Section 5


What is the above investigation?

Barium swallow

What is the diagnosis?

Pharyngeal pouch / Zenker’s diverticulum

List four presenting symptom the patient may describe

  • Dysphagia
  • Regurgitation
  • Halitosis
  • Weight loss
  • Recurrent chest infections

What is Boyce’s sign?

Gurgling neck mass on palpation

Describe the anatomy of the condition

Pharyngeal pouch represents diverticulum/herniation of the mucosa at Killian’s dehiscence which lies between cricopharyngeus and thyropharyngeus. Both are part of the inferior constrictor of the pharynx.

Name three treatment options

  • Conservative
  • Endoscopic division of pharyngeal pouch bar
  • Open surgery

Supporting Information

Pharyngeal pouch- herniation at Killian’s dehiscence between cricopharyngeus and thyropharyngeus. It is diagnosed on barium swallow. 

    • Symptoms- halitosis, dysphagia, regurgitation, weight loss, chest infections- Boyce’s sign (gurgling neck mass on palpation)
    • Presents 60-90 yrs, more common in men.
  • Treatment:
    • Conservative- if small and asymptomatic
    • Medical– botox to cricopharyngeus
    • Surgical– endoscopic stapling (Weerda diverticuloscope and endoscopic stapler) or open procedure- risks, oesophageal perforation, infection, stricture, bleeding, mediastinitis, recurrence, hoarseness, damage to teeth, lips and gums.

Pharynx- 

  • Surrounded by a circular muscle layer – superior and inferior constrictors. 
  • Inferior constrictor splits into the thyropharyngeus and the cricopharyngeus below. The gap between these is the killian’s dehiscence–>pharyngeal pouch herniation. 
  • Pharynx lowered and elevated by:
    • Stylopharyngeus– from styloid process- thyroid cartilage
    • Salpingopharyngeus– cartilage of eustachian tube- upper thyroid cartilage with palatopharyngeus
    • Palatopharyngeus- palatine aponeurosis and hard palate- thyroid cartilage
  • Arterial supply– ascending pharyngeal, ascending/descending palatine, maxillary, lingual, facial. 
  • Venous drainage – Internal jugular vein
  • Nerve supply- 
    • Motor– glossopharyngeal, vagus, hypoglossal and facial
    • Sensory– 
      • Nasopharynx- CN V2, maxillary trigeminal
      • Oropharynx – glossopharyngeal
      • Hypopharynx- vagus nerve.
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