INTRODUCTION — The hypopharynx lies posterior and inferior to the oropharynx and extends to the esophageal inlet. Over 95 percent of hypopharyngeal cancers are squamous cell carcinomas. Other less common histologies include basaloid squamous carcinomas, spindle cell carcinomas, and minor salivary gland carcinomas.
At diagnosis, less than 15 percent of hypopharyngeal cancers are confined to the hypopharynx. Most have spread to the regional lymph nodes (at least 65 percent) or distantly (20 percent) [1-5]. Presenting symptoms can include dysphagia, odynophagia, otalgia, hoarseness, dyspnea/stridor, and/or a painless neck mass. Diagnosis at an early stage is uncommon due to a lack of alarming symptoms until local progression or a neck metastasis is present. Countries that have introduced national diagnostic screening programs for early gastrointestinal malignancies are more likely to detect hypopharyngeal malignancy at an earlier stage.
The treatment of early hypopharyngeal cancer is presented here. The treatment of locally advanced hypopharyngeal cancer is discussed separately, as is the management of metastatic disease.
●(See "Treatment of metastatic and recurrent head and neck cancer".)
EPIDEMIOLOGY AND RISK FACTORS — Hypopharyngeal cancers account for approximately 6 percent of all head and neck cancers [6]. The worldwide incidence varies from 0.8 to 6 cases per 100,000 persons [1,7]. Hypopharyngeal cancers are more common in resource-abundant areas compared with resource-limited areas and are more common in males than females [8,9]. The median age at diagnosis is 65 years for males and 68 years for females. (See "Epidemiology and risk factors for head and neck cancer".)
In North America and Europe, smoking and alcohol use are the main risk factors [9-11]. Tobacco chewing also has been identified as an independent risk factor [12]. Other environmental factors associated with hypopharyngeal cancer include iron and vitamin C deficiencies, occupational exposure to asbestos, steel/coal dusts, and iron compound fumes, and exposure to indoor air pollution from solid fuels, such as wood, crop residue, or coal [13-16].
Plummer-Vinson syndrome (the triad of dysphagia, glossitis, and iron deficiency anemia) has been associated with postcricoid hypopharyngeal cancers, especially in females from Scandinavian countries. However, improved nutrition, and iron and vitamin dietary fortification have dramatically reduced the incidence of Plummer-Vinson syndrome in developed countries and, thus, its role in the etiology of hypopharyngeal cancers [17]. Gastric reflux, which leads to chronic irritation of the pharynx, has also been implicated [18]. (See "Esophageal rings and webs".)
ANATOMY AND STAGING — The hypopharynx is bordered by the oropharynx superiorly (at the level of the hyoid bone) and the esophageal inlet inferiorly (at the lower end of the cricoid cartilage (figure 1)).
The hypopharynx is divided into three anatomic subsites:
●The pyriform sinus is bounded medially and superiorly by the aryepiglottic fold, laterally by the superior edge of the thyroid cartilage, and anterosuperiorly by the pharyngoepiglottic fold. Its apex opens into the esophagus. Cancers arising from the pyriform sinus account for 65 to 85 percent of hypopharyngeal cancers.
●The posterior pharyngeal wall extends from the level of the vallecula to the level of the cricoarytenoid joints; it is formed by the constrictor muscles covered with a mucosal lining. This area is the origin of approximately 10 to 20 percent of these cancers.
●The postcricoid space is the dorsal surface of the posterior wall of the larynx, bounded laterally by the pyriform fossa, inferiorly by the inferior edge of the cricoid ring, and superiorly by the apex of the arytenoid cartilage. Approximately 5 to 15 percent of hypopharyngeal tumors arise in the postcricoid space.
The eighth edition tumor, node, metastases (TNM) system of the American Joint Committee on Cancer and the Union for International Cancer Control is used to stage hypopharyngeal cancers (table 1 and table 2) [19]. By definition, early-stage hypopharyngeal cancers are stage I (primary tumor ≤2 cm, T1N0) or stage II (primary tumor ≤4 cm, T2N0) without clinical evidence of regional lymph node involvement.
PRETREATMENT EVALUATION — Delineation of tumor size and extent of invasion is critical for selection of appropriate therapy. Hypopharyngeal cancers tend to spread within the mucosa beneath intact epithelium and can involve multiple adjacent mucosal areas [20]. (See "Overview of the diagnosis and staging of head and neck cancer".)
Routes of primary tumor spread are influenced by hypopharyngeal subsite:
●Cancers of the pyriform sinus can invade the laryngeal paraglottic space anteriorly, the thyroid cartilage laterally, the postcricoid area and cervical esophagus inferiorly, the oropharynx superiorly, and the constrictor muscles and prevertebral fascia posteriorly.
●Cancers of the posterior pharyngeal wall extend into the lower oropharynx, while cancers of the postcricoid space can spread superiorly within the hypopharynx and extrapharyngeally. Due to the proximity to the cervical esophagus and prevertebral fascia, fixation to or direct invasion of these organs can occur.
Direct visualization — Flexible fiberoptic endoscopy provides the initial assessment of tumor extent. Typical findings include closure or obliteration of the pyriform fossa, mucosal ulceration, pooling of saliva in the pyriform fossa, edema of the arytenoids, and fixation of the cricoarytenoid joint, true vocal cords, or both. However, these findings often are not evident in early-stage disease.
The full extent of hypopharyngeal tumors on the posterior pharyngeal wall can be difficult to appreciate on in-office fiberoptic examination. Early pyriform sinus tumors may be very subtle, and examination with a modified Valsalva maneuver during in-office fiberoptic endoscopy while instructing the patient to blow against closed lips may be helpful since normal pyriform sinus mucosa will distend. Evaluation under anesthesia is desirable. Direct laryngoscopy, performed in the operating room, allows a more accurate evaluation of superficial tumor spread and extent.
Imaging — The degree of deep tumor spread (preepiglottic space, paraglottic space, laryngeal framework, and direct neck extension) cannot be evaluated by endoscopy and thus requires additional radiologic examination.
●Contrast-enhanced computed tomography (CT) is typically used as the initial imaging modality to assess local tumor extent and evaluate for pathologic lymphadenopathy. CT is generally the most useful single modality for staging hypopharyngeal cancers since it can accurately identify gross cartilage invasion. However, CT may not identify minor invasion.
●Magnetic resonance imaging (MRI) provides improved soft-tissue imaging and is complementary to CT. MRI can distinguish pharyngeal muscles from the mucosa and lymphoid tissue lining the inner wall of the hypopharynx and has a higher sensitivity for the detection of early cartilage invasion [21-23]. In addition, MRI is superior for assessing carotid involvement in cases with neck extension or nodal disease with extracapsular spread. However, motion artifacts are particularly frequent at the laryngeal/hypopharyngeal level, which may limit the utility of MRI [24].
●Combined positron emission tomography (PET) and CT (PET/CT) scans appear to be more accurate than CT or PET alone for the depiction of malignancy in the head and neck. It can help to evaluate the primary site, identify occult nodal involvement, and detect distant metastasis or synchronous primary tumors that are missed by conventional imaging [24-27]. While PET/CT is recommended for stage III/IV hypopharyngeal cancer, it is often used to complete staging of those with earlier-stage disease.
There is large variation in reported sensitivity and specificity for both CT and MRI in detecting cervical adenopathy, particularly in the clinically negative neck [28,29]. PET scanning may help to identify pathologically involved lymph nodes that are suspicious on CT or MRI but do not meet traditional size-based criteria for classification as abnormal [24,30,31]. In one series that included 50 patients with previously untreated head and neck squamous cell carcinoma, the positive and negative predictive values for staging clinically N0 neck by PET/CT were determined to be 58 and 89 percent, respectively [32].
TREATMENT OF PRIMARY TUMOR — In general, radiation therapy (RT) is the treatment of choice for early-stage hypopharyngeal cancer. RT results in high rates of laryngeal preservation and can treat both the primary tumor site and all elective nodal stations as a single modality. With the development of transoral robotic and laser techniques and better endoscopic visualization, carefully selected cases of early hypopharynx cancer can be surgically treated; this should be combined with surgical treatment of the neck because of the high propensity for occult spread to cervical lymph nodes and for accurate pathologic staging.
The choice of RT or surgical resection for a specific patient is based on a number of factors, including patient preference; geographic distance to an RT or surgical center; patient fitness, especially pulmonary function; surgeon and radiation oncologist experience; and technology available to the radiation oncologist and surgeon.
General principles — The goal of treatment for early hypopharyngeal cancer is to achieve locoregional tumor control and long-term survival while maintaining functional (respiration, swallowing, and speech) organ preservation. Whenever possible, preservation of laryngeal function with a conservative surgical procedure or definitive RT is preferred over total laryngectomy or laryngopharyngectomy, which are usually reserved for more-advanced disease. A multidisciplinary approach with input from head and neck surgeons, radiation oncologists, and medical oncologists is recommended.
In patients with early-stage hypopharyngeal cancer, overall and disease-specific survival following definitive RT are comparable with those for radical surgery (total laryngectomy) or larynx-conserving surgery [33]. Several studies have demonstrated that transoral approaches in carefully selected patients can preserve function while achieving equivalent outcomes [34-38].
Surgery and RT have not been directly compared in randomized trials in patients with early hypopharyngeal cancer. However, observational studies suggest that treatment modality chosen (surgery versus RT) does not impact disease-free survival (DFS) or overall survival (OS) [39-41]. Data are as follows:
●One retrospective study of 185 patients with cT1 to T2 hypopharynx cancer treated with either primary larynx-preserving surgery or RT showed similar oncologic outcomes across both treatment modalities for patients with cT1 disease. For patients with cT2 disease, although surgery was associated with higher five-year DFS (57 versus 36 percent) and OS compared with RT, treatment modality was not associated with DFS or OS on multivariate analysis [42]. Similarly, in another observational study of patients with hypopharyngeal cancer from the National Cancer Database, treatment modality did not influence five-year OS for stage I to II disease [41].
●In another retrospective observational study limited to potentially resectable hypopharyngeal cancer patients who received definitive treatment, there was no significant difference in OS or DFS between those treated with RT and those treated surgically [43]. In both groups, the five-year DFS for early-stage patients was approximately 75 percent [39]. In another representative series of RT alone for hypopharyngeal cancer, the actuarial five-year OS was 52 percent, reflecting the frequency of deaths from other causes [40].
Local recurrences are the most frequent pattern of progression after definitive RT. In contrast, distant metastases are more common with surgery. The incidence of neck recurrences is similar with both RT and surgery [39].
Surgery — In early-stage hypopharyngeal cancer, surgery is a treatment option for patients who have disease that is technically resectable for a laryngeal-sparing approach. This includes patients with upper pyriform sinus and posterior pharyngeal wall tumors. The improved flexibility and access of the single-port robotic system, will likely allow more distal tumors to be reached and successfully treated [44]. A wide range of larynx-sparing (conservative) surgical approaches that aim to preserve speech and swallowing have been used in appropriately selected patients with early (T stage) hypopharyngeal cancer (table 3) [45-52].
Conservative approaches are generally not indicated for early-stage patients with transglottic tumor extension, postcricoid invasion, and deep pyriform sinus invasion. Although excellent local control (70 to 90 percent) and functional outcome are reported, most of the series using conservative surgical procedures include the use of induction chemotherapy and/or adjuvant RT (table 3). It is unclear if conservative surgery alone would achieve a comparable outcome [34,50,51,53].
Transoral approaches have the potential to decrease patient morbidity and increase quality of life in carefully selected patients. Both transoral robotic surgery (TORS) and transoral laser microsurgery (TLM) can have accessibility issues and are contraindicated for extensive lesions with extensive arytenoid involvement, posterior cricoarytenoid involvement, significant esophageal or base of tongue disease, or neck extension with carotid involvement. TORS may offer several advantages over transoral laser-based strategies, including en bloc resection for pathologic evaluation, but its role in early-stage hypopharyngeal cancer treatment is evolving [54-56]. In a systematic review and meta-analysis of patients undergoing minimally invasive surgery for hypopharyngeal carcinoma, the cumulative rate of functional larynx preservation was approximately 94 percent, with similar rates observed for TORS and TLM [52].
TORS was successfully utilized to treat 10 patients with early-stage (T1 to T2) hypopharyngeal cancer, with only five patients requiring adjuvant RT. Four patients required additional margin resection based on frozen section analysis, and one patient had a positive margin on permanent section analysis. There were no local recurrences, and all larynxes were preserved after a mean follow-up of 26 months. None of the patients required a permanent gastrostomy tube or tracheostomy, and voice and swallow were deemed adequate in all patients [56].
In a contemporary study using TLM, the five-year local control rates for pT1 and pT2 tumors were 88.1 and 74.8 percent, respectively. The five-year estimates of overall survival, disease-specific survival, and recurrence-free survival for early-stage I and II disease were 68.2, 96.7, and 74.6 percent, respectively [57]. Importantly, a high percentage of patients (95.7 percent) maintained gastrostomy tube independence with a rapid return to oral alimentation, even with 85 percent of the cohort being of advanced stage.
The most common complication was a postoperative bleeding rate of 10.4 percent, which was readily managed. In addition, the pharyngeal fistula rate of 0.9 percent was well below that historically observed in open procedures. Total laryngectomy or laryngopharyngectomy, procedures that are typically reserved for T3 and T4 tumors, may also be required for small lesions that involve the pyriform sinus apex or postcricoid region if surgery is the only modality used.
Adjuvant RT or chemoradiotherapy is indicated following surgery for patients who have positive resection margins, lymphovascular or perineural invasion, extranodal extension, and/or pathologically positive lymph nodes identified after neck dissection. Patients with close margins may also need additional treatment. (See "Adjuvant radiation therapy or chemoradiation in the management of head and neck cancer".)
Definitive radiation therapy — For T1 and small T2 hypopharyngeal cancers, definitive RT is feasible. The primary tumor is treated with a minimum dose of 70 Gy in 2 Gy fractions or 66 Gy in 2.2 Gy fractions. Elective nodal regions are treated with 44 to 50 Gy in 2 Gy fractions. Definitive RT has resulted in variable rates of laryngeal preservation, ranging from 41 to 100 percent for T1 tumors and from 41 to 86 percent for T2 tumors [58-64]. (See "Definitive radiation therapy for head and neck cancer: Dose and fractionation considerations" and "General principles of radiation therapy for head and neck cancer".)
Bilateral elective nodal irradiation including coverage of the retropharyngeal nodes and level V is routinely recommended due to a high rate of occult lymph node metastasis. For tumors involving the postcricoid region or apex of the pyriform sinus, elective nodal irradiation should also include level VI (figure 2) [65]. Additionally, tumors extending to or arising from the posterior hypopharyngeal wall require a more-posterior border, splitting the vertebral body when using conventional nonconformal fields. Contemporary RT techniques, as well as the dose and schedule of RT, are discussed elsewhere. (See 'Management of the neck' below.)
Acute toxicities from RT commonly include fatigue, mucositis, xerostomia, hoarseness, dysphagia, aspiration, skin hyperpigmentation, and desquamation [59]. Chronic dysphagia of various degrees may be seen in the majority of patients after treatment, although it is not well reported. Serious late toxicities can include chondritis of the larynx, prolonged dysphagia requiring chronic enteral tube feedings, persistent mucosal ulceration, webbing of the pharynx requiring dilatation, and laryngeal edema requiring tracheostomy [58]. Myelitis is an extremely rare complication with properly planned RT, occurring in less than 1 percent of cases. (See "Management and prevention of complications during initial treatment of head and neck cancer" and "Management of late complications of head and neck cancer and its treatment".)
For patients with an incomplete response to RT and for those with a local recurrence without evidence of distant metastasis, surgery can be considered for salvage therapy [66,67]. Often, however, salvage may not be feasible due to prevertebral or carotid involvement with residual/recurrent disease, unlike laryngeal cancers that undergo initial nonsurgical therapy. Surgery following irradiation with or without chemotherapy is associated with an increased frequency of complications compared with upfront surgery, and it usually requires pedicled or microvascular flap reconstruction to restore pharyngeal tissue for adequate oral intake as well as to prevent salivary fistula perioperatively.
MANAGEMENT OF THE NECK — Due to a high incidence of occult cervical node metastasis (30 to 50 percent (table 4A-C)) [68] in clinically node-negative hypopharyngeal cancer patients, either elective neck dissection or radiation therapy (RT) should be a component of initial treatment in patients undergoing resection or irradiation of the primary site, respectively. A nomogram model for cT1-2N0 hypopharyngeal cancer uses age, drinking history, histological differentiation of tumor, and depth of tumor invasion to predict occult cervical lymph node metastasis [69].
The hypopharynx has an extensive lymphatic drainage pattern, which may vary depending on the specific site of the tumor within the hypopharynx; hypopharyngeal cancers may spread to multiple lymph node levels, and bilateral spread is common. The pyriform sinus drains to levels II through IV (jugulodigastric chain), level V (posterior triangle), and the retropharyngeal lymph nodes (figure 2). The pyriform sinus apex also commonly drains to level VI [70,71]. The posterior pharyngeal wall drains to levels II and III, and the retropharyngeal lymph nodes. The postcricoid space drains to levels III and V, and the paratracheal nodes.
The most commonly involved lymph nodes in the clinical N0 neck are level II (relative frequency 67 to 75 percent), followed by level III (33 to 75 percent), level VI (9 to 14 percent), and level IV (0 to 7 percent) [68,70-73]. In the clinical N0 neck, retropharyngeal lymph nodes are involved in up to 15 percent (0 to 15 percent) of cases and are more common with primary tumors of the posterior pharyngeal wall [74-76].
If surgery is used to treat the primary tumor, bilateral selective neck dissection of levels II, III, and IV should be performed for N0 presentations. For tumors invading the pyriform sinus apex, we also offer dissection of level VI lymph nodes [60,70,71].
For patients who undergo definitive RT to the primary tumor, the neck is treated with RT. The entire bilateral neck, including the retropharyngeal and supraclavicular nodes, generally should be part of the treatment volume, even in patients with early tumors and clinically negative neck.
The standard dose for clinically uninvolved nodal regions is usually 44 to 50 Gy delivered in 2 Gy daily fractions or 53 to 60 Gy delivered in 1.6 to 1.8 Gy daily fractions. Either three-dimensional conformal RT or intensity-modulated RT is routinely used. Given the need to electively irradiate multiple lymph node levels bilaterally, intensity-modulated RT is preferable as it can be used to minimize the radiation dose to the parotid glands. (See "General principles of radiation therapy for head and neck cancer" and "Definitive radiation therapy for head and neck cancer: Dose and fractionation considerations".)
PROGNOSTIC FACTORS — Hypopharyngeal cancer has a relatively poor prognosis, with estimated five-year overall survival rates for stage I and II disease of approximately 40 to 70 percent [7,34,57,60,75,77,78].
Tumor location is associated with prognosis, with pyriform sinus tumors having a higher survival than pharyngeal wall tumors, followed by postcricoid tumors, which have the lowest survival [7,79]. Survival also declines with older age, male sex, lower socioeconomic status, and being a Black person [80,81]. Observational data also suggest that human papillomavirus (HPV)-positive hypopharyngeal cancers are associated with improved overall survival [41,82,83]. Comorbidities have also been shown to correlate with worse outcomes and prognosis, and the hypopharynx subsite, compared with other head and neck cancer subsites, has increased competing mortality from death resulting from noncancer causes and second malignances [84,85].
Patients previously treated for early-stage hypopharyngeal primaries are at increased risk for second primary tumors at an annual average rate of 2.1 percent in one series. Such second primary tumors adversely affect overall survival for patients with early hypopharyngeal cancer [39,60,86]. As an example, in one series of 115 patients with stage I and II hypopharyngeal cancer, 65 patients (57 percent) had synchronous or metachronous cancers, and of the 115 patients, 19 died of hypopharyngeal cancer, 10 died of second primary cancers, and 14 died of other causes during the study (median follow-up of 47 months) [60].
Second primary tumors most commonly occur in the upper aerodigestive tract, including the oral cavity, esophagus, and lung. Alcohol consumption strongly increases the risk of developing another malignancy after treatment for laryngeal or hypopharyngeal cancer, and a history of heavy cumulative cigarette smoking increases the risk of developing lung cancer [87]. (See "Second primary malignancies in patients with head and neck cancers".)
POSTTREATMENT SURVEILLANCE — Regular posttreatment follow-up is an essential part of the care of patients after potentially curative treatment of hypopharyngeal cancer. Patients should be educated about possible signs and symptoms of tumor recurrence, including hoarseness, sore throat, ear pain, dysphagia, bleeding, and enlarged lymph nodes. In some situations, operative endoscopy is necessary to determine pathologic disease status due to treatment-related edema and anatomic distortion in the months following chemoradiation.
In general, the intensity of follow-up is greatest in the first two to four years, as approximately 80 to 90 percent of all recurrences occur within this timeframe. Several groups have developed guidelines. As an example, the National Comprehensive Cancer Network recommends a history and physical examination every one to three months year 1, every two to four months year 2, every four to six months years 3 to 5, and every 6 to 12 months beyond five years. Posttreatment baseline imaging of the primary tumor site with CT scan is recommended within six months of treatment, with further imaging indicated based on signs and/or symptoms. There is no role for routine positron emission tomography (PET)/CT scan following the completion of therapy for early-stage hypopharyngeal cancer.
Following baseline reassessment, direct visualization on clinical examination is the appropriate evaluation of the primary tumor. Continued follow-up beyond five years is generally suggested to assess these patients for late toxicity as well as to evaluate for a second primary malignancy. Because of the higher risk of recurrence and second primary malignancy in those who continue tobacco use, many schedule more-frequent surveillance visits for these patients and continue for longer duration (ie, beyond five years). The specific recommendations concerning follow-up and controversies in this area are reviewed separately. (See "Posttreatment surveillance of squamous cell carcinoma of the head and neck".)
Irradiated patients are at risk of developing hypothyroidism; thus, monitoring of serum thyroid stimulating hormone levels is routine in irradiated patients. Dental follow-up should be twice yearly at a minimum for dentate patients who have received radiation. Patients should also have periodic assessment for other treatment-related toxicity (eg, neck fibrosis, carotid stenosis, trismus, and speech and swallowing function).
An important aspect of posttreatment follow-up is to evaluate and address any functional problems that might be associated with the diagnosis and/or treatment of the disease. Following irradiation of the hypopharynx, treatment-related edema can result in dysphagia and aspiration. Therefore, patients with hypopharyngeal tumors often benefit from prospective evaluation and surveillance by speech-language pathologists, with swallowing exercises and serial evaluation of the efficiency and safety for oral alimentation. These interventions must begin before and continue throughout nonsurgical therapy to maintain swallowing function and avoid permanent gastrostomy use. (See "Speech and swallowing rehabilitation of the patient with head and neck cancer".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Head and neck cancer".)
SUMMARY AND RECOMMENDATIONS
●Anatomy of the hypopharynx – The hypopharynx lies behind and below the oropharynx and extends to the esophageal inlet. It can be divided into three subsites: pyriform sinus, postcricoid area, and posterior pharyngeal wall. (See 'Anatomy and staging' above.)
●Treatment goals – The primary goals for treatment of early hypopharyngeal cancer (stage I and II (table 1 and table 2)) are to maximize survival outcomes and minimize the functional consequences of the disease and treatment, including voice production, swallowing, and airway protection and patency. For appropriately selected patients, both conservative surgery (minimally invasive and open larynx-sparing surgical approaches) and definitive radiation therapy (RT) have been shown to offer good local tumor control and survival. (See 'General principles' above.)
●Management of the primary tumor – The use of surgery and RT for management of the primary tumor have not been compared in a randomized trial, and the decision to choose one modality over the other depends on a number of factors, including tumor accessibility, predicted functional outcome, risk of carotid stenosis, patient health and preference, and the availability of treatment expertise. All patients with early-stage hypopharyngeal cancer should be assessed by a multidisciplinary team that represents all three oncologic modalities as well as by speech and swallow therapists. (See 'Surgery' above and 'Definitive radiation therapy' above.)
●Management of the neck
•Primary surgery – If surgery is used to treat the primary tumor, we recommend bilateral selective neck dissection of levels II, III, and IV lymph nodes (figure 2) for early-stage hypopharyngeal cancer (with a clinically negative neck (Grade 1C)). For those with tumors involving the pyriform sinus apex, we also offer dissection of level VI lymph nodes. (See 'Management of the neck' above.)
-Indications for adjuvant RT – For patients treated with primary surgery, we offer adjuvant (postoperative) RT for those with lymphovascular or perineural invasion, and/or pathologically positive lymph nodes identified after neck dissection. Patients with positive margins or extracapsular extension of a positive lymph node benefit from postoperative concurrent chemoradiation. (See "Adjuvant radiation therapy or chemoradiation in the management of head and neck cancer".)
•Definitive RT – For patients who undergo definitive RT, we recommend elective RT to the bilateral neck as the treatment volume, including the retropharyngeal and supraclavicular nodes (Grade 1C). (See 'Management of the neck' above.)
●Posttreatment surveillance – Hypopharyngeal tumors are associated with one of the highest risks of dysphagia and aspiration both pre- and posttherapy. These patients may benefit from prospective evaluation and surveillance by speech-language pathologists, with swallowing exercises and serial evaluation of the efficiency and safety for oral alimentation. (See 'Posttreatment surveillance' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Suisui Song, MD, and Joseph K Salama, MD, who contributed to earlier versions of this topic review.
69 : A nomogram for predicting occult lymph node metastasis in early hypopharyngeal cancer with cN0.
70 : The impact of paratracheal lymph node metastasis in squamous cell carcinoma of the hypopharynx.
