Hypopharyngeal pouch & stylalgia ent .ppt

Ent ppt
popharyngeal pouch & stylalgia full

1. Hypopharyngeal
Pouch & Styalgia
Dr. Sunil Singh

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
diverticulumcaused 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. Origin of Zenker diverticulum

6. Origin of Zenker diverticulum

7. Etiology

8. 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.

9. Clinical Features

10. 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: in left posterior
triangle, reduces with gurgling sound (Boyce sign)

11. Sequelae & 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)

12. Investigations
•Chest X-ray: may show sac + air -fluid level
•Barium swallow
•Barium swallow with video-fluoroscopy
•Rigid Oesophagoscopy

13. Barium swallow

14. Barium swallow with
Video-fluoroscopy

15. Rigid esophagoscopy

16. Rigid esophagoscopy

17. Staging of pharyngeal pouch
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

18. Stage 1

19. Stage 2

20. Stage 3

21. 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

22. Cricopharyngeal myotomy

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

24. Diverticulum invagination

25. External diverticulectomy

26. Incision + exposure of pouch

27. Suturing of opening + excision

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

29. Weerda Laryngoscope

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

31. View through diverticuloscope

32. Excision of party wall

33. Dohlman’s instruments

34. Cautery diverticulotomy

35. Cautery diverticulotomy

36. Laser diverticulotomy

37. Laser diverticulotomy

38. Endoscopic staple
diverticulostomy

39. Endo-stitch instrument

40. Passing of stitch

41. Anchoring of septum

42. Endoscopic stapler

43. Stapling completed

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

45. Diverticulopexy

46. 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

47. Complications of surgery

48. 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

49. Styalgia
(Eagle Syndrome)

50. Introduction
•Normal length of styloid process is 2.0–2.5 cm
•Length >40 mmin radiography is considered
an elongated styloid process
•4% 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.

51. Classical variety
•Due to scar tissue in tonsillar fossa engulfing
branches of glossopharyngeal nerve
•Occurs several years after tonsillectomy
•Pharyngeal foreign body sensation
•Dysphagia
•Dull pharyngeal pain on swallowing, rotation of
neck or protrusion of tongue
•Referred otalgia

52. Carotid artery syndrome
•Carotid artery compression by styloid process
presents as carotidynia, 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

53. Normal styloid process

54. Normal styloid process

55. Elongated styloid process

56. Elongated styloid process

57. 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

58. Diagnosis
1.Digital palpation over styloid 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

59. X-ray neck lateral view

60. Coronal C.T. scan

61. Ortho-pantomogram

62. Coronal 3-D C.T. scan

63. 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

64. Styloid process
excision

65. 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

66. Before tonsillectomy

67. Incision over tonsil fossa

68. Exposure of styloid process

69. Styloid process excision

70. 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.

71. Thank You