- DCE perfusion
Layngopharyngectomy, free jejunal flap, neck dissection, RT
cor sag
1st F-up @ 6months, recurrence local + nodal @ 2.5y
(Rouviere‘s lymph node): Pretracheal lymph node Mediastinal lymph node
Therapy: Primary radiochemotherapy
F-up assessment structural + metabolic
Tumour persistence?
other entities : Venous vascular malformation
Hypopharynx = rare locationmost common type of vm
size by valsalva, position
transspatial extension !
phleboliths
delayed Gd uptake (venous)
Hypopharynx external invasion
Anaplastic thyroid carcinoma
Hypopharynx external compression1. osseous 2. vascular : CCA
Imaging algorithm
• MRI: tumor location, extension, DD
cartilage , larynx involvement
prevertebral fascia, ICA, mediastinum affected?
LN involvement ?
local recurrence ?
• CT (critical ill pats) obstructing neoplasm, airway compromise,
noncooperative, MR noncompatible pacemaker
• PET-CT for staging T3, T4;
Tx response ? Recurrence ?
- thank you
Zürich
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