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1. KILLIAN’S DEHISENCE

2. PHARYNGEAL CONSTRICTOR MUSCLE

3. KILLIANS DEHISENCE Weak area of posterior pharyngeal wall between thyropharyngeus and cricopharyngeus of inferior constrictor muscle of pharynx

4. ZENKER’S DIVERTICULUM

5. PHARYNGEAL POUCH It’s a protrusion of mucosa through killian’s dehiscence . It starts in midline of posterior pharyngeal wall . Once it expands and reaches the vertebrae it deviates to left side of neck. Imperfect relaxation of cricopharyngeus increases the pressure in pharynx which leads to protrusion of mucosa through killian’s dehiscence. Thyropharyngeus is supplied by pharyngeal plexus from cranial accessory nerve. Cricopharyngeus is supplied by external laryngeal nerve. Pharyngeal pouch is a pulsion diverticulum

6. FEATURES Pain, dysphagia, recurrent respiratory infection, swelling in the neck on the left side which is smooth, soft and tender. Regurgitation during night while turning neck, smooth, soft, tender swelling in the posterior triangle of the left side of the neck; typical gurgling noise while swallowing are typical features. It is common in males. Swelling is deep to sternocleidomastoid muscle below the level of thyroid cartilage; initially soft and emptying; impulse on coughing may be evident unless opening of the pouch is blocked due to recurrent inflammation. Halitosis from decayed food in the pouch is not uncommon. Dyspnoea and change in voice can also occur. Differential diagnosis : Branchial cyst; lymph cyst; cold abscess in the neck; haemangioma neck; other causes of dysphagia like carcinoma, webs and stricture.

7. INVESTIGATIONS Barium swallow-lateral view shows pharyngeal pouch- videofluoroscopy . Chest X-ray shows pneumonia. CT neck is very useful-ideal. Indirect laryngoscopy may show pooling of saliva in pyriform fossa.

8. TREATMENT Antibiotics and nutritional support initially. Surgery Diverticulectomy with cricopharyngeal anyetopia donein large lesion. After general anaesthesia, oesophagoscope ispassed and pouch is packed with acriflavine gauze. Nasogastric tube is passed under vision through the oesophagus. Oblique or horizontal incision in the neck is muscle is cut; diverticula is excised; oesophagopharyngeal wall is closed after doing cricopharyngeal myotomy (circular muscle fibers are cut at posterior midline without opening the mucosa) is done to relieve the spasm; drain is placprocedure neck; nasogastric tube is kept in situ for 7 days.
Inversion or diverticulopexy are other procedures.

9. Endoscopic Minimally Invasive Technique Dohlman's approach: Pouch is excised using double lipped end oscopy . Cautery or laser is used. It is quicker procedure with shorter duration of anaesthesia ; with faster recovery. Stapling of the diverticula.