-Case Reports-

Downhill Varices in the Hypopharynx of a Patient with a Large Thyroid Tumor: A Case Report

Ryuta Nagaoka¹, Marie Saitou¹, Kiyotaka Nagahama², Ritsuko Okamura¹, Haruki Akasu³, Takehito Igarashi¹, Kazuhiko Yokoshima⁴, Ryuji Ohashi⁵ and Iwao Sugitani¹

¹Department of Endocrine Surgery, Nippon Medical School, Tokyo, Japan
²Department of Pathology, Kyorin University School of Medicine, Tokyo, Japan
³Department of Endocrine Surgery, Nippon Medical School Musashi Kosugi Hospital, Kanagawa, Japan
⁴Department of Head and Neck Surgery and Oncology, Tochigi Cancer Center, Tochigi, Japan
⁵Department of Integrated Diagnostic Pathology, Nippon Medical School, Tokyo, Japan

Downhill varices are usually caused by superior vena cava (SVC) obstruction due to bronchogenic carcinoma or mediastinal tumors. These structures exhibit retrograde blood flow and are located in the proximal esophagus. Varices in the hypopharynx resulting from mediastinal thyroid tumor are extremely rare. A 70-year-old man with a 35-year history of a growing thyroid tumor on the right side of his neck visited a local hospital. Fine-needle aspiration cytology of the tumor revealed benign goiter. Contrast-enhanced computed tomography showed a huge tumor (13 × 10 × 5 cm) in the right to left lobe of the thyroid that extended into the mediastinum. A well-enhanced mass mimicking hypopharyngeal cancer was identified in the hypopharynx. Endoscopic examination showed varices in the postcricoid region, so biopsy was contraindicated. The preoperative diagnosis was adenomatous goiter and hypopharyngeal varices caused by obstruction of the internal jugular and brachiocephalic vein by the goiter. Total thyroidectomy was performed and the hypopharyngeal varices had disappeared by the next day. The histopathological diagnosis of the thyroid tumor was poorly differentiated carcinoma. Mediastinal thyroid tumor rarely causes downhill varices due to SVC obstruction. However, signs of SVC obstruction were absent in this case, and varices were present in the hypopharynx, not in the upper esophagus. Obstructed venous flow from the thyroid plexus might circulate via the superior laryngeal vein and cause varices in the postcricoid region. When a patient with a large mediastinal tumor has a tumor-like lesion in the hypopharynx, downhill varices should be considered before scheduling a biopsy.

J Nippon Med Sch 2023; 90: 408-413

Keywords
downhill varix, hypopharynx, superior vena cava obstruction, poorly differentiated thyroid carcinoma, mediastinal thyroid tumor

Correspondence to
Ryuta Nagaoka, MD, PhD, Department of Endocrine Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
ryuta-n@nms.ac.jp

Received, March 14, 2022
Accepted, July 8, 2022