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Lateral pharyngeal diverticula
LATERAL
LATERAL
PHARYNGEAL
DIVERTICULA
PHARYNGEAL
4zI
DIVERTICULA
BY J. K E R R McMYN, B.Se., M.B., CH.B., D.M.R.D. RADIOLOGIST, GREEN LANE HOSPITAL, AUCKLAND~ NEW ZEALAND
LATERAL pharyngeal diverticula are rarely described, and according to T e m p l e t o n (i944) , are an even rarer cause of s y m p t o m s . T h e p r e s e n t author has seen 3 cases having no s y m p t o m s referable to the pharynx. O n the other h a n d 2 cases with s y m p t o m s are described by Buckstein and R e i c h (I95O), and i by K a u f m a n (1956). All these appear to arise laterally or anterolateraUy f r o m the wall of the pharynx, at the vallecular level. A further e x a m p l e of this apparently rare condition p r o d u c i n g s y m p t o m s is described below, and reference m a d e to o t h e r conditions confused w i t h it.
CASE REPORT Case I . - - U . W., a woman of 33 years, complained of food sticking in the gullet. This symptom had been present many years, probably since childhood, and she often brought up a little undigested food some hours after a meal. After a swallow of thin barium cream, a fairly large pocket of barium was seen to remain in the
Fig. 379.--Case I. Anterior viewof pharynx after barium swallow, with barium in diverticulum and valleculm.
Fig. 38o.--Case I. Lateralview after barium swallow.
pharynx. It lay to the right and slightly in front of the vallecula and was about twice the size of the latter (Figs. 379, 380). A lateral film during swallowing (Fig. 381) shows the pocket drawn forwards and upwards with the larynx.
DISCUSSION A e t i o l o g y . - - J o h n s t o n e (195 o) states that lateral pharyngeal diverticula are p r o d u c e d by i n c o m plete closure of t h e second branchial cleft : " A small berry-like p o u c h situated at some point, usually near the tonsil, on a line b e t w e e n tonsillar and p y r i f o r m foss~e." Buckstein and Reich consider t h e m to arise f r o m the h y p o p h a r y n x at about the level of the p y r i f o r m sinuses, a r e m n a n t of either the third or f o u r t h branchial pouches.
422
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
Kaufman refers to the above and presents evidence in favour of their congenital origin, quoting Arey (r942), and stating that they result from incomplete closure of the cervical sinus, formed from branchial clefts. Templeton's case resembles the present cases and those of Buckstein and Reich, except that the out-pouchings were not seen in the resting stage. When the Valsa!va test was performed, that portion of the pharynx which contained the diverticulum and which lay immediately
Fig. 38I.--Case I. Lateral view during barium swallow; diverticulum drawn forwards and upwards with larynx.
Fig. 382.--Normal out-pouching of pyriform sinuses with Valsalva manoeuvre following barium swallow.
above the thyroid cartilage ballooned out more than that on the opposite side. He considered that the pouching was caused by a weakness in the lateral wall of the middle constrictor muscle. Further support to this latter theory is given by recent cineradiographic studies of the mechanism of swallowing. Ardran and Kemp (1952) found that a bolus, when swallowed, is received into the vallecula3, where there is a momentary pause. Some then spills over the lateral pharyngo-epiglottic folds into the lateral food channels, but the bulk of it is held upon the epiglottis (vallecular arrest). Ardran and Kemp pointed out, as did Negus (195o), that in the lower animals the laryngeal airway is protected because the fluid or bolus is directed to either side into the lateral food channels. It seems reasonable to suppose that a weakness in the lateral walls, combined with pressure so produced at the vallecular level, may be a factor in the development of this type of diverticulum. The posterior or Zenker's pharyngeal diverticulum is considered to result from a herniation of mucous membrane at the junction of the inferior constrictor and cricopharyngeus during distension of the pharynx while swallowing (Negus). In the same way, Gray (x932) considered the pharyngeal dimple to be a potential diverticulum and a precursor of the posterior type. It may be that a similar weak spot is present at the vallecular level, or that the combination of a congenital defect plus the above mechanism accounts for their formation. Thus, although lateral pharyngeal diverticula are probably congenital, mechanical factors may influence their development. S y m p t o m s . - - T h e s e are similar to those found with pharyngeal pouches and would appear to depend on whether or not food is retained in the pouch after swallowing. They are : - -
LATERAL
PHARYNGEAL
DIVERTICULA
423
I. Dysphagia--food appearing to stick in the gullet. This may be episodic, but of long duration. 2. A sense of fullness in the neck or a sore throat from retention of food, relieved if the sac is emptied by a change in posture or by lavage. 3- Regurgitation of undigested food from the sac.
Differential Diagnosis.-I . Normal Small Out-pouchings of the Lateral Pharyngeal Walls.--These occur just above the laminae of the thyroid cartilage and between it and the hyoid bone. They are seen in many patients during the Valsalva test. They are mentioned by Young (194o) and Templeton (i944) , who describes them as " ear-like pouches". Examples of these are shown
Fig. 383.--Case 2.
T o m o g r a m (antero-posterior neck). Airpocket on left side of neck, originally diagnosed as a laryngocele,
Fig. 384.--Case 2.
B a r i u m and Valsalva show bilateral pouchings of p y r i f o r m sinuses ; larger on left,
in Figs. 382-386, from patients picked at random during routine barium examinations. They are apparently the superolateral extremities of the pyriform sinuses, which normally balloon with the Valsalva test. Ramsey, Watson, Gramiak, and Weinberg (1955) state that a large bolus fills out the lumen and distends the pyriform sinuses to the limit, with a bulging of their lateral walls between the upper margins of the laminae of the thyroid cartilage and the hyoid. He says that they are usually seen in the anterior view, but occasionally in the lateral view, and are well demonstrated by the Valsalva test. Most text-books, however, do not refer to them. He doubts whether these lateral pouches deserve to be called diverticula, except in extreme cases. The fact that several examples were quickly obtained during routine examinations lends support to this view. In this respect it should be mentioned that performance of the Valsalva test in children has been said to damage the pharynx. Two eases considered to come under this heading, with pyriform sinuses which distend easily or were over-'distended on one side, are mentioned below. They are of interest in that a diagnosis of laryngocele was first made, but this was disproved by barium swallow.
424
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
Case 2.--F. G., male, aged 47. Examined by a laryngologist for laryngitis when a slight bulge was noted on the left side of the neck on coughing. A plain film and a tomogram (Fig. 383) in 1952 showed an air-pocket, and a diagnosis of laryngocele was made. Barium swallow (Fig. 384) in 1955 showed that both pyriform sinuses distended easily and became coated with barium. Case 3.--J. H. H., male, aged 3 i. Thyrotoxicosis with moderate thyroid enlargement Which produced some displacement of the trachea (Fig. 385). Again, with barium (Fig. 386) this was shown to be the pyriform sinus, with one bulge above and another below the thyroid cartilage on the left, both of which became coated with barium. 2. Pharyngocele.--The pockets just mentioned may vary in degree and if extreme may be pathological.
T h e term ' pharyngocele ', was given by Atkinson (I952) and seems a satisfactory
Fig. 385.--Case 3. Air-space on left.
Plain film of neck (antero-posterior). Right-sided thyroid enlargement.
Fig. 386.--Case 3.
After barium a n d Valsalva. out-pouching of pyriform sinuses.
Bilateral
one to describe this condition. Hankins (1944) describes the case of a trumpet player who could produce a bulge the size of an egg in his neck when playing. This was said to have occurred suddenly. Radiographs showed the dilated pyriform sinus above the level of the thyroid as above, b u t with extreme dilatation on one side. 3. Artificial Pouches.--Another condition which has been called ' lateral pharyngeal divertic u l u m ' is described by two authors. Negus describes as " a p s e u d o - d i v e r t i c u l u m " an artificial dilatation of the normal pyriform sinus which, according to him, is sometimes used by habitual criminals as a pouch in which to conceal money. I n a note by Morris (1952) there is a plain radiograph of the neck showing a coin in a pouch. He states that pharyngeal diverticula of traumatic origin are quite common amongst habitual convicts in India, and that they are formed by ulceration of the pharynx deliberately produced by means of a piece of lead threaded on silk which is left in situ at night. 4. Zenker's Posterior Pharyngeal Diverticulum.--A typical example of this arising laterally has been called ' lateral pharyngeal diverticulum' by Negus.
LATERAL
PHARYNGEAL SUMMARY
AND
DIVERTICULA
425
CONCLUSIONS
A case of lateral pharyngeal diverticulum causing symptoms is described. Attention is drawn to the normal out-pouchings of the pyriform sinus and lateral walls of the pharynx seen with barium swallow during the Valsalva test. I t would seem that a distinction should be drawn between : - I, Anterolateral pharyngeal diverticula occurring at the vallecular level and retaining b a r i u m in the resting state, probably congenital. 2. Normal ear-like pouches of the lateral wall of the pharynx, accentuated by the Valsalva test. 3. Extreme cases of these pouchings of the pyriform sinuses which may be c a l l e d ' pharyngocele ' 4: Artificial pouches--traumatic. 5. Lateral types of Zenker's posterior pharyngeal diverticula between the cricopharyngeus and the upper fibres of the cesophagus. All these have been called ' lateral pharyngeal diverticula ', b u t it is suggested that only the first type should be so called. REFERENCES ARDRAN, G. M., and KEMP, F. H. (I952), Brit. J. Radiol., 25, 4o6. ABEY, L. B. (I94e), quoted by KAUFMAN(I956), Developmental Anatomy, i5o. Philadelphia : W. B. Saunders. ATKINSON,L. (I952), quoted by KAUFMAN(I956), Jlrch. Middlesex Hosp., 245. BUCKSTEIN,J. B., and REICH, S. (z95o), J. Amer. med. Ass., 144 , z 154. GRAY, E. D. (I932), Brit. J. Radiol., 5, 640. HANKINS,W. D. (I944) , Radiology, 42, 499. JOHNSTONE,A. S. (I950), A Text-book ofX-ray Diagnosis by British Authors, 2nd ed., 3, 2i. London : H . K . Lewis. KAUFMAN, S. A. (I956), Amer. J. Roentgenol., 75, 238. MORRIS, M. (I952), J. R. Army med. Cps, 98, 349. NEGUS, V. E. (I95O), Brit. J. Surg., 38, I~9. RAMSEY, G. H., WATSON,J. S., GRAMIAK,R., and WEINBERC, S. A. (1955), Radiology, 64, 498. TEMPLETON, F. E. (I944), X-ray Examination of the Stomach, 85, 186. Chicago : University of Chicago Pres:. YOUNe, B. R. (I94O), Amer. J. Radiol., 44, 5z9.
BOOK REVIEWS Radiology o f the Heart and Great Vessels. By ROBERT N. COOLEY, M.D., Professor and Chairman of the Department of Radiology, University of Texas Medical Branch, Galveston, Texas ; and ROBERT D, SLOAN, M.D., Professor and Director of the Department of Radiology, University of Mississippi Medical Center, Jackson, Mississippi. I O $ × 7:} in. Pp. 309 with 195 iUustrations, I956. London : Bailli~re, Tindall and Cox. 96s. THIS book represents a reprint of Chapter 4 on Roentgenology of the Heart and Great Vessels from the well-known loose-leaf text-book on Diagnostic Roentgenology which was re-edited by Ross Golden in I956. In the opening sections of the book the authors deal in the conventional way with radiographic procedures in the investigation of cardiovascular diseases. It is rather surprising that under the discussion on rapid film-changing equipment, the Elema machine, working.at I2 films a second, and the Schonander machine, working at a slightly slower speed, are not mentioned. The retrograde Seldinger technique for arteriography and aortography is not discussed, a procedure which has partly superseded other methods in the investigation of peripheral vascular diseases. In the description of the normal appearance of the heart and great vessels, convincing use is made of angiocardiograms in the interpretation of the normal appearance of the cardiac chambers in the various radiographic positions. It is refreshing to note that the authors stress the lateral projection when interpreting individual heart chambers. r
29
LATERAL
PHARYNGEAL
DIVERTICULA
PHARYNGEAL
4zI
DIVERTICULA
BY J. K E R R McMYN, B.Se., M.B., CH.B., D.M.R.D. RADIOLOGIST, GREEN LANE HOSPITAL, AUCKLAND~ NEW ZEALAND
LATERAL pharyngeal diverticula are rarely described, and according to T e m p l e t o n (i944) , are an even rarer cause of s y m p t o m s . T h e p r e s e n t author has seen 3 cases having no s y m p t o m s referable to the pharynx. O n the other h a n d 2 cases with s y m p t o m s are described by Buckstein and R e i c h (I95O), and i by K a u f m a n (1956). All these appear to arise laterally or anterolateraUy f r o m the wall of the pharynx, at the vallecular level. A further e x a m p l e of this apparently rare condition p r o d u c i n g s y m p t o m s is described below, and reference m a d e to o t h e r conditions confused w i t h it.
CASE REPORT Case I . - - U . W., a woman of 33 years, complained of food sticking in the gullet. This symptom had been present many years, probably since childhood, and she often brought up a little undigested food some hours after a meal. After a swallow of thin barium cream, a fairly large pocket of barium was seen to remain in the
Fig. 379.--Case I. Anterior viewof pharynx after barium swallow, with barium in diverticulum and valleculm.
Fig. 38o.--Case I. Lateralview after barium swallow.
pharynx. It lay to the right and slightly in front of the vallecula and was about twice the size of the latter (Figs. 379, 380). A lateral film during swallowing (Fig. 381) shows the pocket drawn forwards and upwards with the larynx.
DISCUSSION A e t i o l o g y . - - J o h n s t o n e (195 o) states that lateral pharyngeal diverticula are p r o d u c e d by i n c o m plete closure of t h e second branchial cleft : " A small berry-like p o u c h situated at some point, usually near the tonsil, on a line b e t w e e n tonsillar and p y r i f o r m foss~e." Buckstein and Reich consider t h e m to arise f r o m the h y p o p h a r y n x at about the level of the p y r i f o r m sinuses, a r e m n a n t of either the third or f o u r t h branchial pouches.
422
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
Kaufman refers to the above and presents evidence in favour of their congenital origin, quoting Arey (r942), and stating that they result from incomplete closure of the cervical sinus, formed from branchial clefts. Templeton's case resembles the present cases and those of Buckstein and Reich, except that the out-pouchings were not seen in the resting stage. When the Valsa!va test was performed, that portion of the pharynx which contained the diverticulum and which lay immediately
Fig. 38I.--Case I. Lateral view during barium swallow; diverticulum drawn forwards and upwards with larynx.
Fig. 382.--Normal out-pouching of pyriform sinuses with Valsalva manoeuvre following barium swallow.
above the thyroid cartilage ballooned out more than that on the opposite side. He considered that the pouching was caused by a weakness in the lateral wall of the middle constrictor muscle. Further support to this latter theory is given by recent cineradiographic studies of the mechanism of swallowing. Ardran and Kemp (1952) found that a bolus, when swallowed, is received into the vallecula3, where there is a momentary pause. Some then spills over the lateral pharyngo-epiglottic folds into the lateral food channels, but the bulk of it is held upon the epiglottis (vallecular arrest). Ardran and Kemp pointed out, as did Negus (195o), that in the lower animals the laryngeal airway is protected because the fluid or bolus is directed to either side into the lateral food channels. It seems reasonable to suppose that a weakness in the lateral walls, combined with pressure so produced at the vallecular level, may be a factor in the development of this type of diverticulum. The posterior or Zenker's pharyngeal diverticulum is considered to result from a herniation of mucous membrane at the junction of the inferior constrictor and cricopharyngeus during distension of the pharynx while swallowing (Negus). In the same way, Gray (x932) considered the pharyngeal dimple to be a potential diverticulum and a precursor of the posterior type. It may be that a similar weak spot is present at the vallecular level, or that the combination of a congenital defect plus the above mechanism accounts for their formation. Thus, although lateral pharyngeal diverticula are probably congenital, mechanical factors may influence their development. S y m p t o m s . - - T h e s e are similar to those found with pharyngeal pouches and would appear to depend on whether or not food is retained in the pouch after swallowing. They are : - -
LATERAL
PHARYNGEAL
DIVERTICULA
423
I. Dysphagia--food appearing to stick in the gullet. This may be episodic, but of long duration. 2. A sense of fullness in the neck or a sore throat from retention of food, relieved if the sac is emptied by a change in posture or by lavage. 3- Regurgitation of undigested food from the sac.
Differential Diagnosis.-I . Normal Small Out-pouchings of the Lateral Pharyngeal Walls.--These occur just above the laminae of the thyroid cartilage and between it and the hyoid bone. They are seen in many patients during the Valsalva test. They are mentioned by Young (194o) and Templeton (i944) , who describes them as " ear-like pouches". Examples of these are shown
Fig. 383.--Case 2.
T o m o g r a m (antero-posterior neck). Airpocket on left side of neck, originally diagnosed as a laryngocele,
Fig. 384.--Case 2.
B a r i u m and Valsalva show bilateral pouchings of p y r i f o r m sinuses ; larger on left,
in Figs. 382-386, from patients picked at random during routine barium examinations. They are apparently the superolateral extremities of the pyriform sinuses, which normally balloon with the Valsalva test. Ramsey, Watson, Gramiak, and Weinberg (1955) state that a large bolus fills out the lumen and distends the pyriform sinuses to the limit, with a bulging of their lateral walls between the upper margins of the laminae of the thyroid cartilage and the hyoid. He says that they are usually seen in the anterior view, but occasionally in the lateral view, and are well demonstrated by the Valsalva test. Most text-books, however, do not refer to them. He doubts whether these lateral pouches deserve to be called diverticula, except in extreme cases. The fact that several examples were quickly obtained during routine examinations lends support to this view. In this respect it should be mentioned that performance of the Valsalva test in children has been said to damage the pharynx. Two eases considered to come under this heading, with pyriform sinuses which distend easily or were over-'distended on one side, are mentioned below. They are of interest in that a diagnosis of laryngocele was first made, but this was disproved by barium swallow.
424
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
Case 2.--F. G., male, aged 47. Examined by a laryngologist for laryngitis when a slight bulge was noted on the left side of the neck on coughing. A plain film and a tomogram (Fig. 383) in 1952 showed an air-pocket, and a diagnosis of laryngocele was made. Barium swallow (Fig. 384) in 1955 showed that both pyriform sinuses distended easily and became coated with barium. Case 3.--J. H. H., male, aged 3 i. Thyrotoxicosis with moderate thyroid enlargement Which produced some displacement of the trachea (Fig. 385). Again, with barium (Fig. 386) this was shown to be the pyriform sinus, with one bulge above and another below the thyroid cartilage on the left, both of which became coated with barium. 2. Pharyngocele.--The pockets just mentioned may vary in degree and if extreme may be pathological.
T h e term ' pharyngocele ', was given by Atkinson (I952) and seems a satisfactory
Fig. 385.--Case 3. Air-space on left.
Plain film of neck (antero-posterior). Right-sided thyroid enlargement.
Fig. 386.--Case 3.
After barium a n d Valsalva. out-pouching of pyriform sinuses.
Bilateral
one to describe this condition. Hankins (1944) describes the case of a trumpet player who could produce a bulge the size of an egg in his neck when playing. This was said to have occurred suddenly. Radiographs showed the dilated pyriform sinus above the level of the thyroid as above, b u t with extreme dilatation on one side. 3. Artificial Pouches.--Another condition which has been called ' lateral pharyngeal divertic u l u m ' is described by two authors. Negus describes as " a p s e u d o - d i v e r t i c u l u m " an artificial dilatation of the normal pyriform sinus which, according to him, is sometimes used by habitual criminals as a pouch in which to conceal money. I n a note by Morris (1952) there is a plain radiograph of the neck showing a coin in a pouch. He states that pharyngeal diverticula of traumatic origin are quite common amongst habitual convicts in India, and that they are formed by ulceration of the pharynx deliberately produced by means of a piece of lead threaded on silk which is left in situ at night. 4. Zenker's Posterior Pharyngeal Diverticulum.--A typical example of this arising laterally has been called ' lateral pharyngeal diverticulum' by Negus.
LATERAL
PHARYNGEAL SUMMARY
AND
DIVERTICULA
425
CONCLUSIONS
A case of lateral pharyngeal diverticulum causing symptoms is described. Attention is drawn to the normal out-pouchings of the pyriform sinus and lateral walls of the pharynx seen with barium swallow during the Valsalva test. I t would seem that a distinction should be drawn between : - I, Anterolateral pharyngeal diverticula occurring at the vallecular level and retaining b a r i u m in the resting state, probably congenital. 2. Normal ear-like pouches of the lateral wall of the pharynx, accentuated by the Valsalva test. 3. Extreme cases of these pouchings of the pyriform sinuses which may be c a l l e d ' pharyngocele ' 4: Artificial pouches--traumatic. 5. Lateral types of Zenker's posterior pharyngeal diverticula between the cricopharyngeus and the upper fibres of the cesophagus. All these have been called ' lateral pharyngeal diverticula ', b u t it is suggested that only the first type should be so called. REFERENCES ARDRAN, G. M., and KEMP, F. H. (I952), Brit. J. Radiol., 25, 4o6. ABEY, L. B. (I94e), quoted by KAUFMAN(I956), Developmental Anatomy, i5o. Philadelphia : W. B. Saunders. ATKINSON,L. (I952), quoted by KAUFMAN(I956), Jlrch. Middlesex Hosp., 245. BUCKSTEIN,J. B., and REICH, S. (z95o), J. Amer. med. Ass., 144 , z 154. GRAY, E. D. (I932), Brit. J. Radiol., 5, 640. HANKINS,W. D. (I944) , Radiology, 42, 499. JOHNSTONE,A. S. (I950), A Text-book ofX-ray Diagnosis by British Authors, 2nd ed., 3, 2i. London : H . K . Lewis. KAUFMAN, S. A. (I956), Amer. J. Roentgenol., 75, 238. MORRIS, M. (I952), J. R. Army med. Cps, 98, 349. NEGUS, V. E. (I95O), Brit. J. Surg., 38, I~9. RAMSEY, G. H., WATSON,J. S., GRAMIAK,R., and WEINBERC, S. A. (1955), Radiology, 64, 498. TEMPLETON, F. E. (I944), X-ray Examination of the Stomach, 85, 186. Chicago : University of Chicago Pres:. YOUNe, B. R. (I94O), Amer. J. Radiol., 44, 5z9.
BOOK REVIEWS Radiology o f the Heart and Great Vessels. By ROBERT N. COOLEY, M.D., Professor and Chairman of the Department of Radiology, University of Texas Medical Branch, Galveston, Texas ; and ROBERT D, SLOAN, M.D., Professor and Director of the Department of Radiology, University of Mississippi Medical Center, Jackson, Mississippi. I O $ × 7:} in. Pp. 309 with 195 iUustrations, I956. London : Bailli~re, Tindall and Cox. 96s. THIS book represents a reprint of Chapter 4 on Roentgenology of the Heart and Great Vessels from the well-known loose-leaf text-book on Diagnostic Roentgenology which was re-edited by Ross Golden in I956. In the opening sections of the book the authors deal in the conventional way with radiographic procedures in the investigation of cardiovascular diseases. It is rather surprising that under the discussion on rapid film-changing equipment, the Elema machine, working.at I2 films a second, and the Schonander machine, working at a slightly slower speed, are not mentioned. The retrograde Seldinger technique for arteriography and aortography is not discussed, a procedure which has partly superseded other methods in the investigation of peripheral vascular diseases. In the description of the normal appearance of the heart and great vessels, convincing use is made of angiocardiograms in the interpretation of the normal appearance of the cardiac chambers in the various radiographic positions. It is refreshing to note that the authors stress the lateral projection when interpreting individual heart chambers. r
29