Complete hypopharyngeal obstruction by mucosal adhesions: a complication of intensive chemoradiation for advanced head and neck cancer.
BACKGROUND
Severe swallowing dysfunction is the dominant long-term complication observed in patients treated for head and neck squamous cell carcinoma (HNSCC) with treatment protocols using intensive concurrent chemotherapy with radiation therapy (chemo/XRT). We identified a subset of these patients, who were seen with complete obstruction of the hypopharynx distal to the site of the primary cancer, and in whom we postulate that the obstruction was caused by separable mucosal adhesions rather than obliteration by a mature fibrous stricture.


METHODS
Seven patients were referred to the senior author with a diagnosis of complete hypopharyngeal obstruction between 1992 and 2001. The diagnosis was confirmed by barium swallow imaging and/or endoscopy before referral in all patients. Patients underwent recanalization by passing a Jesberg esophagoscope under general anesthesia, followed by serial dilations and intensive swallowing therapy. Patient charts were reviewed retrospectively after institutional review board approval.


RESULTS
All seven patients were successfully recanalized. No patient had a perforation or other significant complication related to the recanalization procedure or subsequent dilations. Five of the seven patients showed improvement in swallowing at some point after the initial procedure, but just two patients recovered sufficiently to have their gastrostomy tube removed permanently.


CONCLUSIONS
We conclude that complete hypopharyngeal obstruction secondary to mucosal adhesions is one cause of gastrostomy tube dependence in patients who have been treated with chemo/XRT for HNSCC. It is a difficult problem to treat, but most patients can recover useful swallowing function without undergoing laryngectomy or major surgical reconstruction. The postulated pathophysiology has implications for prevention as well as treatment.
Franzmann
Elizabeth J
EJ
Department of Otolaryngology, University of Miami/Sylvester Comprehensive Cancer Center, 1475 NW 12th Avenue, Suite 4037, Miami, FL 33136, USA.
Lundy
Donna S
DS
Abitbol
Andre A
AA
Goodwin
W Jarrard
WJ
D000368:Aged; D000970:Antineoplastic Agents / Q000009:adverse effects; D002294:Carcinoma, Squamous Cell / Q000188:drug therapy / Q000532:radiotherapy / Q000628:therapy*; D003131:Combined Modality Therapy; D003680:Deglutition Disorders / Q000209:etiology* / Q000503:physiopathology; D005260:Female; D005774:Gastrostomy; D006258:Head and Neck Neoplasms / Q000188:drug therapy / Q000532:radiotherapy / Q000628:therapy*; D006801:Humans; D007013:Hypopharynx / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D009092:Mucous Membrane / Q000473:pathology; D010608:Pharyngeal Diseases / Q000209:etiology* / Q000503:physiopathology; D011878:Radiotherapy / Q000009:adverse effects; D012189:Retrospective Studies; D000267:Tissue Adhesions; D016896:Treatment Outcome
D000970:Antineoplastic Agents