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 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
Origin of Zenker’s diverticulum
History First described in 1769 by Ludlow Friedrich Zenker & von Ziemssen first described its picture in their book in 1877
Hugo von Ziemmsen
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.
1.Entrapment of food in pouch: sensation of food sticking in throat & later dysphagia 2.Regurgitation of entrapped food: leads to foul taste bad odor nocturnal coughing choking 3.Hoarseness: due to spillage laryngitis or sac pressure on recurrent laryngeal nerve 4.Weight loss: due to malnutrition 5.Compressible neck swelling on left side: reduces with a gurgling sound (Boyce sign)
Complications 1.Lung aspiration of sac contents 2.Bleeding from sac mucosa 3.Absolute oesophageal obstruction 4.Fistula formation into: trachea major blood vessel 5.Squamous cell carcinoma within Zenker diverticulum (0.3% cases)
Investigations Chest X-ray: may show sac + air - fluid level Barium swallow Barium swallow with video-fluoroscopy Rigid Oesophagoscopy Flexible Endoscopic Evaluation of Swallowing
Barium swallow with Video-fluoroscopy
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
1.Cricopharyngeal myotomy: combined with others 2.Diverticulum invagination: Keyart 3.Diverticulopexy: Sippy-Bevan 4.External or open Diverticulectomy: Wheeler 5.Rigid Endoscopic Diverticulotomy Cautery (Dohlman) Laser Stapler 6.Flexible Endoscopic Diverticulotomy with Laser
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 pushed into hypopharynx lumen & muscle + adjacent tissue are oversewn. CP myotomy is usually combined with this.
Endoscopic diverticulotomy Diverticuloscope advanced so its upper lip is within esophagus & lower lip is within diverticulum
View through diverticuloscope Cautery, laser, or stapling device used to divide common party wall between pouch & esophagus
View through diverticuloscope
Cutting & Stapling
Diverticulopexy Sac mobilized & its fundus fixed to sternocleido- mastoid muscle in a superior, non-dependent position. CP myotomy is also done.
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.
History Watt Weems Eagle described this in 1937 with 200 cases. 2 types: classical & carotid artery syndrome
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 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
Normal Styloid Process
Elongated Styloid Process
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 Irritation of glossopharyngeal nerve Irritation of sympathetic nerve plexus around internal carotid artery Inflammation of stylo-hyoid ligament Stretching of overlying pharyngeal mucosa
Diagnosis 1.Digital palpation of styloid process in tonsillar fossa elicits similar pain 2.Relief of pain with injection of 2% Xylocaine solution into tonsillar fossa 3.X-ray neck lateral view 4.Ortho-pan-tomogram (O.P.G.) 5.Coronal C.T. scan skull 6.3-D reconstruction of C.T. scan skull
X-ray neck lateral view
Coronal C.T. scan
Coronal 3-D C.T. scan
Medical Treatment 1.Oral analgesics 2.Injection of steroid + 2% Lignocaine into tonsillar fossa 3.Carbamazepine: 100 – 200 mg T.I.D. 4.Operative intervention reserved for: failed medical management for 3 months severe & rapidly progressive complaints
Styloid Process Excision
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 & fossa incision
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 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