1. Hypopharyngeal Pouch & Styalgia
Dr. Vishal Sharma

2. Hypopharyngeal pouch

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

4. 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.

5. Weak spots b/w muscles

6. 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

7. Origin of Zenker’s diverticulum

8. History First described in 1769 by Ludlow
Friedrich Zenker & von Ziemssen first described its picture in their book in 1877

9. Friedrich Zenker

10. Hugo von Ziemmsen

11. Etiology

12. 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.

13. Clinical Features

14. 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)

15. 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)

16. Investigations Chest X-ray: may show sac + air - fluid level
Barium swallow
Barium swallow with video-fluoroscopy
Rigid Oesophagoscopy
Flexible Endoscopic Evaluation of Swallowing

17. Barium swallow

18. Barium swallow with Video-fluoroscopy

19. Rigid Oesophagoscopy

20. Rigid Oesophagoscopy

21. 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

22. Stage 1

23. Stage 2

24. Stage 3

25. Surgical Treatment

26. 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

27. 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

28. Cricopharyngeal myotomy

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

30. External diverticulectomy

31. Endoscopic diverticulotomy
Diverticuloscope advanced so its upper lip is within esophagus & lower lip is within diverticulum

32. View through diverticuloscope
Cautery, laser, or stapling device used to divide
common party wall between pouch & esophagus

33. View through diverticuloscope

34. Endoscopic diverticulotomy

35. Dohlman’s instruments

36. Cautery

37. Laser

38. Endoscopic Stapler

39. Cutting & Stapling

40. Haemostasis achieved

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

42. Complications of surgery

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

44. Styalgia (Eagle Syndrome)

45. 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.

46. History
Watt Weems Eagle described this in 1937 with 200 cases. 2 types: classical & carotid artery syndrome

47. 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

48. 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

49. Normal Styloid Process

50. Elongated Styloid Process

51. 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

52. 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

53. 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

54. X-ray neck lateral view

55. Coronal C.T. scan

56. Ortho-Pantomogram

57. Coronal 3-D C.T. scan

58. 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

59. Styloid Process Excision

60. 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

61. Tonsillectomy & fossa incision

62. Styloidectomy

63. 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.

64. 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

65. Thank You