Pathology

1. Pharyngeal pouch
   • Formed by the herniation of pharyngeal mucosa (pulsion diverticulum) through its muscular coat at its weakes point (Killian's dehiscence) between the thryopharyngeus and cricophyrngeus muscles that form the inferior constrictor

     

2. Seen commonly in elderly
3. Usually asymptomatic for a long period of time, then followed by dysphagia and hoarseness associated with regurgitation of undigested food and associated weight loss

Approach

• As for neck examination

1. Inspect
   • Cystic swelling low down in the posterior triangle of the neck
2. Palpation
   • Deep palpation produces a squelching sound due to free fluid in the pouch
3. Other
   • Halitosis is a frequent features (as food regurgitated into the neck)

Completion

1. Ask to listen to chest
2. History
   • Associated symptoms - regurgitation leading to coughing, dysphagia
   • Complications: chest infection from pulmonary aspiration, diverticular neoplasia (less than 1% of cases)
   • Effect of lump on life

Investigations

1. Barium swallow - delineate anatomy
2. Chest X-ray - look for aspiration pneumonia, collapse of lobe, lung abscess 

Treatment

1. Non-surgical
   • Leave alone if small and asymptomatic
2. Surgical
   • Minimally invasive surgery: Dohlman's procedure; endoscopic diathermy resection of the posterior pharyngeal wall or endoscopic stapling
   • Surgical excision - simple inversion and oversewing (diverticulopexy) as pouch is left in situ
     • Incision along inferior half of SCM
     • Dissect out pouch
     • Send pouch for histology to exclude carcinoa