Hypopharyngeal stenosis

Clinical example

A 50-year-old male patient with a T3N2 nasopharyngeal carcinoma underwent concurrent chemotherapy and radiation. Treatment consisted of cisplatinum given concomitantly with irradiation to a total dose of 70 Gy. Two months after this treatment he underwent a comprehensive neck dissection and a myotomy of the cricopharyngeal muscle because of persistent neck nodes and swallowing complaints. The patient was referred 4 months after the neck dissection because of the inability to eat and drink since the chemoradiation had finished. CT and PET-CT showed no residual tumor.

A flexible gastroscopy and swallow test showed a complete blockage in the area of the upper esophageal sphincter. The length of the stenosis (3 to 4 cm) in the postcricoid area was confirmed on retrograde esophagoscopy. It was decided to bypass the stenosis by using a variation of the ‘classical’ free jejunal graft interposition technique.

 
Treatment of postcricoid hypopharyngeal stenosis. (Click on the links to view/hide the consecutive images.)

a. The pharynx is opened at the left side proximal to the stenotic area. The cervical esophagus is incised circumferentially immediately below the stenotic area.

Hypopharyngeal stenosis

b. A jejunal patch is sutured between hypopharynx and cervical esophagus. The jejunum is revascularized by suturing the mesenteric artery to the external carotid artery (end-to-side) and the mesenteric vein to the internal jugular vein (end-to-side).

Hypopharyngeal stenosis

 
A Barium swallow study after 2 months showed the tube reconstruction with good patency of the upper and lower anastomoses. The Barium swallow clearly showed the longitudinal orientated mucosal plicae.

Radiology after reconstruction. (Click on the links to view/hide the consecutive images.)

a. Barium swallow 1. The proximal anastomosis is indicated by 1; the distal anastomosis is indicated by 2. A good bolus passage through the reconstruction is visible with minimal or no aspiration.

 
Barium swallow after reconstruction

b. Barium swallow 2. After the swallowing action, the jejunal tube is emptying. The longitudinal oriented mucosal folds are visible.

 
Barium swallow after reconstruction

View movie: Free jejunum patch 1 - (Quicktime - 9 Mbytes) - Download Quicktime