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 musclesPosterior: 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

1. Entrapment of food in pouch: sensation of food

sticking in throat & later dysphagia

2. Regurgitation of entrapped food: leads to foul

taste bad odor nocturnal coughing choking

3. Hoarseness: due to spillage laryngitis or sac

pressure on recurrent laryngeal nerve

4. Weight loss: due to malnutrition

5. Compressible neck swelling on left side:

reduces with a gurgling sound (Boyce sign)

Complications1. Lung aspiration of sac contents

2. Bleeding from sac mucosa

3. Absolute oesophageal obstruction

4. Fistula formation into:

trachea major blood vessel

5. 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

StagingLahey 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 Treatment1. Cricopharyngeal myotomy: combined with others

2. Diverticulum invagination: Keyart

3. Diverticulopexy: Sippy-Bevan

4. External or open Diverticulectomy: Wheeler

5. Rigid Endoscopic Diverticulotomy

Cautery (Dohlman) Laser Stapler

6. Flexible Endoscopic Diverticulotomy with Laser

Treatment Protocol1. 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):

Open Diverticulectomy with CP myotomy

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

1. Bleeding & haematoma formation

2. Infection: mediastinitis & pneumonitis

3. Esophageal or diverticulum perforation

4. Oesophageal stricture

5. Recurrence

6. Recurrent Laryngeal Nerve paralysis

7. Pharyngo-cutaneous fistula

8. 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

Diagnosis1. Digital palpation of styloid process in

tonsillar fossa elicits similar pain

2. Relief of pain with injection of 2% Xylocaine

solution into tonsillar fossa

3. X-ray neck lateral view

4. Ortho-pan-tomogram (O.P.G.)

5. Coronal C.T. scan skull

6. 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 Treatment1. Oral analgesics

2. Injection of steroid + 2% Lignocaine into

tonsillar fossa

3. Carbamazepine: 100 – 200 mg T.I.D.

4. 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

Thank You