Hypopharyngeal Pouch & Styalgia

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): Open Diverticulectomy with CP myotomy 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 Eagledescribed 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