Pharyngeal pouch

  • Is posteromedial pulsion diverticulum through Killian's dehiscence
  • Occurs between thyropharyngeus and cricopharyngeus muscles
  • Both form the inferior constrictor of the pharynx
  • Male : female ratio is  5:1
  • Usually only seen in the elderly
  • Aetiology is unknown but upper oesophageal sphincter dysfunction may be important

Pharyngeal pouch

Clinical features

  • Commonest symptoms are dysphagia, regurgitation and cough
  • Recurrent aspiration can result in pulmonary complications
  • A carcinoma can develop within the pouch
  • Clinical signs are often absent
  • A cervical lump may be present that gurgles on palpation

Investigation

  • Barium swallow show residual pool of contrast within the pouch

Barium swallow showing a pharyngeal pouch

  • Indirect laryngoscopy may show a pooling of saliva within the pyriform fossa

Treatment

  • Depends on size of pouch and age of patient
  • Options include:
    • Diverticulectomy
    • Dohlman's procedure

Diverticulectomy

  • Following rigid endoscopy the pouch is packed with gauze
  • A 32 Fr bougie is placed with in the oesophagus
  • Collar incision made at level of cricoid cartilage
  • Fascia at anterior border of sternomastoid is divided
  • Pouch is identified anterior to prevertebral fascia
  • Pouch is then excised an defect closed
  • Cricopharyngeal myotomy is performed to prevent recurrence
  • Patient should be feed via a nasogastric tube for a week postoperatively
  • Complications include:
    • Recurrent laryngeal nerve palsy
    • Cervical emphysema
    • Mediastinitis
    • Cutaneous fistula

Dohlman's procedure

  • Is an endoscopic procedure
  • A double-lipped oesophagoscope is used
  • Wall between the diverticulum and oesophageal wall is exposed
  • Hypopharyngeal bar divided with diathermy or laser
  • Minimally invasive techniques allow:
    • Shorter duration of anaesthesia
    • More rapid resumption of oral intake
    • Shorter hospital stay
    • Quicker recovery

Bibliography

Aly A,  Devitt P G,  Jamieson.   Evolution of surgical treatment for pharyngeal pouch.  Br J Surg 2004;  91:  657-664.

Hoay C B, Sharp H R, Bates G J. Current practices in pharyngeal pouch surgery in England and Wales. Ann R Coll Surg Eng 1997; 79: 190-194.

Laing M R, Murthy P, Ah-See K W, Cockburn J S. Surgery for pharyngeal pouch: audit of management with short and long-term follow up. J R Coll Surg Ed 1995; 40: 315-318.

Siddiq M A,  Sood S,  Strachan D.  Pharyngeal pouch (Zenker's diverticulum).  Postgrad Med J 2001;  77:  506-511.

 

 
 

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