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Clinical case: Pharyngeal diverticula: want to learn more about it?

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Clinical case: Pharyngeal diverticula

In this article we describe a case of a man suffering from progressive dysphagia and odynophagia, both of them literally caused by two pockets that developed in the walls of his pharynx. Do you want to find out more about these outpouchings and how they develop? Read this article to find out how they manifest, their diagnosis, imaging, management, and anatomy.

Key facts
Pharyngeal constrictors

There are three: superior, middle, and inferior pharyngeal constrictors. They are all innervated by the pharyngeal plexus and pharyngeal branch of the vagus nerve. They all act on the pharynx, either constricting or elevating it.

Stages of deglutition

1st stage (voluntary) -  the purpose of this stage is to form a bolus and pass it into oropharynx, an act initiated by the tongue.

2nd stage (involuntary) - this stage consists of a series of reflexes of the pharyngeal mucosa, soft palate, and larynx that ultimately push the bolus towards the esophagus.

3rd stage (involuntary) - the purpose of this stage is to push the bolus into the esophagus, especially through the action of the inferior pharyngeal constrictor.

After reviewing this case you should be able to describe the following:

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.

Case description

History

A 65-year-old male presented with a 12-month history of progressive dysphagia (difficulty in swallowing) and odynophagia (painful swallowing) for solids. The patient indicated that typically his swallowing pain was at the level of the sternal notch.

Imaging

In order to diagnose the patient’s problem, a radiographic with barium swallow exam was performed that revealed bilateral moderately sized pharyngeal diverticuli that changed in size during the different phases of swallowing (Figure 1A).

Figure 1. Radiographic images from barium swallow exam showing bilateral diverticuli (white circles) before (A) and after (B) surgery. Although reduced, the left diverticulum was still evident. Note that most of the labeling in this image is approximate because the contrast material obscures many of the bony landmarks.

The diverticuli were higher and more lateral than expected for the known types of diverticuli, prompting a CT scan of the neck (Figure 2).

Figure 2. Axial CT scan showing bilateral pouches (diverticuli).

The CT scan revealed the pharyngeal pouches to be 17mm in diameter and arising between the hyoid bone and thyroid cartilage (Figure 3&4).

Figure 3. Dissection image showing the hyoid and thyroid cartilages and also the thyrohyoid membrane being penetrated by the internal laryngeal nerve.

Management and evolution

After discussion with the patient, definitive surgery was planned. The mouth of the diverticulum on the right side was packed from the pharyngeal side, just above the level of the superior border of the thyroid lamina.

Figure 4. Dissection image like (figure 3) but more lateral orientation, the left thyroid lamina has been reflected forward to revealing the underlying membrane and muscle.

The pouch was subsequently found to be herniating through the superior constrictor muscle and related closely to the superior laryngeal neurovascular bundle (Figure 5). This right-sided diverticulum had a narrow base and was readily excised. The left-sided pouch had a broader base and was sutured closed. A nasogastric tube was inserted and the patient remained in the hospital for five days until oral intake was resumed.

At a two month follow-up there was significant improvement of symptoms. Unfortunately, swallowing deteriorated again at three months, and a repeat barium swallow was done (Figure 1B), Results of this barium swallow suggested that the diverticuli were reduced in size and no longer the cause of the new pain. Instead, this more recent dysphagia was thought likely due to cricopharyngeal muscle spasm. The patient then underwent injection of botulinum toxin into the cricopharyngeus, which alleviated the dysphagia. 

Figure 5. Cadaver image of the posterior pharyngeal wall.

Surgical and anatomical considerations

This case depicts a unique diverticulum that occurred bilaterally and originated between the hyoid bone and thyroid cartilage. This patient thus represents a unique case of pharyngoesophageal diverticulum that is similar in symptoms to the more commonly described diverticuli, Zenker’s, Killian-Jamieson’s, or Laimer’s diverticuli (see below).

Figure 6. Sagittal section of head and neck showing the three divisions of the pharynx.

The pathogenesis of pharyngoesophageal diverticuli is explained by peristaltic forces acting against an obstruction, usually a dysfunctional cricopharyngeus, resulting in increased intraluminal pressure and herniation of the pharyngeal mucosa through weakened areas of the pharyngo-esophagus. The present case, however, involves bilateral diverticuli located between the hyoid bone and thyroid cartilage, and thus not directly related to the cricopharyngeus muscle. A possible explanation for the occurrence of this pouch is that a weakness existed in the thyrohyoid membrane that was associated with the passage of the internal laryngeal nerve (branch of the superior laryngeal nerve) and vessels through the membrane (Figure 7).

Figure 7. An image showing the passage of the internal laryngeal nerve through the thyroid membrane.

The fact that the patient’s symptoms fully resolved with treatment of the cricopharyngeus muscle suggests that the diverticuli were manifestations of the swallowing problem and not the basic cause, which is a situation that is similar to that in Zenker’s diverticulum. The surgery used here involved an external approach, which allowed for accurate identification and closure of the pouches, with preservation of the neurovascular bundle. It is likely that the sternal discomfort was associated with inflammation of the mediastinum, which can be associated with motility abnormalities, including diffuse spasm.

The most common pharyngeal diverticulum is a Zenker’s diverticulum, which is characterized by a posterior outpouching originating from Killian’s dehiscence (a triangular area in the pharyngeal wall between the thyropharyngeal and cricopharyngeus parts of the inferior constrictor of the pharynx (Figure 5). The Killian-Jamieson diverticulum is much less common and is an anterolateral herniation located superolateral to the longitudinal muscle of the esophagus and inferior to the cricopharyngeal muscle. The rarest variant of pharyngeal diverticulum is often referred to as Laimer’s or Laimer-Haeckerman’s diverticulum. Similar to the Killian-Jamieson diverticulum, a Laimer’s diverticulum originates between cricopharyngeus and the longitudinal muscle of the esophagus; however, it is located posteriorly and midline.

Clinical case: Pharyngeal diverticula: want to learn more about it?

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