• Is posteromedial pulsion diverticulum through Killian's dehiscence
• Occurs between thyropharyngeus and cricopharyngeus muscles
• Both form the inferior constrictor of the pharynx
• Male : female ratio is 5:1
• Usually only seen in the elderly
• Aetiology is unknown but upper oesophageal sphincter dysfunction may be important

Clinical features

• Commonest symptoms are dysphagia, regurgitation and cough
• Recurrent aspiration can result in pulmonary complications
• A carcinoma can develop within the pouch
• Clinical signs are often absent
• A cervical lump may be present that gurgles on palpation

Investigation

• Barium swallow show residual pool of contrast within the pouch

• Indirect laryngoscopy may show a pooling of saliva within the pyriform fossa

Treatment

• Depends on size of pouch and age of patient
• Options include:
  • Diverticulectomy
  • Dohlman's procedure

Diverticulectomy

• Following rigid endoscopy the pouch is packed with gauze
• A 32 Fr bougie is placed with in the oesophagus
• Collar incision made at level of cricoid cartilage
• Fascia at anterior border of sternomastoid is divided
• Pouch is identified anterior to prevertebral fascia
• Pouch is then excised an defect closed
• Cricopharyngeal myotomy is performed to prevent recurrence
• Patient should be feed via a nasogastric tube for a week postoperatively
• Complications include:
  • Recurrent laryngeal nerve palsy
  • Cervical emphysema
  • Mediastinitis
  • Cutaneous fistula

Dohlman's procedure

• Is an endoscopic procedure
• A double-lipped oesophagoscope is used
• Wall between the diverticulum and oesophageal wall is exposed
• Hypopharyngeal bar divided with diathermy or laser
• Minimally invasive techniques allow:
  • Shorter duration of anaesthesia
  • More rapid resumption of oral intake
  • Shorter hospital stay
  • Quicker recovery

Bibliography

Aly A, Devitt P G, Jamieson. Evolution of surgical treatment for pharyngeal pouch. Br J Surg 2004; 91: 657-664.
Hoay C B, Sharp H R, Bates G J. Current practices in pharyngeal pouch surgery in England and Wales. Ann R Coll Surg Eng 1997; 79: 190-194.
Laing M R, Murthy P, Ah-See K W, Cockburn J S. Surgery for pharyngeal pouch: audit of management with short and long-term follow up. J R Coll Surg Ed 1995; 40: 315-318.
Siddiq M A, Sood S, Strachan D. Pharyngeal pouch (Zenker's diverticulum). Postgrad Med J 2001; 77: 506-511.