Pharyngeal pouch

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Also known as Zenker's diverticulum. It is an outpouching of the pharyngeal mucoase through Killian's dehiscence. The dehiscence is in the midline but 90% of these pouches are found on the left. It is important to be aware of this as a differential diagnosis of dysphagia because unwary endoscopy can lead to perforation.

Contents

Aetiology

Pathophysiology

  • Exact cause is unknown
  • Herniation of pharyngeal mucosa through a weak part of the posterior pharyngeal wall
  • Killian's dehiscence is at the lower part of the inferior constrictor muscle and is bound by thyropharyngeus fibres superiorly and cricopharygeus fibres inferiorly
  • Cricopharyngeal spasm leads to increased pharyngeal pressure, and propulsion of the pouch through the weak spot
  • Food and saliva enter the pouch, and cause it to increase in size
  • Pouch causes pressure on the oesophagus, causing dysphagia

Clinical assessment

  • Sensation of lump in throat
  • Weight loss
  • Vomiting/regurgitation of undigested food from previous day
  • Halitosis
  • Recurrent pneumonitis (from aspiration)
  • Hoarseness (due to aspiration and reflux)
  • Pouch is usually (90%) on the left side
  • Boyce's sign - pouch gurgles when palpated

Investigations

  • Barium swallow demonstates pouch
  • Endoscopy either before or during surgery
    • Carcinoma of the pouch is rare, but should be excluded
    • Positioning of a nasogastic tube to feed patient prior to surgery

Treatment

  • Conservative - if small, and patient asymptomatic
  • Dohlman's procedure - endoscopic division of the bar between the pouch and the oesophagus, followed by stapling
  • Diverticulectomy and cricopharyngeal myotomy - traditional procedure, now reserved for very large pouches, or when endoscopic division has failed

Complications of surgery

Immediate

  • Bleeding
  • Surgical emphysema
  • Pneumothorax

Early

  • Bleeding (usually due to infection)
  • Fistula
  • Mediastinitis

Late

  • Hoarseness (Damage to recurrent laryngeal nerve)
  • Stricture
  • Recurrence (7% endoscopic, 2% diverticulectomy)

Other diverticulae

These are marginally less common than hens' teeth.

  • Congenital lateral diverticulum
  • Posterior pharyngeal diverticulum
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