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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  • Hypopharyngeal diverticulum

  • Zenker’s diverticulum

  • Pharyngo-oesophageal pouch

  • Retropharyngeal pouch

  • Killian’s diverticulum


  • 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


  • First described in 1769 by Ludlow

  • Friedrich Zenker & von Ziemssen first described its picture in their book in 1877

Hypopharyngeal pouch styalgia

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.

Hypopharyngeal pouch styalgia

  • 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)


  • 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)


  • Chest X-ray:may show sac + air - fluid level

  • Barium swallow

  • Barium swallow with video-fluoroscopy

  • Rigid Oesophagoscopy

  • Flexible Endoscopic Evaluation of Swallowing


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


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

Hypopharyngeal pouch styalgia

  • Bleeding & haematoma formation

  • Infection: mediastinitis & pneumonitis

  • Esophageal or diverticulum perforation

  • Oesophageal stricture

  • Recurrence

  • Recurrent Laryngeal Nerve paralysis

  • Pharyngo-cutaneous fistula

  • Surgical emphysema


  • 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.


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


  • 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


  • 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