Help! Endoscopist Barber Needed: A Case of Hirsute Hypopharynx

Abstract

FigureIntroduction: Hirsute hypopharynx/esophagus is an extremely rare endoscopic finding seen in patients with a history of head and neck carcinomas who underwent pharyngo-esophageal reconstructive surgery using skin grafts to restore the affected area. We present such a patient that was treated at our institution. Methods: A 65-year-old Caucasian veteran with a history of recurrent laryngeal squamous cell carcinoma presented for an upper endoscopy after developing progressive dysphagia. Ten months prior to presentation, he underwent extensive neck dissection including resection of the hypopharynx with left rectus muscle free flap reconstruction. Subsequently, he underwent secondary tracheoesophageal puncture and voice prosthesis placement for esophageal phonation. Post-surgery, patient began to experience progressive dysphagia, globus sensation and choking spells. Endoscopy revealed significant skin flap hair growth causing narrowing of the lumen of the neopharynx. Other than a non-obstructing Schatzki's ring, the esophagus, stomach, and duodenum were otherwise unremarkable. Follow up video fluoroscopy showed pharyngeal dysphagia with slow, restricted movement of oral intake and poor distension of the lumen of the neo-pharynx.Figure 1Conclusion: Hirsute pharynx/esophagus is a rare complication of pharyngo-esophageal reconstructive surgery. According to literature review, only eight cases have been reported so far. With extensive surgical resection, delto-pectoral or pectoralis major flaps are frequently used to reconstruct and restore the anatomy and function of the operative area. The reconstructed tube is formed by rotating the skin flap, with the raw surface on the spine and the skin turned on itself, so that the outer epithelial surface becomes the inner lining. The epithelial surface of flaps may bear hair, resulting in a “hairy pharynx or esophagus.” Excessive hair growth may lead to symptoms of progressive dysphagia, hair-spitting, and choking episodes. Hair growth tends to cease spontaneously within six to twelve months of surgery. However, on rare occasions it may persist. Various treatment modalities such as bougienage dilatation and “haircuts” using forceps and/or scissors and radiation therapy have been reported. It should be noted that, in our patient, another possible cause for his globus sensation could be the voice prosthesis in his cervical esophagus.