Hypopharyngeal Pouch & Styalgia Dr. Vishal Sharma

Hypopharyngeal pouch

Synonyms Hypopharyngeal diverticulum Zenker’s diverticulum Pharyngo-oesophageal pouch Retropharyngeal pouch Killian’s diverticulum

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

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

Friedrich Zenker

Hugo von Ziemmsen

Etiology

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.

Clinical Features

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)

Complications 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)

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

Barium swallow with Video-fluoroscopy

Rigid Oesophagoscopy

Rigid Oesophagoscopy

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

Stage 1

Stage 2

Stage 3

Surgical Treatment

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 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): or Diverticulopexy with CP myotomy

Cricopharyngeal myotomy

Diverticulum invagination Diverticulum pushed into hypopharynx lumen & muscle + adjacent tissue are oversewn. CP myotomy is usually combined with this.

External diverticulectomy

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

Endoscopic diverticulotomy

Dohlman’s instruments

Cautery

Laser

Endoscopic Stapler

Cutting & Stapling

Haemostasis achieved

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

Complications of surgery

Bleeding & haematoma formation Infection: mediastinitis & pneumonitis Esophageal or diverticulum perforation Oesophageal stricture Recurrence Recurrent Laryngeal Nerve paralysis Pharyngo-cutaneous fistula Surgical emphysema

Styalgia (Eagle Syndrome)

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 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

X-ray neck lateral view

Coronal C.T. scan

Ortho-Pantomogram

Coronal 3-D C.T. scan

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

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

Styloidectomy

Styloidectomy 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

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