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Lateral pharyngeal diverticulum: a report of 3 cases.

Abstract

Pharyngocele, or lateral pharyngeal diverticulum (LPD), is rare, as only a few cases have been described. This condition is characterized by local bulging in the piriform recess or in a vallecula. The diagnosis, which is clinically difficult, is made by barium-swallow examination of the pharynx. Surgical repair is indicated when symptoms are present. We report 3 new cases of LPD, and we discuss the etiology and clinical features of this entity. We also present a short review of the literature.

Introduction

Patients with a pharyngocele, or a lateral pharyngeal diverticulum (LPD), exhibit local bulging through one of the weak areas of the pharynx. The bulging can be aggravated by an increase in air pressure within the pharynx. (1) LPD usually presents in the fifth or sixth decade of life (mean age: 51.8 yr), but young adults have also been affected. The reported male-to-female ratio ranges from 3:1 to 8:1. (1,2) The first well-documented case of a pharyngocele was reported by Wheeler (3) in 1886, and the first roentgenographic study of a pharyngocele was published by Hankins (4) in 1944.

LPDs can be congenital or acquired (5-7):

* Acquired pharyngoceles are of the pulsion type, and they have been found protruding only from the piriform recess. (8) No typical cases arising from the tonsillar fossa have been described. Two factors are relevant to the etiology of LPD: a loss of muscle elasticity with increasing age and an increase in intrapharyngeal air pressure. The weakened areas in the lateral wall of the pharynx provide a potential site for muscular herniation and diverticulum development. Pressure changes--such as those prompted by deglutition, excessive coughing spells, and blowing on a musical wind instrument--may provide additional strain for such herniation. (3,6,9) Most of these diverticula are unilateral, and their diameter generally ranges from 1 to 2.5 cm. (5)

* Congenital LPDs are truly branchial cleft cysts and tracts that connect internally with the pharynx and blindly in the neck. No external opening in the skin is observed. Clinically, almost all of the internally opening branchial cysts are derived from the second branchial cleft, and their ducts enter the lower portion of the lateral wall of the tonsillar fossa or the adjacent vallecula. (5,10-13)

In this article, we report 3 new cases of LPD, and we present a short review of the literature.

Case reports

Patient 1. A 48-year-old woman was referred to our outpatient clinic complaining of a sensation of something caught in her throat, retention of food in the throat, and eventual elimination of small amounts of undigested food. These signs and symptoms had been present for many years, and they were mild and intermittent. Throat clearing kept her discomfort to a minimum.

Findings on physical examination were within normal limits. In particular, no lumps were found in the neck or the orifices of the oropharynx and hypopharynx. A barium-swallow x-ray was obtained while the patient performed the Valsalva maneuver, and it detected LPDs on both sides of the neck (figure 1).

Since the patient was able to tolerate her condition, we decided not to intervene. She was advised on healthy dietary habits and oral hygiene to prevent major bacterial growth. During long-term follow-up, she reported no changes in her signs and symptoms.

[FIGURE 1 OMITTED]

Patient 2. A 30-year-old man was referred to us for evaluation of an "enlarged neck" and thyroid function. He complained of a sensation of "stocking food" in his throat and the eventual elimination of undigested food remnants after a meal. He also reported a weight gain of almost 8 kg during the previous months.

The results of the physical examination were normal, and no lumps were found in the neck. His thyroid function was normal. A barium-swallow x-ray performed during the Valsalva maneuver identified a small LPD (figure 2).

Again, since the patient was experiencing only minimal discomfort, no surgery was performed. He was instructed on healthy eating and oral hygiene measures to reduce symptoms. During long-term follow-up, he was satisfied with this type of management, and no progression of symptoms was observed.

[FIGURE 2 OMITTED]

Patient 3. A 26-year-old woman was referred to us with a 1-year history of a foul taste in her mouth and a continuous sensation of a lump in her throat. As a consequence, she was frequently clearing her throat. These symptoms detracted from her social and professional life, and she often preferred to stay home because she feared that other people would notice her bad breath. The patient reported no dysphagia or dysphonia, and she had no history of exposure to occupational factors that might account for her condition, leaving us to consider chronically increased intrapharyngeal pressure as the culprit.

No anomalies were found on physical examination, but indirect laryngoscopy revealed a 4- to 5-mm oval slit on the lateral glossoepiglottic fold. Fiberoptic laryngoscopy demonstrated a 5- mm pharyngocele and food remnants in the adjacent vallecula (figure 3). A barium-swallow x-ray confirmed the diagnosis of an LPD. The patient was scheduled for surgery.

[FIGURE 3 OMITTED]

With the patient under general anesthesia and her neck rotated to the left, a #12 catheter was introduced into the pouch by direct laryngoscopy in order to identify the site of the diverticulum. An incision was then made through the skin and the platysma muscle in the left submandibular area, exposing the superficial layer of the deep fascia. A thin-walled structure (~2.0 x 1.0 cm) of mucous appearance was found in the inferior border of the submandibular gland, and it protruded laterally from the thyrohyoid membrane. The diverticulum was excised, and its base was closed in two layers with Vicryl 4-0 sutures and inversion of the mucosal edges into the pharynx. The subcutaneous tissue, platysma layer, and skin were closed in a standard fashion.

The patient's postoperative course was uneventful. She was put on a liquid diet on the second postoperative day, and she was able to ingest a solid diet after 5 days. No symptoms were observed during follow-up, and a barium-swallow x-ray and fiberoptic laryngoscopy revealed no pharyngocele on the left. Microscopic examination revealed that the pharyngocele was made up of normal squamous mucosa consistent with a pharyngeal diverticulum.

Discussion

Anatomically, the pharynx has two weak areas on each side, two superior and two inferior. The superior areas lie at the junction of the superior and middle pharyngeal constrictor muscles. Intraluminally, this area is located in the area of the inferior pole of the tonsil next to the vallecula. The inferior areas are located between the middle and inferior pharyngeal constrictor muscles and the thyroid membrane. Intraluminally, this area is located in the area of the base of the piriform fossa. (2,5,9,14) When certain mechanical factors are present, bulging of the mucous membrane may occur and become exaggerated over time. The ballooning of the lateral wall of the pharynx during the Valsalva maneuver is considered to be a typical finding or even a pseudodiverticulum. (5,6,15)

All patients with complaints of swallowing difficulties or other upper digestive tract symptoms should be submitted to a careful workup, which should include x-ray examination of the oropharyngeal and esophageal swallowing mechanism. These symptoms usually indicate an organic disease; in toto, they should never be automatically interpreted as a psychoneurologic symptom. (2)

The differential diagnosis is extensive, which emphasizes the importance of a careful evaluation. Patients with a pharyngocele exhibit a variety of signs and symptoms, depending on the size of the pharyngeal orifice, the size of the diverticulum, whether the pouch drains easily, and whether it is infected. (7) The primary symptom is usually dysphagia. Other signs and symptoms include neck pain, weight loss, regurgitation, dysphonia, a globus sensation, a neck mass, and other upper digestive tract problems. (2,11,13,15-17) Conversely, some diverticula are asymptomatic.

A normal small outpouching of the lateral pharyngeal wall immediately above the laminae of the thyroid cartilage is one of the differential diagnoses of LPD. This outpouching is seen in many patients during the Valsalva maneuver. (10) Other conditions that should be considered in the differential diagnosis are Zenker diverticulum, laryngocele, esophageal diverticulum, an artificial pouch, cricopharyngeal spasm, foreign body, neurologic disease, myopathies, and globus hystericus. Although LPD is rare, it should be considered in the differential diagnosis of dysphagia and hoarseness. (13,14,18)

The recommended diagnostic tools are fiberoptic laryngoscopy or telelaryngoscopy and a barium swallow x-ray during the Valsalva maneuver. Radiologically, LPD is best visualized in the frontal plane. It appears as a barium-filled sac of variable size connected to the bulging hypopharyngeal "ear" by a short neck. (5,18-20)

The recommended treatment of a pharyngocele varies. Conservative management consists of healthy dietary habits and oral hygiene to prevent major bacterial growth, as was recommended for our patients 1 and 2. When trauma appears to have played a role, discontinuation of the inciting factor is advised. (16) We suggest that well-delineated pouches be surgically excised via an external approach, as we did for our patient 3. (1) An interesting surgical approach for correction of LPD was described by Fowler in 1962. (7) In that case, surgery was initiated with the patient under local anesthesia. The patient was asked to distend the sac repeatedly by performing Valsalva maneuvers, thus facilitating dissection. After the pouch and pharyngeal wall were clearly delineated, surgery was completed with general endotracheal anesthesia.

In conclusion, diverticula of the lateral wall of the pharynx are not as uncommon as was once believed, but their true prevalence remains unknown. LPD should be considered in the diagnosis of patients with upper digestive tract symptoms or hoarseness, especially in a patient with long-term and intermittent symptoms that have no apparent cause. Some defects in the lateral pharyngeal wall occur as a result of continuous pressure on an anatomically weak point in the wall, and others are congenital. Surgical repair is indicated when symptoms are present. Surgery should resolve the problem.

References

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2. Norris CW. Pharyngoceles ofthe hypopharynx. Laryngoscope 1979; 89(11):1788-1807.

3. Wheeler WI. Pharyngocele and dilatation of pharynx. Dublin J Med Sci 1886;82:349-57.

4. Hankins WD. Traumatic hernia of the lateral pharyngeal walls. Radiology 1944;42(5):499.

5. Bachman AL, Seaman WB, Macken KL. Lateral pharyngeal diverticula. Radiology 1968;91(4):774-82.

6. Ettuaan IK, Ramey DR III. Lateral pharyngeal diverticulum: Unusual cause of dysphagia and hoarseness. Am J Gastroenterol 1967;47 (6):490-7.

7. Fowler WG. Lateral pharyngeal diverticula. Ann Surg 1962; 155(1): 161-5.

8. Wilson CP. Pharyngeal diverticula, their cause and treatment. J Laryngol Otol 1962;76:151-80.

9. McMyn JK. Lateral pharyngeal diverticula. Journal of the Faculty of Radiologists 1957;8:421-5.

10. Buckstein J, Reich S. Lateral pharyngeal diverticula as a cause of dysphagia. JAMA 1950;144(14):1154-5.

11. Hayashi N, Tamaki N, Konishi J, et al. Lateral pharyngoesophageal diverticulum simulating thyroid adenoma on sonography. J Clin Ultrasound 1984;12(9):592-4.

12. Porcaro-Salles JM, Oliveira IG, Silva AL. Faringocele lateral. In: Silva AL, ed. Hernias. Silo Paulo: Livraria Roca; 1992:298-301.

13. Atkinson L. Pharyngeal diverticula, with particular reference to lateral protrusions of various types. Arch Middx Hosp 1952;2(4): 245-54.

14. Dohlman G, Mattsson O. The role of the cricopharyngeal muscle in cases ofhypopharyngeal diverticula: A cineroentgenographic study. Am J Roentgenol Radium Ther Nud Med 1959;81(4):561-9.

15. Serrano Badia E, Dalman Galofre J, Pons Rocher F, et al. Pharyngocele [in Spanish]. Acta Otorrinolaringol Esp 1994;45(3):215-17.

16. Ward PH, Fredrickson JM, Strandjord NM, Valvassori GE. Laryngeal and pharyngeal pouches. Surgical approach and the use of cinefluorographic and other radiologic techniques as diagnostic aids. Laryngoscope 1963;73:564-82.

17. Lee SW, Lee JY. Lateral pharyngealdiverticulum. Otolaryngol Head Neck Surg 2010; 143(2):309-10.

18. Pace-Balzan A, Habashi SM, Nassar WY. View from within. Radiology in focus: Lateral pharyngeal diverticulum. J Laryngol Otol 1991;105(9):793-5.

19. Mantoni M, Ostri B. Acquired lateral pharyngeal diverticulum. J Laryngol Otol 1987;101(10):1092-4.

20.Liston SL. Lateral pharyngeal diverticula. Otolaryngol Head Neck Surg 1985;93(5):582-5.

Jose Maria Porcaro-Salles, MD; Joao Marcos Arantes Soares, PhD; Alexandre de Andrade Sousa, MD; Gustavo Meyer, MD; Marco Homero de Sa Santos, MD

From the Instituto Alfa de Gastroenterologia, Hospital das Clinicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.

Corresponding author: Dr. Jose Maria Porcaro-Salles, Rua Silo Pedro da Unifio, no 142, Sion, Belo Horizonte 30.315-440, Brazil. Email: jmporcaro@terra.com.br
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Title Annotation:ORIGINAL ARTICLE
Author:Porcaro-Salles, Jose Maria; Soares, Joao Marcos Arantes; Sousa, Alexandre de Andrade; Meyer, Gustavo
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Oct 1, 2011
Words:2093
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