SALEH TAWFIQUE FRCS FRCSEd DLO HYPOPHARYNGEAL POUCH ZENKER’S DIVERTICULUM MANAGEMENT and CASE PRESENTATION PRESENTED BY SALEH TAWFIQUE FRCS FRCSEd DLO Assistance Professor Otolaryngologist KBMS Erbil Iraq

HYPOPHARYNGEAL POUCH MANAGEMENT and CASE PRESENTATION INTRODUCTION This is a posterior pulsion diverticulum which occurs between the upper oblique and the lower horizontal fibers of the inferior constrictor muscle of the pharynx. The pouch herniates through a potentially weak triangular area above the cricopharyngeal sphincter known as Killian’s triangle. The first case was described in 1764 by a surgeon from Bristol , Mr. A. ludlow ( a case of obstructive deglutition from a dilatation of and bag formed in the pharynx.) Zenker and Van Zeimssen reported later 1874 , 22 cases , 5 of their own.

HYPOPHARYNGEAL POUCH MANAGEMENT and CASE PRESENTATION ANATOMY OF HYPOPHARYNX Hypopharynx is extended from the upper margin of the epiglottis down to the inferior border of cricoid cartilage . It is situated dorsally to larynx and covers larynx laterally, forming piriform fosse. The posterior wall of Hypopharynx formed by inferior constrictor muscle of pharynx , which is corresponds to C3 – C6 vertebrae.

HYPOPHARYNGEAL POUCH PHYSIOLOGY OF SWALLOWING The upper oesophagus sphincter is in state of contraction always. During swallowing the sphincter relaxes by central inhibition reflex action. The presence of bolus in the mouth cavity will stimulate afferent receptors of cranial nerves V , IX and X, which convey the sensation to Medulla, then to motor nuclei of V,VII, IX, X and XII nerves, and swallowing process will be initiated. Swallowing consists of a very quick , coordinated sequence of events, and activities in groups of muscles in the mouth cavity, pharynx, larynx and oesophagus which occur by reflex action controlled by swallowing center in Medulla. When a person is awake , he swallows 70 times per an hour. This will be reduced to 7 time during sleeping

HYPOPHARYNGEAL POUCH Physiology of swallowing Swallowing process has 3 stages: Oral stage, voluntary stage Pharyngeal stage , non voluntary stage Oesophageal stage, non voluntary stage

HYPOPHARYNGEAL POUCH ANATOMY Hypopharynx continues down below to oesophagus. Cricopharyngeal sphincter makes the lower limitation of hypopharynx. Just above this sphincter posteriorlly , is Killian’s dehiscence. Killian’s Dehiscence: This is a triangular area just above cricopharyngeal sphincter posteriorlly . It is bounded inferiorly by horizontal fibers of inferior constrictor muscle ( Cricopharyngeus muscle) and on each side by oblique fibers of inferior constrictor muscle ( thyropharyngeus muscle). This triangular area is weakly covered by muscles and it is the site where Zenker’s diverticulum arises.

HYPOPHARYNGEAL POUCH Swallowing process Oral stage: the food particles are chewed and divided to small pieces and will be mixed with saliva, forming a bolus. By the movement and contraction of the tongue the bolus will be pushed backward and upwards against the palate down to pharynx. To prevent regurgitation of food particles through the nose, the tongue remains contracted against the hard palate while the soft palate raises upwards and backwards to close the nasopharynx, meanwhile the bolus descends down to oropharynx.

HYPOPHARYNGEAL POUCH Swallowing process: Pharyngeal stage: this is non voluntary stage initiated in cortex and Medulla by a coordinated sequence of muscular activities and waves of contraction in the pharynx and larynx. The contraction of muscles in the floor of mouth raises the hyoid bone and larynx. The epiglottis moves backwards and aryepiglottic folds contract medially meanwhile both vocal cords adduct, in this way the laryngeal inlet will be closed and the bolus will be prevented to descends to larynx or into trachea. Pharyngeal constrictor muscles contract and pushing the bolus down to the entrance of oesophagus. This process to some extend will be helped by action of gravidity also. The larynx raises and at the same time the Cricopharyngeus muscle relaxes to receive the bolus down to upper oesophagus.

HYPOPHARYNGEAL POUCH Swallowing process Oesophageal stage: the peristaltic action initiated in pharynx continue down to oesophagus pushing the bolus down to stomach. This process will be hasten by action of gravidity. Finally all muscles in the floor of mouth and pharynx and larynx relax and hyoid bone and larynx descend to normal position. The cricopharyngeal sphincter will return to contraction state .

HYPOPHARYNGEAL POUCH ETIOLOGY OF HYPOPHARYNGEAL DIVERTICULUM The real etiology is unknown. There is much controversy about causes of this condition. However zenker’s diverticulum always arises posteriorlly from the weak triangular area (Killian dehiscence). But we all have this anatomical weak area , yet we all do not get diverticulum!! Probably it is dysfunction of hypopharynx which leads to in coordination between hypopharynx contraction and opening of cricopharyngeal sphincter. This means that cricopharyngeal sphincter fails to open when the bolus descends to oesophagus at the end of second stage of swallowing. This eventually builds a high pressure in the hypopharynx , which causes herniation of mucosal lining of pharynx through the Killian’s triangle.

HYPOPHARYNGEAL POUCH ETIOLOGY There are different theory for the etiology of hypopharyngeal diverticulum: Continuous spasm of cricopharyngeal sphincter, which fails to open during swallowing. This builds high pressure in hypopharynx and eventual herniation. The Cricopharyngeus is not in spasm, but fails or there is delay in in relaxation due to neuromuscular in coordination. Secondary swallow and mega pharynx. Here the pharynx, due to senility, is huge and relax, at the end of each swallowing there will be residual food particles in the pharynx. The patient attempts a second swallowing process while the cricopharyngeal sphincter is still not relaxed .Eventually high pressure builds in hypopharynx and this may cause herniation through Killian’s triangle. Congenital neuromuscular in coordination during swallowing process.

HYPOPHARYNGEAL POUCH ETIOLOGY All these theories do not explain real etiology of this condition. However all agree that : There is weak anatomical triangle posteriorlly in hypopharynx. There is always high intapharyngeal pressure in hypopharynx. The cricopharyngeus muscle function is not normal. The familial tendency of this condition has been reported. There is also association of reflux oesophagitis and hiatus hernia and Zenker’s diverticulum. These conditions may increase the tone of cricopharyngeas muscle .

HYPOPHARYNGEAL POUCH CLINICL PRESENTATION Incidence: Hypopharyngeal diverticulum is rare condition. The incidence is around 0.0005% in UK , around 0.0022 in Sweden. However , radiological studies shown higher incidence , around 0.12-0.18%. This is due to that some cases are symptom free. Sex and Age: majority of patients are elderly , over 50 years. male to female ratio is 2:1 Negroes are very rarely affected by this condition.

HYPOPHARYNGEAL POUCH Symptoms This condition has very insidious onset. Due to variety and vague initial symptom, some patients present with a very well developed pouch. Dysphagia. This symptom may not be quite clearly explained by the patient , initially the patient may feel a sensation of lump in the throat (may be diagnosed as globus). Feeling of food sticking in the throat, requiring repeated swallowing attempts. Increase the length of time taken to eat. Progressive dysphagia, initially for solid, then for semisolid and finally even for liquid. This eventually leads to: Weight loss

HYPOPHARYNGEAL POUCH Symptoms Regurgitation of undigested food, specially when the patient lying down in bed at night. Foul taste in mouth or foul breath , due to the prolonged foot retention inside the pouch. Gurgling sound and sensation during swallowing , due to mixture of air and fluid in the sac.

HYPOPHARYNGEAL POUCH Other Symptoms Spillage of food may cause also lower resp tract infection, such as pneumonia, lung abscess. Hoarseness of voice , due to spillage of food from the sac to larynx. It may be also due to recurrent laryngeal nerve paralysis. Other rare symptom such as pain, bleeding from the pouch due to ulceration or CA change.

Signs This includes: HYPOPHARYNGEAL POUCH Emaciation Swelling on the neck. Usually on the left side in the anterior triangle of neck. which is Soft , gurgle on palpation (Boyce, sign). A spasm of cough may be initiated by palpation of the neck mass , due to spillage of the content to the larynx. Indirect laryngoscopy may show red laryngeal mucosa , pooling of saliva in pyriform fossa or even undigested food particles may be seen.

HYPOPHARYNGEAL POUCH INVESTIGATIONS Radiological investigation are require to confirm the clinical suspicious of the condition. Plain radiography, of soft tissue of the neck may show * increase width of soft tissue at post cricoid region * air fluid level in the sac Contrast radiography and cineradiography. This investigation must include the pharynx, oesophagus and stomach , to demonstrate other associated abnormalities which may exist in lower oesophagus such as hiatus hernia or reflux oesophagitis. * sac is seen specially on lateral view , it’s size and extend is demonstrated. * spillage of barium to larynx or trachea may be seen.

Radiological investigation HYPOPHARYNGEAL POUCH Radiological investigation This investigation must include the pharynx, oesophagus and stomach , to demonstrate other associated abnormalities may exist in lower oesophagus such as hiatus hernia. * sac is seen specially on lateral view. It’s size and extend is demonstrated.

HYPOPHARYNGEAL POUCH Other investigation : Ultrasound Oesophageal manometery during rest and during swallowing Pharyngoesophagoscopy Biopsy from the sac if CA is suspected

HYPOPHARYNGEAL POUCH MANAGEMENT and CASE PRESENTATION Having diagnosed a pouch , then there are different way to treat this condition. The management depends on : Age of the patient and state of his general condition Size of the pouch Presence of any complication, exp CA Skill of the surgeon Available resources

HYPOPHARYNGEAL POUCH MANAGEMENT IF THE CASE REQUIRES TREATMENT , THEN THE CHOICE AVAILABLE BETWEEN: ENDOSCOPIC SURGERY EXTERNAL SURGERY DILATATION ENDOSCOPIC DIATHERMY(DOHLMAN’S OPERATION) ENDOSCOPIC LASER SURGERY ENDOSCOPIC STAPLING DIVERTICULECTOMY +CRICOPHARYNGEAL MYOTOMY DIVERTICULO-OESOPHAGOSTOMY

HYPOPHARYNGEAL POUCH TRAETMENT Both External surgical or Endoscopic surgery has advantages and disadvantages. Endoscopic surgery It is rapid and takes short period to be performed Can be done under both LA or GA The post operative recovery is rapid and short. So it is useful for elderly patients, whose general condition may not allow long surgical procedure. However , there are high rate of recurrence of diverticulum As the sac will not be removed , then the future risk of Ca change is still existing. The procedure can not be applied for any diverticulum. Stapling can not be performed for small sac. A very large diverticulum can not also be treated by one endoscopic session . It may need 2 or 3 sessions.

External surgical procedures HYPOPHARYNGEAL POUCH Treatment External surgical procedures It is lengthy procedure Post op recovery is long Rate of complications is high Therefore may not be suitable for elderly patients with bad general condition. However , Rate of recurrence of the diverticulum is very low As the sac is totally removed , there is no risk of future Ca development .

If we apply a rule of thumb HYPOPHARYNGEAL POUCH TREATMENT If we apply a rule of thumb No treatment is require in a small pouch causes very little symptom or If the general condition of the patient is bad A very large diverticulum which extends down to mediastinum , can be treated by diverticulo-oesophagostomy. The fundus of the sac drains to oesophagus. A pouch smaller than the height of a vertebra is best treated by either: endoscopic laser surgery or total excision by ext approach. A pouch about height of 3 vertebrae is treated by either endoscopic laser surgery, or stapling or diverticuloctomy. A diverticulum larger than height of 3 vertebrae is treated by either stapling or diverticulectomy.

HYPOPHARYNGEAL POUCH DILATATION: this is not used currently as a treatment for existing pouch . It is recommended for cases develop stricture after surgical treatment. Dohlman’s op. is not popular now a day , as there are other procedures This operation requires specialized instrument, for endoscopic diathermy of the septum between the pouch and oesophagus

HYPOPHARYNGEAL POUCH STAPLING TECHNIQUE IS POPULAR IN UK and USA Using a special staple-gun through a Oesophageal speculum with split beak , The septum between the pouch and oesophagus staples with stainless steel staples .

HYPOPHARYNGEAL POUCH and coagulated , converting ENOSCOPIC LASER SURGERY. with CO2 laser the septum between the pouch and oesophagus evaporated and coagulated , converting the pouch and esophagus to one sac.

HYPOPHARYNGEAL POUCH DIVERTICULECTOMY The patient pre operatively is restricted to fluid diet for 48 h. Operation is performed under GA with endotracheal intubations. Oesophagoscopy done first. A nasogastric tube is passed through cricopharyngeal sphincter to the stomach . The pouch is inspected for CA change. The pouch cleaned from food particles and packed with ribbon gauze soaked in proflavin, the proximal end brought out through the mouth . The pouch will be explored through a collar neck incision at the level of upper border of cricoid cartilage and totally excised . Finally cricopharyngeal myotomy is done. The wound is drained and closed. N G tube will be left for 5-7 days

HYPOPHARYNGEAL POUCH DIVERTICULECTOMY

HYPOPHARYNGEAL POUCH DIVERTICULECTOMY Incision and exposure of the pharyngo-oesophageal segment The diverticulum dissected to the neck of the sac and clamped prior to excision . The line of division for cricopharyngeal myotomy. and line of closure of pharynx a.

HYPOPHARYNGEAL POUCH DIVERTICULECTOMY e. The myotomy incision is extended inferiorly to include the upper part of circular fibers of oesophagus d. Closure of the pharyngeal defect. Wound drained and closed in layers

HYPOPHARYNGEAL POUCH Complications of surgical management IMMEDIATE COMPLICATIONS Haemorrhage Pneumothorax Surgical emphysema EARLY COMPLICATIONS Secondary Haemorrhage Hoarseness of voice Wound infection and abscess Mediastinitis Aerocoele LATE COMPLICATIONS Persistence hoarseness of voice Stricture Recurrence of the pouch Carcinoma may arise from the pouch or residual of it, specially after endoscopic surgery , when the pouch will not be removed. Incidence is around 0.5-1.0%.

HYPOPHARYNGEAL POUCH MANAGEMENT and CASE PRESENTATION END OF PRESENTATION THANK YOU ANY QUESTIONS ?