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The best course of treatment for all patients presenting with a throat complaint or neck mass is to undergo a full head and neck examination. General physical examination should include the checking of weight and weight loss, nutrition status and anaemia. The pharynx and larynx may be examined in the clinic using either indirect laryngoscopy or more commonly with a flexible fiberoptic nasopharyngoscope that passes through the nose. Particular attention should be paid to obvious swellings or ulceration, as well as the presence of pooling in the piriform sinus (Chevalier Jackson’s sign) and oedema of the arytenoids. Assessment of vocal cord mobility is paramount in medial wall tumours sited in the piriform sinus and postcricoid area. Palpation of the neck is necessary to determine the presence or absence of enlarged lymph nodes, and record their number, size and distribution. Also, during neck palpation it is possible to assess the mobility of the laryngopharynx on the cervical vertebrae, tumour extension to the prevertebral muscles causes loss of laryngeal crepitus (Trotter’s sign), suggesting a large tumour.

Table 1. Evaluation of a patient suspected of hypopharyngeal cancer

Fig. 1. Anatomical sub-sites of the hypopharynx. Piriform sinus (orange), postcricoid region (blue) and posterior pharyngeal wall (green) are shown. This was published in the 5th edition of Stell and Maran’s Head and Neck Surgery and Oncology in 2012. Reprinted with permission from Hodder Arnold.

When using a nasopharyngosocpe or a transnasal endoscope, the piriform sinus may be distended by the patient performing a Valsalva manoeuvre with the glottis open, and the nostrils pinched. If patients are unable to cooperate or experience sever discomfort while performing hypopharyngeal or upper oesophageal examination, then these procedures should be performed when patients are under general anaesthesia [10]. Reports exist of patients with hypopharyngeal cancer being missed on flexible endoscopy, so attention to the hypopharyngeal area when the endoscope is being withdrawn [11].