Download Hypopharyngeal pouch & stylalgia

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 & Cricopharyngeus: 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)
Complications
1. 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
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
1. 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 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
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 sternocleidomastoid 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
Diagnosis
1. 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 Treatment
1. 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