Pharyngeal pouches and its applied anatomy.pptx

Pharyngeal pouches, embryology, applied aspect

1. Pharyngeal pouches Dr. Abha Kiran K.C. 1 st year resident GMSMA of ENT-HNS MMC, IOM, TUTH

2. Roadmap Relevant embryology and anatomy Definition Types Presentation Management Carcinoma in pouch

3. Pharyngeal arch Typical feature in head and neck development In early 4 th wk Neural crest cells migration

4. Contd … Arches separated from each other by pharyngeal grooves Clefts = outside (ectoderm) Pouches = inside (endoderm)

5. Contd … Each arch contains Cartilage Cranial nerve Artery Muscle component

6. Contd …

7. Pharyngeal pouch Herniation of pharyngeal mucosa through a defect in the pharyngeal wall

8. Constrictor muscles

9. Anatomical weak areas Lateral Above superior constrictor Between superior and middle constrictors Between middle and inferior constrictors Below Cricopharyngeus

10. Contd … Posterior Laimer-Hackermann’s area Killian’s dehiscence

11. Pharyngeal diverticula Lateral Congenital Acquired Normal bulges Traumatic Pharyngocoeles

12. Contd … Posterior Congenital Acquired Traumatic Raised intrapharyngo-oesophageal pressure Zenker’s diverticulum

13. Contd …

14. Congenital lateral pouch Extremely rare Branchial cleft remnants Swelling in anterior triangle of neck

15. Normal bulges In pyriform fossa or tonsillar fossa Elderlies Asymptomatic, bilateral

16. Traumatic lateral pouch Self-inflicted In between the middle and superior constrictors

17. Pharyngocoeles Raised intra-pharyngeal pressure Loss of muscular resilience Usually unilateral, symptomatic

18. Congenital posterior pouch Very rare Arises above the cricopharyngeus Lined by normal pharyngeal mucosa Covered with muscle

19. Contd … Posterior to the oesophagus Extending into posterior mediastinum

20. Traumatic pseudodiverticulum Rare Newborn infants, adults Hypopharyngeal trauma Transmural or submucosal hypopharyngeal mucosal tear

21. Contd … False passage tracking down into posterior mediastinum within prevertebral space Features of mediastinitis

22. Diverticulum due to raised intrapharyngo-oesophageal pressure Rare Through Laimer - Hackermann area Elderlies Usually asymptomatic

23. Zenker’s diverticulum Pouch lying between the oesophagus and vertebral column, originating from posterior pharyngeal wall

24. Mechanism of swallowing Complex neuromuscular function 3 stages Oral phase - preparatory - propulsive Pharyngeal phase Oesophageal phase

25. Pharyngeal phase 5 neuromuscular activities Velopharyngeal closure Tongue base retraction Pharyngeal contraction Airway protection – elevation & closure of larynx Cricopharyngeal opening Duration <1 sec , constant

26. Contd …

27. Aetiology Cricopharyngeus muscle tonic spasm Negus (1950) Killian’s dehiscence Spasm due to inflammation, stenosis , neurological deficit

28. Contd … Lack of cricopharyngeus inhibition Dohlman and Mattsson (1959) Failure of sphincter to relax Muscle stretch  Reflex arc  Relaxation of sphincter

29. Contd … Second swallow Wilson (1962) Pharyngeal muscle laxity  Weak stripping wave  Second swallow to clear the residue against a closed sphincter

30. Contd … Neuromuscular incoordination and congenital weakness Korkis (1958) Presence of congenital weakness Precipitating neurological disorder

31. Anatomical consideration Exact site of Killian’s dehiscence ??? Divarications in cricopharyngeus  Denuded portions  More liable to mucosal herniation

32. Radiological cosideration Weak or absent oropharyngeal contraction Premature cricopharyngeal closure with disturbed pharyngeal constrictor function

33. Manometric consideration High resting cricopharyngeal pressure Premature relaxation with early contraction Low resting sphincter pressure Swallowing incoordination

34. Electromyography Invasive Altered normal response or swallow

35. Epidemiology Usually >50 yrs of age Male : Female 2 : 1 Affects Caucasians Rare in Asian and Afro- caribbean races

36. Symptoms Insidious in onset Usually long-standing, slowly progressive symptoms Dysphagia

37. Contd … Regurgitation Nocturnal coughing, choking Weight loss

38. Contd … Hoarseness of voice Pulmonary complications Occasionally, pain, bleeding, diverticulo -tracheal fistula

39. Signs Emaciation Neck swelling Usually on left Gurgling on palpation Spasm of coughing on palpation Indirect laryngoscopy

40. Investigations Plain radiographs Triangular lucency

41. Contd … Barium swallow

42. Contd … Contrast video swallow

43. Contd … Ultrasonography Oesophagoscopy Biopsy

44. Endoscopic treatment Diathermy Laser Stapling device

45. Contd … Can be staged

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51. Contd … Oral fluids on POD1 Soft diet on 2 nd or 3 rd POD Discharge on 5 th POD Normal diet after 2 weeks

52. External surgical approach One-stage diverticulectomy

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56. Contd … NG feeding for 5-7 days Fluids  Soft diet Normal diet after 10 days of surgery

57. Contd … Sac inversion Fluids on 1 st POD Discharge on 2 nd or 3 rd POD Decreased risk of fistula, abscess or mediastinitis

58. Contd … Use of staple gun Cricopharyngeal myotomy Diverticulopexy

59. Postoperative complications Immediate Haemorrhage Pneumothorax Surgical emphysema

60. Contd … Early Secondary haemorrhage Hoarseness (3-5%) Wound infection, abscess (1.5-5%) Fistula (1-8%) Mediastinitis Aerocoele

61. Contd … Late Hoarseness Stricture Recurrence

62. Carcinoma of the diverticulum Rare (0.5-1%) Male : Female 5 : 1 Long-standing cases (> 7 yrs) Usually >50 yrs of age

63. Contd … Rapidly progressing dysphagia Weight loss Blood in regurgitated food Neck nodes SCC

64. Contd … Barium swallow Constant filling defect in lower 2/3 rd of the pouch

65. Contd … Surgery + Postoperative radiotherapy

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