hypopharyngeal pouch styalgia
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Hypopharyngeal Pouch & Styalgia. Dr. Vishal Sharma. Hypopharyngeal pouch. Synonyms. Hypopharyngeal diverticulum Zenker’s diverticulum Pharyngo-oesophageal pouch Retropharyngeal pouch Killian’s diverticulum. Introduction.

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synonyms
Synonyms
  • Hypopharyngeal diverticulum
  • Zenker’s diverticulum
  • Pharyngo-oesophageal pouch
  • Retropharyngeal pouch
  • Killian’s diverticulum
introduction
Introduction
  • Hypopharyngeal pouch is an acquired pulsion diverticulum caused by posterior protrusion of mucosa through pre-existing weakness in muscle layers of pharynx or esophagus.
  • In contrast, congenital diverticulum like Meckel\'s diverticulum is covered by all muscle layers of visceral wall.
weak spots b w muscles1
Weak spots b/w muscles

Posterior: 1. Between Thyropharyngeus & Crico-

pharyngeus: Killian\'s dehiscence (commonest)

2. Below cricopharyngeus: Laimer-Hackermann area

Lateral: 1. Above superior constrictor

2. Between superior & middle constrictors

3. Between middle & inferior constrictors

4. Below cricopharyngeus: Killian-Jamieson area

history
History
  • First described in 1769 by Ludlow
  • Friedrich Zenker & von Ziemssen first described its picture in their book in 1877
slide12
1. Tonic spasm of cricopharyngeal sphincter:

 C.N.S. injury  Gastro-esophageal reflux

2. Lack of inhibition of cricopharyngeal sphincter

3. Neuromuscular in-coordination between Thyro-pharyngeus & Cricopharyngeus

4. Second swallow against closed cricopharynx

These lead to increased intra-luminal pressure in

hypopharynx & mucosa bulges out via weak areas.

slide14
Entrapment of food in pouch:sensation of food sticking in throat & later dysphagia
  • Regurgitation of entrapped food:leads to  foul taste  bad odor  nocturnal coughing  choking
  • Hoarseness:due to spillage laryngitis or sac pressure on recurrent laryngeal nerve
  • Weight loss:due to malnutrition
  • Compressible neck swelling on left side:reduces with a gurgling sound (Boyce sign)
complications
Complications
  • Lung aspiration of sac contents
  • Bleeding from sac mucosa
  • Absolute oesophageal obstruction
  • Fistula formation into:

 trachea  major blood vessel

  • Squamous cell carcinoma within Zenker diverticulum (0.3% cases)
investigations
Investigations
  • Chest X-ray:may show sac + air - fluid level
  • Barium swallow
  • Barium swallow with video-fluoroscopy
  • Rigid Oesophagoscopy
  • Flexible Endoscopic Evaluation of Swallowing
staging
Staging

Lahey system:

  • Stage I: Small mucosal protrusion
  • Stage II: Definite sac present, but hypo-pharynx

& esophagus are in line

  • Stage III: Hypopharynx is in line with pouch

& esophagus pushed anteriorly

surgical treatment1
Surgical Treatment
  • Cricopharyngeal myotomy:combined with others
  • Diverticulum invagination: Keyart
  • Diverticulopexy: Sippy-Bevan
  • External or open Diverticulectomy: Wheeler
  • Rigid Endoscopic Diverticulotomy

 Cautery (Dohlman)  Laser  Stapler

  • Flexible Endoscopic Diverticulotomy with Laser
treatment protocol
Treatment Protocol

1. Small sac (< 2cm):

Cricopharyngeal (CP) myotomy + invagination

2. Large sac (2-6 cm):

Open Diverticulectomy with CP myotomy

or Endoscopic Diverticulotomy with CP myotomy

3. Very large sac (> 6 cm):

Open Diverticulectomy with CP myotomy

or Diverticulopexy with CP myotomy

diverticulum invagination
Diverticulum invagination

Diverticulum pushed into hypopharynx lumen & muscle + adjacent tissue are oversewn.

CP myotomy is usually combined with this.

endoscopic diverticulotomy
Endoscopic diverticulotomy

Diverticuloscope advanced so its upper lip is within esophagus & lower lip is within diverticulum

view through diverticuloscope
View through diverticuloscope

Cautery, laser, or stapling device used to divide

common party wall between pouch & esophagus

diverticulopexy
Diverticulopexy

Sac mobilized & its fundus fixed to sternocleido-mastoid muscle in a superior, non-dependent position. CP myotomy is also done.

slide43
Bleeding & haematoma formation
  • Infection: mediastinitis & pneumonitis
  • Esophageal or diverticulum perforation
  • Oesophageal stricture
  • Recurrence
  • Recurrent Laryngeal Nerve paralysis
  • Pharyngo-cutaneous fistula
  • Surgical emphysema
introduction1
Introduction
  • Normal length of styloid process is 2.0–2.5 cm
  • Length >30 mm in radiography is considered an elongated styloid process
  • 5-10% pt with elongated styloid have pain
  • Increased angulation of styloid process both anteriorly & medially, can also cause pain
  • Commonly seen in females over 40 years.
history1
History

Watt Weems Eagledescribed this in 1937 with 200 cases. 2 types: classical & carotid artery syndrome

classical variety
Classical Variety
  • Occurs several years after tonsillectomy
  • Pharyngeal foreign body sensation
  • Dysphagia
  • Dull pharyngeal pain on swallowing, rotation of neck or protrusion of tongue
  • Referred otalgia
  • Due to scar tissue in tonsillar fossa engulfing branches of glossopharyngeal nerve
carotid artery syndrome
Carotid Artery Syndrome
  • Carotid artery compression by styloid process presents as carotodynia, headache & dizziness
  • History of head or neck trauma present
  • External carotid artery involvement: neck pain, radiates to eye, ear, mandible, palate & nose
  • Internal carotid artery involvement: parietal headaches & pain along ophthalmic artery
theories for ossification
Theories for ossification
  • Reactive hyperplasia: trauma  ossification of fibro-cartilaginous remnants in stylohyoid ligament
  • Reactive metaplasia:abnormal post-traumatic healing initiates calcification of stylohyoid ligament
  • Loss of elasticity of stylohyoid ligament: Ageing
  • Anatomic variance:ossification of stylohyoid ligament is an anatomical variation without trauma
theories for pain
Theories for pain
  • Irritation of glossopharyngeal nerve
  • Irritation of sympathetic nerve plexus around internal carotid artery
  • Inflammation of stylo-hyoid ligament
  • Stretching of overlying pharyngeal mucosa
diagnosis
Diagnosis
  • Digital palpation of styloid process in tonsillar fossa elicits similar pain
  • Relief of pain with injection of 2% Xylocaine solution into tonsillar fossa
  • X-ray neck lateral view
  • Ortho-pan-tomogram (O.P.G.)
  • Coronal C.T. scan skull
  • 3-D reconstruction of C.T. scan skull
medical treatment
Medical Treatment
  • Oral analgesics
  • Injection of steroid + 2% Lignocaine into tonsillar fossa
  • Carbamazepine: 100 – 200 mg T.I.D.
  • Operative intervention reserved for:
    • failed medical management for 3 months
    • severe & rapidly progressive complaints
intra oral route
Intra-oral route
  • via tonsil fossa
  • no external scarring
  • poor visibility due to difficult access
  • high risk of damage to internal carotid artery
  • iatrogenic glossopharyngeal nerve injury
  • high risk of deep neck space infection
styloidectomy1
Styloidectomy
  • Tonsillectomy done. Styloid process palpated.
  • Incision made in tonsillar fossa just over the tip.
  • Styloid attachments elevated till its base with periosteal elevator.
  • Styloid process broken near its base with bone nibbler, avoiding injury to glossopharyngeal nv.
  • Tonsillar fossa incision closed.
extra oral route
Extra-oral route
  • Incision extends from mastoid process along sternocleidomastoid to level of hyoid then across neck up to midline of chin
  • external scar present
  • better exposure
  • less morbidity
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