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Percutaneous injection pharyngoplasty for the treatment of a pharyngocele.

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An 84-year-old woman presented with a 3-year history of chronic cough, dysphagia, and regurgitation. She described a feeling of "food hanging in my throat" which she said she tried to cough out. On flexible laryngoscopy, a small left pharyngocele was seen at the thyrohyoid membrane just above the thyroid cartilage and piriform fossa (figure, A). A modified barium-swallow examination confirmed the diagnosis by showing that debris collected in the recess.

Several options were discussed with the patient, including observation, swallowing therapy, percutaneous augmentation of the pharyngocele, and open surgical excision. The patient was advised that surgical excision would carry some risk of injury to the superior laryngeal nerve in addition to the risks of general anesthesia. The patient decided on a percutaneous injection.

Bovine collagen (Zyplast; McGhan Medical Corp.; Fremont, Calif.) was percutaneously injected into the base of the pharyngocele under flexible fiberoptic guidance and with local anesthesia in clinic (see video at www.entjournal.com). This filler everted the sac and prevented food from becoming trapped in the pharyngocele (figure, B). After treatment, the patient's dysphagia resolved for 6 months, which is the duration of clinical benefit that can be expected from an injection of bovine collagen. (1)

A pharyngocele is a diverticulum of the pharyngeal wall. (2) It is believed to be caused by frequent repetitive increases in intrapharyngeal pressure (such as occurs in glass blowers and trumpet players) and by the loss of muscle resilience associated with increasing age. The pharyngeal wall has two weak areas, and these areas correspond to the most common locations for pharyngoceles. The superior location lies between the superior and middle pharyngeal constrictor in the area of the inferior pole of the tonsil and the side of the vallecula; the inferior location is situated between the middle and inferior constrictor and the thyrohyoid membrane. (2)

Pharyngoceles typically arise during the fifth and sixth decades of life, and they are more common in men than in women. Patients are usually asymptomatic. (3) When symptoms do manifest, they may include dysphagia, cough, regurgitation, hoarseness, odynophagia, earache, and cervical pain.

The case described herein illustrates an innovative treatment for a rare cause of dysphagia. After this treatment, our patient's symptoms completely resolved. This percutaneous augmentation is a lowrisk and minimally invasive in-office procedure that can improve a patient's quality of life. A pharyngocele should be considered in the differential diagnosis of dysphagia, and a percutaneous augmentation can be included in the menu of treatment options.

References

(1.) Simpson CB. Treatment of vocal fold paralysis. In: Bailey BJ, Johnson JT, eds. Head & Neck Surgery-Otolaryngology. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2006:848-66.

(2.) Fakhouri H, Arda N. Pharyngocele: A case report of a rare cause of bilateral neck swelling. Jordanian Royal Medical Services 2007; 14(1):53-6.

(3.) Katsinelos P, Chatzimavroudis G, Pilpilidis I, et al. Congenital bilateral pharyngoceles: An unusual case of upper dysphagia. Dysphagia 2008;23(1):98-100.

Amanda Hu, MD, FRCSC; Albert L. Merati, MD, FACS

From the Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle.
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Title Annotation:DYSPHAGIA CLINIC
Author:Hu, Amanda; Merati, Albert L.
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Feb 1, 2012
Words:513
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