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Not all pharyngeal pouches are created equal: management of “non-zenker” hypopharyngeal diverticula
Operative Techniques in Otolaryngology (2016) ], ]]]–]]]
Not All Pharyngeal Pouches are Created Equal: Management of “Non-Zenker” Hypopharyngeal Diverticula Christopher M. Johnson, MD Gregory N. Postma, MD From the Department of Otolaryngology, Center for Voice, Airway, and Swallowing Disorders, Georgia Regents University, Augusta, Georgia KEYWORDS Dysphagia; Hypopharyngeal diverticulum or pouch; Cricopharyngeal myotomy; Swallowing; Zenker’s diverticulum
Zenker diverticulum is the most common hypopharyngeal diverticulum. Alternate types of hypopharyngeal diverticula are uncommon; however, recognition and proper diagnosis is imperative, as treatment may be quite different. Hypopharyngeal diverticula are typically diagnosed using barium esophagography and differences between types of diverticula can be subtle. Although endoscopic management of Zenker Diverticula has become very popular recently, endoscopic exposure of other hypopharyngeal diverticula is not as straightforward. In this article, traction, iatrogenic, KillianJamieson, and Laimer diverticula would be discussed. Treatment options for each would also be explored and compared with treatment of the more common Zenker diverticulum. r 2016 Elsevier Inc. All rights reserved.
Introduction Hypopharyngeal diverticula (also referred to as pharyngeal or pharyngo-esophageal diverticula) have been recognized in the medical literature for over 2 centuries; however, the first successful surgical procedure to excise a Zenker Diverticulum (ZD) was not reported until 1886 by Wheeler. ZD is by far the most common esophageal or pharyngeal diverticulum estimated to be present in 0.01%0.11% of the population.1 No reliable epidemiological data
C.J. is a military service member. This work was prepared as part of his official duties. Title 17, USC, § 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17, USC, § 101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person’s official duties. Address reprint requests and correspondence: Gregory N. Postma, MD, Department of Otolaryngology, Center for Voice, Airway, and Swallowing Disorders, Georgia Regents University, 1120 15th St, BP-4109, Augusta, GA 30912. E-mail address: [email protected] http://dx.doi.org/10.1016/j.otot.2016.04.005 1043-1810/r 2016 Elsevier Inc. All rights reserved.
are available for other pharyngeal and esophageal diverticula as their prevalence is significantly lower. Pharyngeal and esophageal diverticula can be classified in several ways. By location, the diverticulum can reside in the hypopharynx, at the mid-thoracic region or in the epiphrenic region. They can be further characterized by pathophysiology as either pulsion or traction diverticula (TD) and by composition as either a true or false diverticula. Pulsion diverticula herniate through a weakness in the outer muscular wall because of increased intraluminal pressure and are typically considered false diverticula indicating the presence of only mucosa and submucosa within the wall of the pouch. TD form because of external tethering of the pharynx or esophagus owing to some adjacent inflammatory condition and are typically considered true diverticula indicating the presence of mucosa, submucosa, and outer muscular layers. ZD are classified by location as hypopharyngeal diverticula, by pathophysiology as pulsion diverticula, and by composition as false diverticula. Pulsion diverticula are commonly thought to originate from the hypopharynx or the epiphrenic region and form because of
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cricopharyngeal dysfunction or lower esophageal sphincter dysfunction, respectively. TD are said to most commonly occur in the mid-thoracic region because of a classic association with hilar lymphadenopathy from neoplasia, tuberculosis, or fungal infections. The vast majority of hypopharyngeal diverticula are of the pulsion type and occur above the cricopharyngeus muscle (ZD). Likewise, most of the TD originates in the mid-thoracic region. However, as with most classification schemes, there are exceptions. These exceptions are the focus of this article. Specifically, Killian-Jamieson and Laimer diverticula are thought to be pulsion diverticula that originate below the cricopharyngeus. Furthermore, TD can occur in the upper esophagus and pharynx. Aside from infectious causes, iatrogenic diverticula thought to be directly related to anterior approaches to the cervical spine have been reported over the past 2 decades. Given the common location of these less prevalent diverticula, standard barium esophagography may not definitively differentiate them from the more common ZD. This has implications on management as only ZD are easily amenable to endoscopic surgical approaches.
Background and Anatomical Description In Figure 1, there are 3 anatomical points of weakness in the pharyngeal musculature through which pulsion diverticula may protrude. From the posterior view in Figure 1A, one can visualize Killian’s triangle between the cricopharyngeus and the inferior constrictor muscles, through which a ZD is said to originate. The etiology of ZD is considered to be some form of cricopharyngeus muscle malfunction. ZD protrude posteriorly into the retropharyngeal space; however, nearly all extend slightly to the left and large pouches bulge laterally into the visceral space (Figure 2A).
In Figure 1B, a lateral view of the pharyngeal musculature and primarily illustrates the Killian-Jamieson area that resides below the cricopharyngeus muscle and represents the area of weakness where the recurrent laryngeal nerve enters the larynx. Killian-Jamieson Diverticula (KJD) originate in this region. KJD were first extensively described in 1983 where 13 cases were presented.2 They are considered pulsion diverticula and are almost exclusively found on the left unless bilateral. Owing to its lateral location, the recurrent laryngeal nerve is typically intimately related to the medial wall of the pouch (Figure 2B). Although there are reports of endoscopic management, an open cervical approach is typically favored to minimize the likelihood of damage to the recurrent laryngeal nerve.3 Also in Figure 1A, one can see a triangular area below the cricopharyngeus and between the divergent longitudinal muscle fibers of the proximal esophagus where only the circular fibers of the esophagus are present. This triangular area of weakness is referred to as Laimer’s triangle or the Laimer-Haeckerman area that is thought to be the site of origin of the very rare Laimer diverticulum (LD). Less than 5 LD have been reported in the literature. Of the reported cases, most describe them as true diverticula (Figure 2C); however, they are thought to be pulsion in origin presumably because of esophageal dysmotility.4,5 Although ZD, KJD, and LD are pulsion diverticula with specific sites of origin, infectious or iatrogenic TD can essentially occur in any location dependent upon the site of the nidus of inflammation. Classically, TD are because of scarring or tethering of the esophageal and hypopharyngeal musculature to surrounding tissue after resolution of an esophageal perforation or to an inflamed lymph node after an infection (Figure 2D). In 1991, the first report was published of a hypopharyngeal TD associated with an anterior approach to the cervical spine.6 Overall, less than 20 cases have been reported in the literature; however, some
Figure 1 Posterior (A) and lateral (B) view of the pharyngeal musculature. Note the locations of Killlian's triangle, Laimer's area, and the Killian-Jamieson area. These sites of pharyngeal muscular weakness are the sites of protrusion of Zenker, Laimer, and Killian-Jamieson pulsion diverticula, respectively.
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Figure 2 There are 4 types of hypopharyngeal diverticula: Zenker (A), Killian-Jamieson (B), Laimer (C), and Traction (D). Note the relationship of the Killian-Jamieson diverticulum to the recurrent laryngeal nerve (B). Also, note the presence of reactive lymphadenopathy tethering the esophagus to form a traction diverticulum (D). Tethering to form a traction diverticulum can occur from lymphadenopathy, scarring secondary to a previous esophageal perforation or the presence of an anterior spinal fusion plate.
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authors suggest that the incidence of these iatrogenic TD may rise given the popularity of the anterior cervical approach by spine surgeons.7 These iatrogenic TD associated with cervical spinal hardware between the levels of C4 and C7 can mimic the radiological appearance of any other posteriorly based noniatrogenic diverticula, specifically ZD.
Diagnostic Workup Regardless of location or etiology of the diverticulum, the clinical presentation is essentially identical. Dysphagia and regurgitation are the primary presenting symptoms. A traction diverticulum is associated with prior cervical spine surgery, cervical infection, or esophageal perforation; therefore, history suggesting any of these should be fully elucidated.
The most useful diagnostic modality to identify hypopharyngeal diverticula is a barium study (barium esophagram or modified barium swallow study). A diverticulum of any sort should be readily identifiable on a barium study; however, identification of the cricopharyngeus muscle is essential to determine the exact type and location. A barium study would also show the relationship of a diverticulum to cervical spinal hardware if an iatrogenic traction diverticulum is suspected. Delineation of the rare variant hypopharyngeal diverticula discussed here is sometimes difficult without direct or endoscopic visualization when the cricopharyngeus muscle is not readily apparent. To illustrate this, Figure 3A shows a classic lateral view of a ZD. In Figure 3B, a lateral view of a diverticulum that was described as a ZD; however, it was found to originate below the cricopharyngeus at subsequent endoscopy. Based on location alone, a LD was suspected. During open diverticulectomy, mediastinal lymphadenopathy was noted
Figure 3 Fluoroscopic images of a classic Zenker diverticulum (A), a traction diverticulum because of reactive lymphadenopathy with the appearance of a Zenker diverticulum (B), a traction diverticulum with the appearance of a Killian-Jamieson diverticulum (C), and an iatrogenic traction diverticulum because of an anterior spinal fusion with the appearance of a Zenker diverticulum (D). In B and C, the asterisk indicates the location of the pouch. Note that A, B, and D are lateral fluoroscopic views, whereas C is anterior-posterior.
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tethering the apex of the pouch indicating that it was actually a TD related to a prior infection. In Figure 3C, an anterior-posterior view of what was described as a KJD based on a barium study, but it was found to originate 3 cm distal to the cricopharyngeus on esophageal endoscopy. Further, discussion with the patient revealed history of a small esophageal perforation from ingestion of a bay leaf that was treated nonoperatively in her past, indicating that this is also a TD. In Figure 3D, what appears at first glance to be a ZD; however, there is extensive spinal hardware visible on the radiograph. This patient had an anterior approach to the cervical spine previously; however, plate exposure necessitated removal of the anterior hardware in favor of posterior hardware. An iatrogenic TD formed in the approximate location of a ZD likely caused by postsurgical scarring and tethering. Pulsion diverticula are associated with increased intraluminal pressure because of underlying esophageal dysmotility; therefore, esophageal manometry can be useful before any surgical intervention is undertaken but is not essential. Manometric findings can potentially help differentiate pulsion and TD before surgery.
Treatment There are 2 surgical options for hypopharyngeal diverticula —open and endoscopic approaches. Debate as to which treatment modality is optimal has been ongoing specifically regarding ZD. Although the first open diverticulectomy was reported in the late 1800s by Wheeler, the first endoscopic treatment was reported by Mosher in 1914. However, Mosher abandoned the technique because of unacceptable mortality because of mediastinitis. Endoscopic treatment was reevaluated in the 1960s then gained widespread use subsequently in the 1990s with the introduction of the endoscopic stapler. Today, the endoscopic approach has become very popular for treatment of ZD; however, endoscopic management of other hypopharyngeal diverticula is not well established. As stated previously, open cervical management of KJD is advocated because of its intimate association with the recurrent laryngeal nerve. Furthermore, in a case series of TD associated with anterior cervical spine surgery, Ba et al8 assert that thick scarring of the diverticular wall could prohibit endoscopic stapling. Furthermore, endoscopic exposure of diverticula below the cricopharyngeus muscle is challenging at best. However, an attempt at endoscopic exposure is often attempted first because of decreased operative time and faster return to oral diet with endoscopic management. It should also be noted that iatrogenic hypopharyngeal TD may necessitate removal or replacement of cervical spinal hardware; therefore, planning the procedure in conjunction with a spine surgeon is essential. Because of this, an open diverticulectomy may be a better option in this instance. Even if an open diverticulectomy is planned from the beginning, endoscopic exposure is typically attempted to pack the diverticulum with gauze or to place an esophageal
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Figure 4 Intraoperative identification of a traction diverticular sac using insufflation of air and transillumination from a transnasal esophagoscope in the esophagus. (Color version of figure is available online.)
dilator to aid in identification of the pouch through an open approach. It is the practice of the authors to obtain informed consent for both endoscopic and open approaches before embarking on surgical treatment of hypopharyngeal diverticula under general anesthesia. It is also our practice to provide 24 hours of intravenous clindamycin with the first dose given just before surgery. In the endoscopic approach, a Weerda distending diverticuloscope (Storz, Goleta, CA) is used to attempt to expose the pouch transorally in a similar fashion to the endoscopic approach to ZD. The endoscopic approach to ZD is discussed elsewhere in this publication; therefore, only a brief discussion would be provided here. An attempt is made to place 1 tine of the scope in the esophagus and 1 in the pouch. This is successful in roughly 90% of ZD in our practice; however, success in exposure of diverticula below
Figure 5 After identification of the diverticular sac, a linear stapler is used to transect the neck of the pouch. (Color version of figure is available online.)
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the cricopharyngeus is rare. If the diverticulum is successfully exposed with the Weerda diverticuloscope, the decision is then made based on location and preoperative radiographs if endoscopic techniques such as stapling and carbon dioxide laser would be used. If adequate endoscopic exposure is not accomplished or if an open approach was planned at the outset, the exposure gained with the diverticuloscope is used to endoscopically pack the diverticulum with strip gauze and to place a dilator in the esophagus to aid in identification of the diverticulum from an open transcervical approach. As is often the case with diverticula below the cricopharyngeus muscle, direct line-ofsight exposure might not be possible. Even if the pouch is not exposed, exposure of the upper esophageal sphincter allows for introduction of a transnasal esophagoscope. Using flexible endoscopy with insufflation of air, the diverticulum can then be evaluated and a guidewire can be placed in the esophagus. At this point after the guidewire is placed, the transnasal esophagoscope and the rigid diverticuloscope can be removed in preparation for the open approach. The guidewire can then be used to safely introduce an esophageal dilator into the esophagus (without traumatizing the diverticulum) to aid in identification of the pouch and esophagus intraoperatively during the open approach. In the open approach, a 5 cm horizontal skin incision is made at the level of the inferior border of the thyroid cartilage slightly lateral to the midline. The anteriorposterior view of the barium study should be reviewed just before the skin incision to ensure the correct side. In most cases, the diverticulum extends either posteriorly or to the left within the visceral space. Because of this, the surgical approach is typically from the left side. Subplatysmal flaps are elevated superiorly and inferiorly. The anterior border of the sternocleidomastoid muscle is delineated and the omohyoid muscle is identified. The omohyoid is traced medially to define the lateral edge of the infrahyoid strap muscles and the laryngotracheal complex. Dissection then proceeds between the laryngotracheal complex and the carotid sheath toward the retropharynx. The omohyoid muscle can be incised to improve surgical access. The laryngotracheal complex is retracted by placing a blunt double-prong skin retractor on the posterior edge of the thyroid cartilage to further expose the area of the diverticulum. Palpation of the in-dwelling esophageal dilator aids in identification of the esophagus. If the diverticulum was packed with strip gauze endoscopically, the pouch can be palpated at this point. If inadequate endoscopic exposure prevented packing of the pouch, the dilator can be removed and a transnasal esophagoscope can be reintroduced into the esophagus. In this instance, it is the practice of the authors to use insufflation of air and transillumination of the diverticular sac with the transnasal esophagoscope to aid in identification (Figure 4). Once the sac is identified, it is dissected free of its surrounding tissue delicately using a combination of blunt and sharp dissection until the neck of the diverticulum is clearly defined. In the case of a KJD, the recurrent laryngeal nerve is identified and carefully freed from the diverticular sac. Furthermore, at this
time the wound bed is inspected for lymphadenopathy, signs of infection and scarring if a TD is suspected. A wide superior and inferior esophageal myotomy is performed at this time as well. If the pouch is near the cricopharyngeus muscle, a cricopharyngeal myotomy is performed. A Kelly clamp is then used to cross-clamp the diverticulum whereas endoscopically ensuring patency of the esophageal lumen to prevent postdiverticulectomy esophageal narrowing or stricture. The Kelly clamp is then replaced with a linear stapler and the pouch is excised (Figure 5). After the pouch is excised, the wound bed is filled with saline and the transnasal esophagoscope is used to insufflate air into the esophagus to perform a leak test. If no leak is identified, the incision is closed in layers over a surgical drain and the procedure is terminated. It is the opinion of the authors that the use of a transnasal esophagoscope is very helpful in all open esophageal and hypopharyngeal diverticular surgery.
Conclusion Although exceedingly rare, management of “non-Zenker’s” hypopharyngeal diverticula can be quite different than management of the more common ZD in that open cervical diverticulectomy is often necessary. The diagnosis of a hypopharyngeal diverticulum is typically made using barium esophagography; however, identification of these less common pouches can be difficult using radiological studies alone. Because of this, surgeons should recognize that diverticula other than ZD can occur in the hypopharynx and plan accordingly.
Disclosures The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
References 1. Watemberg S, Landau O, Avrahami R: Zenker’s diverticulum: Reappraisal. Am J Gastroenterol 91(8):1494-1498, 1996 2. Ekberg O, Nylander G: Lateral diverticula from the pharyngoesophageal junction area. Radiology 146:117-122, 1983 3. Undavia S, Anand S, Jacobson A: Killian-Jamieson diverticulum: A case for open transcervical excision. Laryngoscope 123:414-417, 2013 4. Kumoi K, Ohtsuki N, Teramoto Y: Pharyngo-esophageal diverticulum arising from Laimer’s triangle. Eur Arch Otorhinolaryngol 258:184-187, 2001 5. Nguyen D, Moslemi M, Rawashdeh B, et al: Laimer’s diverticulum, a rare true diverticulum inferior to the cricopharyngeus: Report of a case and review of the literature. J Clin Case Rep 4:423, 2014 6. Goffart Y, Lenelle J, Moreau P, et al: Traction diverticulum of the hypopharynx following anterior cervical spine surgery. Ann Otol Rhinol Laryngol 100:852-855, 1991 7. Allis TJ, Grant NN, Davidson BJ: Hypopharyngeal diverticulum formation following anterior discectomy and fusion: Case series. Ear Nose Throat J 89:E4, 2010 8. Ba AM, LoTempio MM, Wang MB: Pharyngeal diverticulum as a sequela of anterior cervical fusion. Am J Otolaryngol 27(4):295-297, 2006
Not All Pharyngeal Pouches are Created Equal: Management of “Non-Zenker” Hypopharyngeal Diverticula Christopher M. Johnson, MD Gregory N. Postma, MD From the Department of Otolaryngology, Center for Voice, Airway, and Swallowing Disorders, Georgia Regents University, Augusta, Georgia KEYWORDS Dysphagia; Hypopharyngeal diverticulum or pouch; Cricopharyngeal myotomy; Swallowing; Zenker’s diverticulum
Zenker diverticulum is the most common hypopharyngeal diverticulum. Alternate types of hypopharyngeal diverticula are uncommon; however, recognition and proper diagnosis is imperative, as treatment may be quite different. Hypopharyngeal diverticula are typically diagnosed using barium esophagography and differences between types of diverticula can be subtle. Although endoscopic management of Zenker Diverticula has become very popular recently, endoscopic exposure of other hypopharyngeal diverticula is not as straightforward. In this article, traction, iatrogenic, KillianJamieson, and Laimer diverticula would be discussed. Treatment options for each would also be explored and compared with treatment of the more common Zenker diverticulum. r 2016 Elsevier Inc. All rights reserved.
Introduction Hypopharyngeal diverticula (also referred to as pharyngeal or pharyngo-esophageal diverticula) have been recognized in the medical literature for over 2 centuries; however, the first successful surgical procedure to excise a Zenker Diverticulum (ZD) was not reported until 1886 by Wheeler. ZD is by far the most common esophageal or pharyngeal diverticulum estimated to be present in 0.01%0.11% of the population.1 No reliable epidemiological data
C.J. is a military service member. This work was prepared as part of his official duties. Title 17, USC, § 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17, USC, § 101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person’s official duties. Address reprint requests and correspondence: Gregory N. Postma, MD, Department of Otolaryngology, Center for Voice, Airway, and Swallowing Disorders, Georgia Regents University, 1120 15th St, BP-4109, Augusta, GA 30912. E-mail address: [email protected] http://dx.doi.org/10.1016/j.otot.2016.04.005 1043-1810/r 2016 Elsevier Inc. All rights reserved.
are available for other pharyngeal and esophageal diverticula as their prevalence is significantly lower. Pharyngeal and esophageal diverticula can be classified in several ways. By location, the diverticulum can reside in the hypopharynx, at the mid-thoracic region or in the epiphrenic region. They can be further characterized by pathophysiology as either pulsion or traction diverticula (TD) and by composition as either a true or false diverticula. Pulsion diverticula herniate through a weakness in the outer muscular wall because of increased intraluminal pressure and are typically considered false diverticula indicating the presence of only mucosa and submucosa within the wall of the pouch. TD form because of external tethering of the pharynx or esophagus owing to some adjacent inflammatory condition and are typically considered true diverticula indicating the presence of mucosa, submucosa, and outer muscular layers. ZD are classified by location as hypopharyngeal diverticula, by pathophysiology as pulsion diverticula, and by composition as false diverticula. Pulsion diverticula are commonly thought to originate from the hypopharynx or the epiphrenic region and form because of
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cricopharyngeal dysfunction or lower esophageal sphincter dysfunction, respectively. TD are said to most commonly occur in the mid-thoracic region because of a classic association with hilar lymphadenopathy from neoplasia, tuberculosis, or fungal infections. The vast majority of hypopharyngeal diverticula are of the pulsion type and occur above the cricopharyngeus muscle (ZD). Likewise, most of the TD originates in the mid-thoracic region. However, as with most classification schemes, there are exceptions. These exceptions are the focus of this article. Specifically, Killian-Jamieson and Laimer diverticula are thought to be pulsion diverticula that originate below the cricopharyngeus. Furthermore, TD can occur in the upper esophagus and pharynx. Aside from infectious causes, iatrogenic diverticula thought to be directly related to anterior approaches to the cervical spine have been reported over the past 2 decades. Given the common location of these less prevalent diverticula, standard barium esophagography may not definitively differentiate them from the more common ZD. This has implications on management as only ZD are easily amenable to endoscopic surgical approaches.
Background and Anatomical Description In Figure 1, there are 3 anatomical points of weakness in the pharyngeal musculature through which pulsion diverticula may protrude. From the posterior view in Figure 1A, one can visualize Killian’s triangle between the cricopharyngeus and the inferior constrictor muscles, through which a ZD is said to originate. The etiology of ZD is considered to be some form of cricopharyngeus muscle malfunction. ZD protrude posteriorly into the retropharyngeal space; however, nearly all extend slightly to the left and large pouches bulge laterally into the visceral space (Figure 2A).
In Figure 1B, a lateral view of the pharyngeal musculature and primarily illustrates the Killian-Jamieson area that resides below the cricopharyngeus muscle and represents the area of weakness where the recurrent laryngeal nerve enters the larynx. Killian-Jamieson Diverticula (KJD) originate in this region. KJD were first extensively described in 1983 where 13 cases were presented.2 They are considered pulsion diverticula and are almost exclusively found on the left unless bilateral. Owing to its lateral location, the recurrent laryngeal nerve is typically intimately related to the medial wall of the pouch (Figure 2B). Although there are reports of endoscopic management, an open cervical approach is typically favored to minimize the likelihood of damage to the recurrent laryngeal nerve.3 Also in Figure 1A, one can see a triangular area below the cricopharyngeus and between the divergent longitudinal muscle fibers of the proximal esophagus where only the circular fibers of the esophagus are present. This triangular area of weakness is referred to as Laimer’s triangle or the Laimer-Haeckerman area that is thought to be the site of origin of the very rare Laimer diverticulum (LD). Less than 5 LD have been reported in the literature. Of the reported cases, most describe them as true diverticula (Figure 2C); however, they are thought to be pulsion in origin presumably because of esophageal dysmotility.4,5 Although ZD, KJD, and LD are pulsion diverticula with specific sites of origin, infectious or iatrogenic TD can essentially occur in any location dependent upon the site of the nidus of inflammation. Classically, TD are because of scarring or tethering of the esophageal and hypopharyngeal musculature to surrounding tissue after resolution of an esophageal perforation or to an inflamed lymph node after an infection (Figure 2D). In 1991, the first report was published of a hypopharyngeal TD associated with an anterior approach to the cervical spine.6 Overall, less than 20 cases have been reported in the literature; however, some
Figure 1 Posterior (A) and lateral (B) view of the pharyngeal musculature. Note the locations of Killlian's triangle, Laimer's area, and the Killian-Jamieson area. These sites of pharyngeal muscular weakness are the sites of protrusion of Zenker, Laimer, and Killian-Jamieson pulsion diverticula, respectively.
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Figure 2 There are 4 types of hypopharyngeal diverticula: Zenker (A), Killian-Jamieson (B), Laimer (C), and Traction (D). Note the relationship of the Killian-Jamieson diverticulum to the recurrent laryngeal nerve (B). Also, note the presence of reactive lymphadenopathy tethering the esophagus to form a traction diverticulum (D). Tethering to form a traction diverticulum can occur from lymphadenopathy, scarring secondary to a previous esophageal perforation or the presence of an anterior spinal fusion plate.
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authors suggest that the incidence of these iatrogenic TD may rise given the popularity of the anterior cervical approach by spine surgeons.7 These iatrogenic TD associated with cervical spinal hardware between the levels of C4 and C7 can mimic the radiological appearance of any other posteriorly based noniatrogenic diverticula, specifically ZD.
Diagnostic Workup Regardless of location or etiology of the diverticulum, the clinical presentation is essentially identical. Dysphagia and regurgitation are the primary presenting symptoms. A traction diverticulum is associated with prior cervical spine surgery, cervical infection, or esophageal perforation; therefore, history suggesting any of these should be fully elucidated.
The most useful diagnostic modality to identify hypopharyngeal diverticula is a barium study (barium esophagram or modified barium swallow study). A diverticulum of any sort should be readily identifiable on a barium study; however, identification of the cricopharyngeus muscle is essential to determine the exact type and location. A barium study would also show the relationship of a diverticulum to cervical spinal hardware if an iatrogenic traction diverticulum is suspected. Delineation of the rare variant hypopharyngeal diverticula discussed here is sometimes difficult without direct or endoscopic visualization when the cricopharyngeus muscle is not readily apparent. To illustrate this, Figure 3A shows a classic lateral view of a ZD. In Figure 3B, a lateral view of a diverticulum that was described as a ZD; however, it was found to originate below the cricopharyngeus at subsequent endoscopy. Based on location alone, a LD was suspected. During open diverticulectomy, mediastinal lymphadenopathy was noted
Figure 3 Fluoroscopic images of a classic Zenker diverticulum (A), a traction diverticulum because of reactive lymphadenopathy with the appearance of a Zenker diverticulum (B), a traction diverticulum with the appearance of a Killian-Jamieson diverticulum (C), and an iatrogenic traction diverticulum because of an anterior spinal fusion with the appearance of a Zenker diverticulum (D). In B and C, the asterisk indicates the location of the pouch. Note that A, B, and D are lateral fluoroscopic views, whereas C is anterior-posterior.
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tethering the apex of the pouch indicating that it was actually a TD related to a prior infection. In Figure 3C, an anterior-posterior view of what was described as a KJD based on a barium study, but it was found to originate 3 cm distal to the cricopharyngeus on esophageal endoscopy. Further, discussion with the patient revealed history of a small esophageal perforation from ingestion of a bay leaf that was treated nonoperatively in her past, indicating that this is also a TD. In Figure 3D, what appears at first glance to be a ZD; however, there is extensive spinal hardware visible on the radiograph. This patient had an anterior approach to the cervical spine previously; however, plate exposure necessitated removal of the anterior hardware in favor of posterior hardware. An iatrogenic TD formed in the approximate location of a ZD likely caused by postsurgical scarring and tethering. Pulsion diverticula are associated with increased intraluminal pressure because of underlying esophageal dysmotility; therefore, esophageal manometry can be useful before any surgical intervention is undertaken but is not essential. Manometric findings can potentially help differentiate pulsion and TD before surgery.
Treatment There are 2 surgical options for hypopharyngeal diverticula —open and endoscopic approaches. Debate as to which treatment modality is optimal has been ongoing specifically regarding ZD. Although the first open diverticulectomy was reported in the late 1800s by Wheeler, the first endoscopic treatment was reported by Mosher in 1914. However, Mosher abandoned the technique because of unacceptable mortality because of mediastinitis. Endoscopic treatment was reevaluated in the 1960s then gained widespread use subsequently in the 1990s with the introduction of the endoscopic stapler. Today, the endoscopic approach has become very popular for treatment of ZD; however, endoscopic management of other hypopharyngeal diverticula is not well established. As stated previously, open cervical management of KJD is advocated because of its intimate association with the recurrent laryngeal nerve. Furthermore, in a case series of TD associated with anterior cervical spine surgery, Ba et al8 assert that thick scarring of the diverticular wall could prohibit endoscopic stapling. Furthermore, endoscopic exposure of diverticula below the cricopharyngeus muscle is challenging at best. However, an attempt at endoscopic exposure is often attempted first because of decreased operative time and faster return to oral diet with endoscopic management. It should also be noted that iatrogenic hypopharyngeal TD may necessitate removal or replacement of cervical spinal hardware; therefore, planning the procedure in conjunction with a spine surgeon is essential. Because of this, an open diverticulectomy may be a better option in this instance. Even if an open diverticulectomy is planned from the beginning, endoscopic exposure is typically attempted to pack the diverticulum with gauze or to place an esophageal
5
Figure 4 Intraoperative identification of a traction diverticular sac using insufflation of air and transillumination from a transnasal esophagoscope in the esophagus. (Color version of figure is available online.)
dilator to aid in identification of the pouch through an open approach. It is the practice of the authors to obtain informed consent for both endoscopic and open approaches before embarking on surgical treatment of hypopharyngeal diverticula under general anesthesia. It is also our practice to provide 24 hours of intravenous clindamycin with the first dose given just before surgery. In the endoscopic approach, a Weerda distending diverticuloscope (Storz, Goleta, CA) is used to attempt to expose the pouch transorally in a similar fashion to the endoscopic approach to ZD. The endoscopic approach to ZD is discussed elsewhere in this publication; therefore, only a brief discussion would be provided here. An attempt is made to place 1 tine of the scope in the esophagus and 1 in the pouch. This is successful in roughly 90% of ZD in our practice; however, success in exposure of diverticula below
Figure 5 After identification of the diverticular sac, a linear stapler is used to transect the neck of the pouch. (Color version of figure is available online.)
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the cricopharyngeus is rare. If the diverticulum is successfully exposed with the Weerda diverticuloscope, the decision is then made based on location and preoperative radiographs if endoscopic techniques such as stapling and carbon dioxide laser would be used. If adequate endoscopic exposure is not accomplished or if an open approach was planned at the outset, the exposure gained with the diverticuloscope is used to endoscopically pack the diverticulum with strip gauze and to place a dilator in the esophagus to aid in identification of the diverticulum from an open transcervical approach. As is often the case with diverticula below the cricopharyngeus muscle, direct line-ofsight exposure might not be possible. Even if the pouch is not exposed, exposure of the upper esophageal sphincter allows for introduction of a transnasal esophagoscope. Using flexible endoscopy with insufflation of air, the diverticulum can then be evaluated and a guidewire can be placed in the esophagus. At this point after the guidewire is placed, the transnasal esophagoscope and the rigid diverticuloscope can be removed in preparation for the open approach. The guidewire can then be used to safely introduce an esophageal dilator into the esophagus (without traumatizing the diverticulum) to aid in identification of the pouch and esophagus intraoperatively during the open approach. In the open approach, a 5 cm horizontal skin incision is made at the level of the inferior border of the thyroid cartilage slightly lateral to the midline. The anteriorposterior view of the barium study should be reviewed just before the skin incision to ensure the correct side. In most cases, the diverticulum extends either posteriorly or to the left within the visceral space. Because of this, the surgical approach is typically from the left side. Subplatysmal flaps are elevated superiorly and inferiorly. The anterior border of the sternocleidomastoid muscle is delineated and the omohyoid muscle is identified. The omohyoid is traced medially to define the lateral edge of the infrahyoid strap muscles and the laryngotracheal complex. Dissection then proceeds between the laryngotracheal complex and the carotid sheath toward the retropharynx. The omohyoid muscle can be incised to improve surgical access. The laryngotracheal complex is retracted by placing a blunt double-prong skin retractor on the posterior edge of the thyroid cartilage to further expose the area of the diverticulum. Palpation of the in-dwelling esophageal dilator aids in identification of the esophagus. If the diverticulum was packed with strip gauze endoscopically, the pouch can be palpated at this point. If inadequate endoscopic exposure prevented packing of the pouch, the dilator can be removed and a transnasal esophagoscope can be reintroduced into the esophagus. In this instance, it is the practice of the authors to use insufflation of air and transillumination of the diverticular sac with the transnasal esophagoscope to aid in identification (Figure 4). Once the sac is identified, it is dissected free of its surrounding tissue delicately using a combination of blunt and sharp dissection until the neck of the diverticulum is clearly defined. In the case of a KJD, the recurrent laryngeal nerve is identified and carefully freed from the diverticular sac. Furthermore, at this
time the wound bed is inspected for lymphadenopathy, signs of infection and scarring if a TD is suspected. A wide superior and inferior esophageal myotomy is performed at this time as well. If the pouch is near the cricopharyngeus muscle, a cricopharyngeal myotomy is performed. A Kelly clamp is then used to cross-clamp the diverticulum whereas endoscopically ensuring patency of the esophageal lumen to prevent postdiverticulectomy esophageal narrowing or stricture. The Kelly clamp is then replaced with a linear stapler and the pouch is excised (Figure 5). After the pouch is excised, the wound bed is filled with saline and the transnasal esophagoscope is used to insufflate air into the esophagus to perform a leak test. If no leak is identified, the incision is closed in layers over a surgical drain and the procedure is terminated. It is the opinion of the authors that the use of a transnasal esophagoscope is very helpful in all open esophageal and hypopharyngeal diverticular surgery.
Conclusion Although exceedingly rare, management of “non-Zenker’s” hypopharyngeal diverticula can be quite different than management of the more common ZD in that open cervical diverticulectomy is often necessary. The diagnosis of a hypopharyngeal diverticulum is typically made using barium esophagography; however, identification of these less common pouches can be difficult using radiological studies alone. Because of this, surgeons should recognize that diverticula other than ZD can occur in the hypopharynx and plan accordingly.
Disclosures The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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