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HYPOPHARYNX

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HYPOPHARYNX anatomy

Last reviewed: October 4, 2026

Introduction

Cancer of the hypopharynx, the lowest part of the throat, is uncommon, making up only a few percent of head and neck cancers. Almost all are squamous cell carcinomas caused by tobacco and alcohol. Because early symptoms are vague, most are found at an advanced stage, and this cancer spreads to neck lymph nodes more often than any other head and neck cancer [1].

Treatment usually combines radiation and chemotherapy, given either at the same time or after a first course of chemotherapy, with the goal of curing the cancer while keeping the voice box. Surgery that removes the larynx and part of the throat (total laryngopharyngectomy), followed by radiation, is used for the most advanced tumors or when other treatment does not work [2, 3, 4]. The sections below cover anatomy, evaluation, treatment and swallowing. A numbered reference list is at the end of the page.

The hypo pharynx is the lowest part of the throat, located behind the voice box (larynx), and leading into the esophagus. View the anatomy here.

The hypopharynx surrounds the back and sides of the larynx like a funnel and has three parts, or subsites [1]:

The pyriform sinuses, two pear-shaped pockets on either side of the larynx where food passes on its way to the esophagus. More than 60% of hypopharyngeal cancers start here.
The postcricoid area, directly behind the lower larynx at the entrance to the esophagus.
The posterior pharyngeal wall, the back wall of the lower throat.

Most people with hypopharyngeal cancer are older men with a long history of smoking and drinking, which act together to raise the risk. Unlike cancer of the tonsils and base of tongue, HPV plays little role [1] (see oropharynx).

Evaluation of a hypopharyngeal mass

A growth in the hypopharynx typically does not cause swallowing, voice, or airway symptoms until it is fairly large, and for this reason, spread to a neck lymph node may occur and become noticeable before a cancer in the hypopharynx is identified. Imaging (such as a CT scan) and a head and neck surgeon looking at the throat with a scope are usual next steps leading to identification of the cancer’s starting location (the primary tumor). A needle biopsy of any suspicious neck lymph node may be done, and a trip to the operating room for an examination of the throat, biopsies of the mass, and note of the anatomic extent of the mass is typical. If the mass is large enough to threaten the airway, a tracheostomy may be placed. A PET-CT scan is arranged if the other imaging techniques do not provide adequate information. When a hypopharyngeal mass is found to be cancer, it is typically the type called squamous cell carcinoma.

Why it is often found late

Early symptoms, such as a feeling of something stuck in the throat, mild throat pain, pain in one ear or slowly increasing difficulty swallowing, are easy to dismiss, and small tumors deep in the pyriform sinus are hard to see. As a result, roughly 7 to 9 in 10 patients are diagnosed at stage III or IV. Hypopharyngeal cancer has a rich lymphatic network and tends to spread beneath the surface lining, so about 70% of patients have enlarged neck lymph nodes when they are diagnosed, and spread to distant sites such as the lungs is more common than with other head and neck cancers [1] (see lymphatics and lymph nodes).

Imaging and staging

The NCCN guidelines recommend CT with contrast and/or MRI of the throat and neck, and PET-CT for advanced tumors to look for spread to the chest and elsewhere [2]. Staging uses the AJCC TNM system; a tumor that fixes the larynx in place or invades the thyroid cartilage or nearby structures is classified as T3 or T4.

Looking for a second cancer

Because the same tobacco and alcohol exposure affects the whole lining of the throat, esophagus and lungs, people with hypopharyngeal cancer are at risk for a second, separate cancer in these areas. A meta-analysis found that PET-CT is very specific but misses about half of second cancers in the esophagus [5]. In a prospective study of 202 head and neck cancer patients screened with upper endoscopy, a second cancer was found in 5%, almost all at an early, curable stage, and none had been seen on routine imaging [6]. Examination of the esophagus (esophagoscopy) is therefore often part of the operating room evaluation.

Treatment of hypopharyngeal cancer

The mainstay of treatment of a hypopharyngeal cancer is radiation therapy. Chemotherapy or immunotherapy may be added for additional treatment effect. Surgery is used in certain situations, such as when the primary tumor is large enough and involving the voice box (larynx) that radiation and medical treatments alone are unlikely to produce a cure, or if these treatments would likely cause enough damage to the throat that larynx function (voice and protecting the lungs during swallowing) would be ineffective. Surgery may also include the removal of lymph nodes in the neck that have cancer spread to them or are at risk for that. The best treatment plan for a given individual is agreed upon by members of the tumor board conference, and this recommendation is relayed to the patient.

Keeping the larynx: chemotherapy first

The EORTC 24891 trial randomly assigned 194 patients with cancer of the pyriform sinus or nearby larynx to immediate surgery (total laryngectomy and partial pharyngectomy) or to chemotherapy first, followed by radiation for those whose tumors responded and surgery for those whose tumors did not. Survival was the same in the two groups [7]. At ten years, overall survival was 13.8% after surgery and 13.1% with the chemotherapy approach, and more than half of the survivors in the chemotherapy group still had a working larynx. The low survival in both groups reflects how serious this cancer is, often because of other smoking-related illnesses and second cancers [3].

The French GORTEC 2000-01 trial then showed that adding a third drug, docetaxel, to cisplatin and fluorouracil (TPF) improved the chance of keeping the larynx. Three-year larynx preservation was 70.3% with TPF compared with 57.5% with the two-drug regimen [8], and the advantage persisted at ten years (70.3% compared with 46.5%) without a difference in overall survival [4].

Keeping the larynx: chemoradiation

Radiation with cisplatin given at the same time, the approach that gave the highest larynx preservation in larynx cancer [9], is also widely used for hypopharyngeal cancer. The NCCN guidelines list chemoradiation, chemotherapy followed by radiation, and surgery as options for most advanced hypopharyngeal cancers that can be removed [2]. As with larynx cancer, a larynx that already does not work, or a tumor that has grown through cartilage, is generally better treated with surgery [10].

Surgery and reconstruction

For advanced tumors, or when cancer remains or returns after radiation, the operation is usually a total laryngectomy with removal of part or all of the hypopharynx (laryngopharyngectomy) and neck dissection, followed by radiation or chemoradiation [2]. The throat is then rebuilt so that food can pass to the esophagus, using tissue such as a forearm or thigh free flap, a segment of small intestine (jejunal free flap), or a chest muscle flap. In a network meta-analysis of 1,357 patients who had the whole circumference of the throat rebuilt, a leak from the throat to the skin (fistula) occurred in about 10% with a jejunal flap and 42% with a tubed chest muscle flap; narrowing (stricture) rates were similar for most methods [11]. Voice after laryngectomy is restored in the same ways described on the larynx page.

Survival

Hypopharyngeal cancer has the lowest survival of the major head and neck cancer sites. In SEER data on 6,647 patients, average five-year survival improved from 37.5% for those diagnosed between 1973 and 1989 to 41.3% for those diagnosed between 1990 and 2003, as radiation-based treatment became more common [12]. Early-stage cancers do much better than advanced ones, and these figures describe large groups rather than any one person.

Swallowing

Swallowing well is essential for maintaining nutrition as well as keeping the lungs free of infection. A decision faced commonly in the treatment of throat cancer is whether to place a gastric feeding tube (G tube).

The hypopharynx is where food is steered around the larynx into the esophagus, so both the cancer and its treatment affect swallowing. Many patients have trouble swallowing and some aspiration (food or liquid entering the windpipe) before treatment begins. The NCCN guidelines recommend evaluation by a dietitian and a speech and swallowing therapist before treatment, swallowing exercises, and a feeding tube for patients who are losing weight or cannot swallow safely [2]. Most patients are able to stop using a feeding tube within the first year or two after treatment, but some need long-term help. More information is on the swallowing page.

Additional links

• Link to an interactive informational site for patients by the American Cancer Society on larynx and hypopharynx cancer.

Summary

Hypopharyngeal cancer is uncommon, usually caused by tobacco and alcohol, and most often starts in the pyriform sinus [1].
Most patients are diagnosed at an advanced stage, and about 70% have neck lymph node spread at diagnosis [1].
Evaluation includes endoscopy with biopsy, CT or MRI, PET-CT for advanced disease, and a search for second cancers [2, 6].
Chemotherapy followed by radiation, or chemoradiation, can cure many patients while keeping the larynx, without lowering survival compared with surgery [3, 4].
Total laryngopharyngectomy with reconstruction is used for the most advanced tumors or when other treatment fails [2, 11].

References

Kwon DI, Miles BA. Hypopharyngeal carcinoma: Do you know your guidelines?. Head Neck. 2019;41(3):569-576. doi:10.1002/hed.24752 PubMed 30570183
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers. Version 2.2026. nccn.org
Lefebvre JL, Andry G, Chevalier D, et al. Laryngeal preservation with induction chemotherapy for hypopharyngeal squamous cell carcinoma: 10-year results of EORTC trial 24891. Ann Oncol. 2012;23(10):2708-2714. doi:10.1093/annonc/mds065 PubMed 22492697
Janoray G, Pointreau Y, Garaud P, et al. Long-term Results of a Multicenter Randomized Phase III Trial of Induction Chemotherapy With Cisplatin, 5-fluorouracil, ± Docetaxel for Larynx Preservation. J Natl Cancer Inst. 2016;108(4). doi:10.1093/jnci/djv368 PubMed 26681800
Ershadifar S, Larsson J, Young K, et al. Efficacy of (18)FDG-PET/CT in Detecting Synchronous Malignancies in Patients With Head and Neck Cancer: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2024;171(6):1639-1649. doi:10.1002/ohn.879 PubMed 38943453
van Tilburg L, van de Ven SEM, de Jonge PJF, et al. Endoscopic screening of the upper gastrointestinal tract for second primary tumors in patients with head and neck cancer in a Western country. Endoscopy. 2023;55(11):981-990. doi:10.1055/a-2111-5935 PubMed 37328150
Lefebvre JL, Chevalier D, Luboinski B, et al. Larynx preservation in pyriform sinus cancer: preliminary results of a European Organization for Research and Treatment of Cancer phase III trial. EORTC Head and Neck Cancer Cooperative Group. J Natl Cancer Inst. 1996;88(13):890-9. doi:10.1093/jnci/88.13.890 PubMed 8656441
Pointreau Y, Garaud P, Chapet S, et al. Randomized trial of induction chemotherapy with cisplatin and 5-fluorouracil with or without docetaxel for larynx preservation. J Natl Cancer Inst. 2009;101(7):498-506. doi:10.1093/jnci/djp007 PubMed 19318632
Forastiere AA, Goepfert H, Maor M, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med. 2003;349(22):2091-8. doi:10.1056/NEJMoa031317 PubMed 14645636
Forastiere AA, Ismaila N, Lewin JS, et al. Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2018;36(11):1143-1169. doi:10.1200/JCO.2017.75.7385 PubMed 29172863
Costantino A, Festa BM, Ferreli F, et al. Circumferential pharyngeal reconstruction after total laryngopharyngectomy: A systematic review and network meta-analysis. Oral Oncol. 2022;127:105809. doi:10.1016/j.oraloncology.2022.105809 PubMed 35298936
Newman JR, Connolly TM, Illing EA, et al. Survival trends in hypopharyngeal cancer: a population-based review. Laryngoscope. 2015;125(3):624-9. doi:10.1002/lary.24915 PubMed 25220657

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