endoscopic diagnosis of pyriform fossa...

Endoscopic diagnosis ofpyriform fossa lymphoma

A THOMSON FRACP, P MARLTON FRACP

Many endoscopists do not inspect the gastrointestinaltract superior to the cricopharyngeus, despite the fact

that gastrointestinal symptoms (dysphagia, odynophagia andchest pain) can be produced by glottic and supraglotticlesions. A case of incoordinate swallowing secondary to aright sided pyriform fossa lymphoma diagnosed at gastro-scopy is presented.

CASE PRESENTATIONAn 84-year-old man presented with a three-month his-

tory of progressive dysphagia and incoordinate swallowing.Food and liquid would “go down the wrong way”, causinghim to cough immediately after swallowing. He had a goodappetite but had lost weight.

Past medical history was remarkable for chronic obstruc-tive airways disease for which he took a theophylline deriva-tive and intermittent courses of antibiotics. Seven yearsearlier he developed a cervical centrocytic non-Hodgkin’slymphoma that was treated with several courses of chemo-therapy.

Examination revealed generalized wasting with bilateraljugulodigastric and submental lymphadenopathy. He alsohad small, palpable lymph nodes in both axillae and in theinguinal regions. Examination of the ninth to 12th cranialnerves was normal, and the trachea was in the midline. Hischest was clear to auscultation and abdominal examinationwas normal. There were no neurological signs to suggestmotor neuron disease or Parkinson’s disease. Four monthspreviously, restaging confirmed stage 4 disease. Chest x-rayrevealed features consistent with right hilar lymphadeno-pathy. A computed tomographic scan of the abdomen wasnot performed because there was existing clinical and radio-logical evidence of disseminated disease. A barium swallowperformed before his referral demonstrated retention of bar-ium within both valleculae and associated marked crico-pharyngeal spasm. There was also incomplete filling of theleft pyriform sinus and tertiary contractions of the loweresophagus. No intrinsic lesion within the esophagus was seenduring the examination.

He was referred for gastroscopy. The day before endo-

A THOMSON, P MARLTON. Endoscopic diagnosis of pyriformfossa lymphoma. Can J Gastroenterol 1996;10(7):447-448.Many endoscopists do not inspect the gastrointestinal tract supe-rior to the cricopharyngeus, despite the fact that gastrointestinalsymptoms (dysphagia, odynophagia and chest pain) can be pro-duced by glottic and supraglottic lesions. A case of incoordinateswallowing secondary to a right-sided pyriform fossa lymphomadiagnosed at gastroscopy is presented.

Key Words: Endoscopic diagnosis, Gastroscopy, Pyriform fossa lym-

phoma

Diagnostic endoscopique d’un lymphome dusinus piriforme

RÉSUMÉ : Peu d’endoscopistes examinent la portion du tractusgastro-intestinal qui se trouve au-dessus du crico-pharynx, malgré lefait que les symptômes digestifs (dysphagie, odynophagie et douleurrétrosternales) peuvent être occasionnés par une atteinte glottique ousupraglottique. On présente ici un cas de déglutition incoordonnéesecondaire à un lymphome du sinus piriforme droit découvert à lagastroscopie.

Department of Gastroenterology and Hepatology, and Department of Haematology, Princess Alexandra Hospital, Brisbane, AustraliaCorrespondence: Dr A Thomson, Department of Gastroenterology, St Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8.

Telephone 416-360-4000 ext 2281, fax 416-864-5882Received for publication November 14, 1995. Accepted March 28, 1996

BRIEF COMMUNICATION

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scopy, the hemoglobin was 13.8 g/dL, the white cell count,4.5x109/L and the platelet count, 59x109/L. At endoscopy, a2 to 3 cm submucosal mass arising from the right pyriformfossa was demonstrated (Figure 1). The esophagus and stom-ach were normal. After consultation with the otolaryngologyservice, the pyriform fossa mass was biopsied during thisgastroscopy. Aspirated blood was coughed after the proce-dure, but this settled following administration of ice.

Histology confirmed a centrocytic lymphoma consistentwith dissemination from the previously diagnosed tumour,and prompt otolaryngological assessment was arranged. Radio-therapy was subsequently commenced and the patient’sswallowing returned to normal over the next 10 days. Thepatient died four weeks later from complications of his lym-phoma. An autopsy demonstrated widespread disseminatedlymphoma, together with bilateral lower lobe bronchopneu-monia, pulmonary hemorrhage and left ventricular fibrosis.The larynx and paralaryngeal structures were macroscopi-cally normal.

DISCUSSIONAlthough about a quarter of patients with non-Hodgkin’s

lymphoma have extranodal disease at presentation, and thehead and neck are common sights for such involvement (1),lymphoma of the larynx and paralaryngeal structures is rare(2). Most series of head and neck lymphomas have focusedon patients whose disease was limited (or at least putativelylimited) to the head and neck. In a series of 156 patients withnon-Hodgkin’s lymphoma of the head and neck where no

such limitation was used (3), three cases involved the larynx.In a larger series of 1467 extranodal non-Hodgkin’s lym-phoma cases (1) in whom there was no evidence of dissemi-nated disease at presentation, eight patients had lymphomaof the larynx and four of the hypopharynx. Siegel et al (4)described a case of cytomegalovirus laryngitis associated withprobable lymphoma of the supraglottic region in a humanimmunodeficiency virus-positive patient presenting withodynophagia, hoarseness and weight loss. Donnelly et al (5)reported a 43-year-old male who died suddenly from airwayocclusion secondary to an undiagnosed 4 cm non-Hodgkin’slymphoma arising from the right aryepiglottic fold. Impor-tantly, extranodal lymphoma in areas threatening the airwayoften responds to radiotherapy and other treatment modali-ties (6).

CONCLUSIONSThe presented case demonstrates that gastroscopy can be

useful in facilitating early diagnosis and prompt referral ofpatients with treatable and life-threatening lesions involvingstructures superior to the cricopharyngeus, and that suchlesions can present with gastrointestinal symptoms ratherthan symptoms suggestive of laryngeal pathology. However,because the presented patient aspirated blood followingendoscopic biopsy – and because performing such biopsies inthis area is not standard practice among endoscopists – it isrecommended that such lesions be referred to ear, nose andthroat specialists for biopsy. Nonetheless it should be thepractice of all endoscopists to inspect the vocal cords andparalaryngeal structures including the epiglottis; the wisdomof this approach is borne out by the presented case.

REFERENCES1. Freeman C, Berg J, Cutler S. Occurrence and prognosis of extranodal

lymphomas. Cancer 1972;29:252-60.2. Shidnia H, Hornback N, Lingeman R, Barlow P. Extranodal

lymphoma of the head and neck area. Am J Clin Oncol1985;8:357-64.

3. Jacobs C, Hoppe R. Non-Hodgkin’s lymphomas of head and neck andextranodal sites. Int J Radiat Oncol Biol Phys 1985;11:357-64.

4. Siegel R, Browning D, Schwartz D, Hudgins P. Cytomegalovirallaryngitis and probable malignant lymphoma of the larynx in a patientwith acquired immunodeficiency syndrome. Arch Pathol Lab Med1991;116:539-41.

5. Donnelly S, Hogan J, Bredin C. Sudden death from primary B-cellnon-Hodgkin’s lymphoma of the larynx. Respir Med 1991;85:77-9.

6. Hessan H, Houck J, Harvey H, Hershey P. Airway obstructiondue to lymphoma of the larynx and trachea. Laryngoscope1988;98:176-80.

Figure 1) Gastroscopic view of larynx showing pyriform fossa mass

448 CAN J GASTROENTEROL VOL 10 NO 7 NOVEMBER/DECEMBER 1996

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