Nouraei S A R, Murray I A, Heathcote K J, Dalton H R
Department of Ear Nose and Throat Surgery, Poole Hospital NHS Foundation Trust, Poole, UK.
Department of Gastroenterology, Raigmore Hospital, Inverness, UK.
Clin Otolaryngol. 2018 Aug;43(4):1088-1096. doi: 10.1111/coa.13115. Epub 2018 May 14.
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.
A subset analysis of the Dysphagia Hotline Cohort, collected between 2004 and 2015, of patients with PLD and a structural diagnosis.
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.
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.
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.
吞咽困难是咽喉癌和食管癌的常见症状。转诊途径的选择取决于吞咽困难被认为是口咽性还是食管性的，而这又反过来受吞咽困难被认为是在胸骨上切迹上方还是下方的影响。我们研究了咽部局限性吞咽困难（PLD）的存在与潜在疾病过程位置之间的一致性。
对2004年至2015年间收集的吞咽困难热线队列中患有PLD和结构诊断的患者进行子集分析。
记录患者人口统计学信息和就诊症状。记录切牙至病变的距离以及病变的性质。采用逻辑回归分析确定恶性肿瘤的独立预测因素。
该研究纳入了177例患者。其中男性92例，就诊时的平均年龄为74岁。最常见的良性病变是伴有或不伴有咽袋的环咽肌功能障碍（n = 67）、消化性狭窄（n = 44）和沙茨基环（n = 11）。有49例癌症病例，包括1例下咽癌、1例颈段食管癌、28例胸段上/中段食管癌、15例胸段下段食管癌和4例贲门食管癌。在105例（59%）患者中，PLD由食管疾病引起。恶性肿瘤的独立预测因素是体重变化（减轻>2.7 kg）、病程短（<12周）和存在吞咽痛。19例（39%）仅表现为咽部吞咽困难的食管癌，硬性食管镜检查无法触及。
咽部局限性吞咽困难更可能是包括癌症在内的食管结构性疾病的转诊症状，而非咽部结构性疾病的主要症状。缺乏如病程短、体重减轻和吞咽痛等其他警示症状，并不能充分排除食管癌的可能性。当PLD的鉴别诊断包括恶性肿瘤时，在未得到其他证明之前，应假定癌症起源于食管或贲门食管区域。这需要使用经口或经鼻柔性内镜直接观察食管和贲门食管区域的黏膜表面，无论最初的评估是在头颈或上消化道疑似癌症的途径中进行。
