Pharyngeal Pouch

What is a pharyngeal pouch?

When we eat food, it passes through the mouth, into the pharynx (the space behind our oral cavity) and then into the oesophagus (food pipe). In some patients, the lower part of the pharynx can bulge or form a pocket that can collect food and become large enough to compress on the food pipe. This 'hernia' is commonly known as the pharyngeal pouch or Zenker's diverticulum.

Is a pharyngeal pouch serious?

A pharyngeal pouch is an uncommon condition presenting predominantly in males than females, usually showing after the age of seventy or later. If the pharyngeal pouch is left untreated, it can become more prominent, and the regurgitation of food into the windpipe can lead to chest infections. In sporadic cases, cancer can form in the pouch.

What are the symptoms of a pharyngeal pouch?

Symptoms of pharyngeal pouch depend on the size. A small pharyngeal pouch mainly presents as a feeling of something stuck in the throat or choking on food, and patients generally maintain weight by changing their eating habits by eating pureed food. If left untreated, an upper oesophageal pocket can balloon out to enlarge along the food pipe and give symptoms of regurgitation of undigested food after a meal, halitosis (bad breath), frequent chest infections, hoarseness, chronic cough and gurgling sounds in the neck. These symptoms can lead to weight loss and regular intensive care admissions due to chest infections if left untreated.

How is the diagnosis of pharyngeal pouch made?

A visit to an ENT surgeon is needed to manage the pharyngeal pouch. The ENT surgeon will take a detailed history, examine you with a tiny endoscope passed through the nose and request radiological investigation. A Barium Swallow (radiological test) will show classical pharyngeal pouch images and tell us the size of the pouch and other associated abnormalities in the lower food pipe.

What symptoms or signs may raise the possibility of cancer within a pharyngeal pouch?

Suppose you notice sudden and progressive difficulty in swallowing, pain and bleeding in vomiting, shortness of breath, and barium swallow pharyngeal pouch images with suspicious findings. In this case, it raises the possibility of cancer within a pharyngeal pouch.

How is pharyngeal pouch treated?

There are a lot of factors that are discussed in consultation when deciding on treatment options. Patient factors that play a crucial role in the discussion are the age of presentation, fitness for anaesthesia, neck stiffness, and mouth opening. The size of the pharyngeal pouch is the next essential factor discussed during consultation.

Generally speaking, pharyngeal pouch management can be endoscopic through the mouth or the neck.

Endoscopic management: pharyngeal pouch stapling, botox (botulinum toxin) injection, LASER surgery to the sphincter.

External approach: pharyngeal pouch removal through the neck, surgery and releasing upper food pipe sphincter.

Planned for Pharyngeal Pouch stapling; what are the key things to remember?

Pharyngeal pouch stapling or endoscopic staple diverticulostomy is a minimally invasive procedure done under general anaesthetic. A double lipped unique scope is placed through the patient's mouth, with one lip in the food pipe and one in the pharyngeal pouch. An auto-suture disposable surgical staple is passed through this endoscope to cut and seal the wall between the pouch and food pipe. The advantage of using the stapling device over LASER are better haemostasis (minimal risk of bleeding), the risk of perforation (tear in food pipe), and infection spreading to the chest (mediastinitis) is very low.

Most patients can go home the next day and start a soft diet.

The primary complications of endoscopic stapling are the surgeon's inability to engage the staple due to the small size of the pouch or neck stiffness of the patient. Rare complications include damage to the teeth, bleeding, wound infection, perforation, chest infection and recurrence of the pouch needing revision surgery.

My ENT surgeon has recommended an external neck approach to the pharyngeal pouch; what are the key things I should know?

In case the size of the pouch is considerable, or due to the neck stiffness and restricted mouth opening, the surgeon is unable to engage double lipped endoscope on the pharyngeal pouch; you may need an external approach.

The procedure is performed under general anaesthetic. Most of the time, the pharyngeal pouch is exposed through a cut in the neck on the left side. The pharyngeal pouch is removed, and the muscle in the upper part of the food pipe is also released to prevent a recurrence. The patient stays in the hospital for seven days, and a check swallow is done before the oral feed is started. During the postoperative period, the patient is fed through a feeding tube passed through the nose.

The main complication of external approach pharyngeal pouch surgery are bleeding, neck wound infection, hoarseness due to damage to the voice box nerve, chest infection, scar in the neck, recurrence of the pharyngeal pouch.

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