A pharyngeal pouch or Zenker’s Diverticulum is an outpouching of the pharynx at the level of the voice box (larynx). It is a rare condition which mostly occurs in older men.
Some of the terms associated with Zenker’s Diverticulum include:
- Swallowing: This is a complicated sequence of the voluntary and reflex movements that require your brain to coordinate many nerves and muscles.
- Dysphagia: It is a medical term for abnormality or a sensation of difficulty of swallowing. It can happen slowly or rapidly and has many causes.
- The pharynx: It is part of the upper aero-digestive tract and it lies between the oesophagus and the mouth. It has an outer lining connective tissue and a muscular wall.
- Pharyngeal Diverticula: These are outpouchings of the pharynx’s wall. They can lie on the side, in the middle or behind the pharynx. They can also lie above or below the Cricopharyngeal muscle (sphincter-like muscle at the upper end of the oesophagus).
Causes of Pharyngeal Pouch
There is no known exact cause of Zenker’s Diverticulum but there are factors which contribute to it. There is a natural area of weakness in all of us in the back-wall of the pharynx, which lies just above the cricopharyngeal muscle, and below the inferior constrictor muscles.
For patients who have Zenker’s, there is a loss of muscle compliance in the area of the cricopharyngeal muscle due to degeneration or scarring. This causes elevated pressures in the area of weakness as food travels down. Over time, the elevated pressure causes an outpouching at the area of weakness until a Zenker’s Diverticulum forms.
Symptoms of Pharyngeal Pouch
The symptoms experienced for Zenker’s Diverticulum are generally due to a combination of residue or food accumulating in the pouch, and the inelasticity of the cricopharyngeal muscle just above the pouch. They include:
- Feeling a sensation of a lump in the throat
- Difficulty in swallowing liquids or solids
- Choking or coughing after swallowing
- Regurgitation of food
- Audible gurgling during swallowing
- Weight loss
- Bad breath
Diagnosis of Pharyngeal Pouch
Diagnosis often involves a thorough case history, clinical examination of the nerves and muscles required for swallowing, digital nasendoscopy of the pharynx and upper airway and an instrumental swallowing evaluation such as a Video-fluoroscopy Swallowing Study (x-ray) and/or Fibreoptic Endoscopic Evaluation of Swallowing.
Additional tests may be required such as videostroboscopy, a standard barium swallow, high resolution impedance manometry, saliva pepsin testing and/or PH testing. A validated questionnaire known as a patient-related outcome measure is often completed initially and repeated on to measure the progress of the patient.
Treatment of Pharyngeal Pouch
Once the swallowing evaluation is complete, swallowing specialists can recommend ways to improve your ability to drink and eat depending on the specific issues found.
Treatment options depend on the cause/s and severity of the problem.
Open Zenker’s Diverticulectomy
Initially the pouch is packed endoscopically so as to make identification in the neck easier. A tube is usually passed into the oesophagus to help identification and retention of the diameter of the oesophagus. An incision is made on the left side of the neck, either horizontally at the level of the cricoid cartilage or diagonally along the anterior border of the sternomastoid muscle.
The pouch is identified, and the muscle layers are then stripped off the surface of it. Depending on the size of the pouch, it is then either excised, suspended or inverted. Larger pouches are normally excised. Excision procedure is best performed using a stapling device that automatically staples the pharynx closed and excises the pouch at the same time. The fibres of the cricopharyngeus muscle are normally divided completely and sometimes excised to prevent recurrence of the pouch. The wound is closed over a drain.
Other treatment options include:
- Endoscopic Zenker Diverticulectomy: This involves dividing the wall between the pouch and the oesophagus, and creating a common pouch, which thus divides the thickened and scarred cricopharyngeal muscle. The division is achieved using a combination of sealing/cutting device such as a stapler, ENSEAL or a laser. No incisions on the neck are involved in the procedure and the operation is fairly rapid.
- Endoscopic approach: This is done in rare cases whereby a flexible scope assisted endoscopic stapling is performed because of difficult access, but it has high recurrence rate.
- Open: In some cases, rather than being excised, the pouch is hitched upwards to the pre-vertebral tissue.
- Swallowing modifications: Strategies to improve swallowing safety such as turning head to side or tucking chin down, can be employed. Safe swallowing strategies such as taking smaller mouthfuls or eating slowly, may also be advised.
- Dietary modifications: Softening of food to make it easier to chew and swallow.
At King’s College Hospital Dubai, we focus on offering an exemplary service from initial consultation through to the final diagnosis and treatment and beyond. Our team of expert doctors and nurses are here to offer tailored management and treatment of your condition, and to answer any questions that you might have throughout your time with us. Whatever you need us for, we’re only a phone-call away.
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