RESUMO
OBJECTIVES: Dysphagia is a presenting symptom of both pharyngeal and oesophageal cancers. The referral pathway choice is determined by whether it is thought to be oropharyngeal or oesophageal, and this is in turn influenced by whether dysphagia is perceived to be above or below the suprasternal notch. We studied the concordance between the presence of pharynx-localised dysphagia (PLD) and the location of the underlying disease processes. DESIGN: A subset analysis of the Dysphagia Hotline Cohort, collected between 2004 and 2015, of patients with PLD and a structural diagnosis. MAIN OUTCOME MEASURES: Information about patient demography and presenting symptoms were recorded. The incisor-to-pathology distance, and the nature of the pathology, were recorded. Logistic regression analysis was used to identify independent predictors of malignancy. RESULTS: The study included 177 patients. There were 92 males, and mean age at presentation was 74 years. The commonest benign pathologies were cricopharyngeal dysfunction with or without pharyngeal pouch (n = 67), peptic stricture (n = 44) and Schatzki's ring (n = 11). There were 49 cases of cancer, including one hypopharyngeal cancer, one cervical oesophageal cancer, 28 cancers of the upper/mid-thoracic oesophagus, 15 cancers of the lower thoracic oesophagus and 4 cardio-oesophageal cancers. In 105 (59%) patients, PLD was caused by oesophageal disease. Independent predictors of malignancy were weight-change (loss >2.7 kg), a short history (<12 weeks) and presence of odynophagia. Nineteen (39%) of oesophageal cancers that presented with dysphagia that was localised only to the pharynx would have been beyond the reach of rigid oesophagoscopy. CONCLUSIONS: Pharynx-localised dysphagia is more likely to be a referred symptom of structural oesophageal disease, including cancer, than a primary symptom of structural pharyngeal disease. Absence of additional alarm symptoms such as a short history, weight-loss, and odynophagia, do not adequately exclude the possibility of oesophageal cancer. When the differential diagnosis of PLD includes malignancy, cancer should be presumed to be arising from the oesophagus or the cardio-oesophageal region until proven otherwise. This requires direct visualisation of the mucosal surfaces of the oesophagus and the cardio-oesophageal region, using either transoral or transnasal flexible endoscopy, irrespective of whether the initial assessment occurs within head and neck or upper gastrointestinal suspected cancer pathways.
RESUMO
Sinonasal inverted papilloma (IP) is a benign epithelial tumour which displays aggressive local behaviour, has a high local recurrence rate and the potential for malignant transformation. It is treated by surgical excision which must be thorough to avoid recurrence. Traditionally this was done by an open approach, but since the early 1990's endoscopic techniques have been increasingly employed and are now widely accepted for the treatment of IP. This has led to debate as to whether the access afforded endoscopically is adequate to treat IP without a higher recurrence rate. Studies comparing the recurrence rates of open to endoscopic approaches have shown similar rates but open approaches are usually considered the gold standard for advanced disease, despite the higher morbidity. Reviewing the literature we found that the recurrence rates with endoscopic surgery have improved significantly since the technique was first introduced and conclude that to accurately compare open and endoscopic techniques historical data, from the early days of endoscopic surgery, should be excluded as it does not truly represent the outcome with modern techniques. In doing this it is apparent that endoscopic surgery is the gold standard for the treatment of the vast majority of IP.