A modified endoscopic submucosal dissection for a superficial hypopharyngeal cancer: a case report and technical discussion
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Adequate working space and a clear view for the dissected lesion are crucial for endoscopic submucosal dissection (ESD). Pharyngeal ESD requires that an otorhinolaryngologist creates working space by lifting the larynx with a curved laryngoscope. However, many countries do not have this kind of curved laryngoscope, and the devices could interfere with endoscope because of the narrow space of the pharynx. To overcome these issues, we used a transparent hood (Elastic Touch, slit and hole type, M (long), Top company, Tokyo Japan) instead of the curved laryngoscope to create adequate working space by pushing the larynx, and pharyngeal ESD could be done by gastroenterologists.
A 64-year-old male patient was admitted to our hospital because of chronic persistent swallowing dysfunction for 2 years. Oesophagogastroduodenoscopy showed a superficial hypopharyngeal cancer in the right pyriform sinus. We used a transparent hood (Elastic Touch, slit and hole type, M (long), Top company, Tokyo Japan) instead of the curved laryngoscope to create adequate working space by pushing the larynx, and dental floss tied to a haemoclip was applied to create counter traction during ESD. The lesion was pathologically confirmed as superficial squamous cell carcinoma and resected completely.
This is the first report of modified ESD for a superficial hypopharyngeal cancer. The modified ESD enables early pharyngeal superficial cancer to be removed completely under endoscope by gastroenterologist.
KeywordsHypopharyngeal cancer Case report ESD Transparent hood
Endoscopic submucosal dissection
Magnifying endoscopy with narrow-band imaging
Endoscopic submucosal dissection (ESD) is an effective procedure for the treatment of superficial mesopharyngeal and hypopharyngeal cancers . The studies from Muto et al.  and Satake et al.  showed that the disease-specific survival and 5-year overall survival were from 97% to 100% and 71% to 85%, respectively, after transoral endoscopic treatment. Endoscopic treatment is less invasive and preserves swallowing and speech functions in comparison with traditional surgical approaches and radiotherapy. However, ESD of the pharyngeal region has not been widely used still because of the limitation of the device manoeuvrability and the complex structure of the region, and because conventional ESD requires an otorhinolaryngologist to create adequate working space by lifting the larynx with a curved laryngoscope, which takes time and increases medical expenses. Another difficulty for the procedure is that the narrow space of the pharynx makes endoscope and other devices to interfere with each other. To overcome these issues, we used a transparent hood (Elastic Touch, slit and hole type, M (long), Top company, Tokyo Japan) instead of the laryngoscope to provide adequate working space and used dental floss tied to a haemoclip to provide a well-visualized dissecting line during ESD of superficial cancer in the hypopharynx region.
Discussion and conclusions
It is difficult for gastrointestinal endoscopists to detect early superficial pharyngeal cancer by conventional white light endoscopy because the cancer presents a few morphological changes [4, 5]. However, the introduction of magnifying endoscopy with narrow-band imaging (ME-NBI) allows better detection for superficial pharyngeal lesions [6, 7]. Previously, pharyngeal cancer was usually detected at advanced stages, and its prognosis has been poor . Surgical resection for advanced pharyngeal cancer is necessary, which could cause swallowing disorders, dysgeusia defect, speech problem, and serious cosmetic deformities of the neck [8, 9]. ESD was first developed in the gastrointestinal tract and has been widely used because of its less invasion and good clinical outcomes. The studies have demonstrated that ESD is clinically feasible in the treatment of superficial pharyngeal cancer, with no severe adverse events, and the indications of ESD for superficial pharyngeal cancer are (1) no evidence of invasion to the muscularis mucosa by white-light endoscopy, (2) no lymph node metastasis by cervical ultrasound or computed tomography (CT) examination, and (3) histopathological diagnosis of squamous cell carcinoma [6, 10]. However, ESD of the pharyngeal region is still not well developed because of its narrow and complex space. The success of ESD for superficial hypopharyngeal cancer depends on adequate wide working space and a clear visualization for the dissected lesion. The narrow space of the pharynx makes the endoscope and other devices to interfere with each other. The conventional ESD usually requires an otorhinolaryngologist to create adequate working space by lifting the larynx with a curved laryngoscope, which takes time and increases medical expenses. To overcome these issues, we have designed a novel method, using a transparent hood (Elastic Touch, slit and hole type, M (long), Top company, Tokyo Japan) instead of the laryngoscope to create adequate working space and using dental floss tied to a haemoclip, which is anchored to mucosal tissue, to provide well-visualized dissecting line during ESD of superficial cancer in the hypopharynx region. The traction method has been developed, which makes ESD safer and faster, similar to the clip-with-line method [11, 12]. Iizuka et al.  reported the usefulness of endoscopic laryngo–pharyngeal surgery, and during which, Fraenkel laryngeal forceps were used to create proper counter traction to provide well-visualized dissecting line during ESD in the pharyngeal region. However, the disadvantage of the procedure is that the endoscope and other devices still interfere with each other in the narrow space of the pharynx. A major advantage of our new method is that a transparent hood is used to replace the curved laryngoscope to create adequate working space and dental floss tied to a haemoclip is applied for counter traction during ESD so that the devices no longer interfere with each other, which makes ESD in the pharyngeal region feasible and easy.
In conclusion, modified ESD in the hypopharynx region, using a transparent hood to create adequate working space and dental floss tied to a haemoclip to create counter traction, enables early pharyngeal superficial cancer to be removed completely under endoscope by gastroenterologist. This is the first report of modified ESD for a superficial hypopharyngeal cancer.
This study was supported by grants from the Engineering Center of Endoscopy Diagnosis and Treatment, Guizhou Province, China, and the Clinical Medical Research Center for Digestive Diseases, Guizhou Province, China. The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing this manuscript.
Availability of data and materials
All data and material generated or analysed during this study are included in this published article.
The study design was performed by BT, KF, and LD. Review of patient data and critical comments were performed by LD, KF, RX, YL, HW, and BT. XW and LD reviewed and described the pathologic findings. The manuscript was written by LD, KF, and BT. All authors read and approved the final manuscript.
Ethics approval and consent to participate
This study was approved by the ethics committee of Zunyi Medical College, and the patient provided written informed consent for the procedure before treatment.
Consent for publication
Written consent for publication was obtained from the patient described and is available for review.
The authors declare that they have no competing interests.
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