Four cases with a neopharyngeal diverticulum following total laryngectomy are presented. Each patient required surgery for complications directly related to the pouch. The relevance of these diverticulae is discussed with reference to their aetiology, complications and management

Farrington, WT

Hartley, C

Saeed, SR

UCL Discovery

The Journal of Laryngology & Otologyhttp://journals.cambridge.org/JLOAdditional services for The Journal of Laryngology & Otology:Email alerts: Click hereSubscriptions: Click hereCommercial reprints: Click hereTerms of use : Click herePost­laryngectomy neopharyngeal diverticulaeC. Hartley, S. R. Saeed and W. T. FarringtonThe Journal of Laryngology & Otology / Volume 108 / Issue 06 / June 1994, pp 479 ­ 483DOI: 10.1017/S002221510012715X, Published online: 29 June 2007Link to this article: http://journals.cambridge.org/abstract_S002221510012715XHow to cite this article:C. Hartley, S. R. Saeed and W. T. Farrington (1994). Post­laryngectomy neopharyngeal diverticulae. The Journal of Laryngology & Otology, 108, pp 479­483 doi:10.1017/S002221510012715XRequest Permissions : Click hereDownloaded from http://journals.cambridge.org/JLO, IP address: 144.82.107.87 on 15 Oct 2012The Journal of Laryngology and OtologyJune 1994, Vol. 108, pp. 479^183Post-laryngectomy neopharyngeal diverticulaeC. HARTLEY, F.R.C.S., S. R. SAEED, F.R.C.S., W. T. FARRINGTON, F.R.C.S.AbstractFour cases with a neopharyngeal diverticulum following total laryngectomy are presented. Each patientrequired surgery for complications directly related to the pouch. The relevance of these diverticulae isdiscussed with reference to their aetiology, complications and management.Key words: Laryngectomy, complications; Diverticulum; Laser surgery; Pharyngeal diseasesIntroductionDiverticulae of the neopharynx are common followingtotal laryngectomy, occurring in 35 to 100 per cent ofcases (Davis et al., 1982; Nayar et al., 1984). Despite thisfrequency, they seldom give rise to symptoms (Al-Saati etal., 1993). We present case histories of four patients, all ofwhom required surgical treatment for complicationsdirectly related to such diverticulae. The aetiology,management and potential complications of neopharyn-geal diverticulae are discussed.Case reportsCase 1A 54-year-old man underwent a course of radical radio-therapy for a T2 glottic carcinoma. Eighteen months later alaryngectomy was performed for symptoms attributableto severe radionecrosis. The pharyngeal defect was closedin three layers without a formal cricopharyngeal myo-tomy. Post-operative recovery was unremarkable.Over the next six months the patient developed increas-ing problems with late regurgitation of undigested food.Pharyngoscopy was performed which revealed no resist-ance to the passage of a size 38 FG bougie. A pouch at thelevel of the vallecula was noted and felt to be responsiblefor the symptoms. A barium swallow confirmed the pres-ence of a marked anterior diverticulum (Figure 1). Thepatient therefore underwent laser division of the bar of tis-sue between the pouch and the pharynx. Unfortunately,the extent of tissue removal was inadequate and a smallsymptomatic pouch remained. Further operative divisionof the party wall was therefore undertaken with goodeffect.Case 2A 55-year-old man underwent a course of radical radio-therapy for a T, carcinoma of the larynx. On three occa-Fio. 1Barium swallow (anterior oblique view) demonstrating neopharyn-geal diverticulum (large arrow) and neopharynx (small arrow).From the University Department of Otolaryngology, Manchester Royal Infirmary, Manchester.Accepted for publication: 23 February 1994.479480 C. HARTLEY. S. R. SAEED. W. T. FARRINGTONFIG. 2(a) Barium swallow (lateral oblique view) demonstrating anteriorpouch (large arrow) and high pharyngeal stricture (small arrow); (b)barium swallow (lateral view) demonstrating bar of tissue (arrows)between the pouch and the pharyngeal lumen; (c) post-operativebarium swallow (lateral view) demonstrating absence of the pouch.POST-LARYNGECTOMY NEOPHARYNGEAL DIVERTICULAE 481'f VFIG. 3Lateral soft tissue cervical X-ray demonstrating radiopaque foreign body (large arrows) and widespread calcification (small arrows) around thestoma (S).sions following this, a barium swallow was performed forthe symptom of persistent dysphagia. These confirmed thepresence of a sliding hiatus hernia and benign lower oeso-phageal stricture, which was dilated by flexible upper GIendoscopy three years after the initial radiotherapy. Thefollowing year, total laryngectomy was undertaken forsevere radionecrosis. A cricopharyngeal myotomy andtwo-layer vertical pharyngeal closure were performed, aswas primary insertion of a Provox® valve. Two weekspost-operatively, the patient developed a left parastomalpharyngocutaneous fistula. This closed spontaneouslywithin three weeks. Ten months following laryngectomy,the patient experienced increasing dysphagia and under-went pharyngoscopy and bougie dilatation of a pharyn-geal stricture to 38 FG. However, the dysphagia persistedand a barium swallow was repeated. This revealed amarked anterior pharyngeal diverticulum at the base of thetongue (Figure 2a,b). Re-operation with laser division ofthe party wall between the diverticulum and the pharynxresulted in relief of the patient's difficulty on swallowing.Some six months later however, a barium swallow wasagain performed for recurrent dysphagia. This demon-strated that the difficulty in swallowing was due to a distaloesophageal stricture and that the pouch had resolved withlaser treatment (Figure 2c).Case 3A 52-year-old man underwent a total laryngectomy fol-lowing failure of radiotherapy for a T, carcinoma of thelarynx. A three-layer vertical closure was performed. Twoweeks post-operatively, the patient developed a right-sided pharyngocutaneous fistula which required delayedprimary closure 12 weeks later.Fourteen years later, the patient presented acutely witha sharp foreign body within the pharynx (Figure 3). Rigidendoscopy confirmed a right lateral neopharyngeal diver-ticulum within which was lodged a spicule of bone. Thebone was removed and, given the absence of a history ofdysphagia or regurgitation, further treatment was notundertaken.Case 4A 61-year-old woman underwent a total laryngectomywith hyoid preservation seven years after radical radio-therapy for a T2 carcinoma of the larynx. A crico-pharyngeal myotomy was not undertaken and the pharynxwas closed in three layers. Three years later, a bariumswallow was performed for increasing dysphagia. Thisdemonstrated a right-sided pharyngeal diverticulum(Figure 4a), below which was a smooth-walled stricture.As there was the suspicion of a filling defect within thepouch (Figure 4b), pharyngoscopy was performed, butthis revealed no abnormality. The saggital bar of tissueextending from the base of the tongue to the right posteriorpharyngeal wall was divided using the CO, laser to pro-vide distal continuity between the diverticulum and neo-482 C. HARTLEY, S. R. SAEED. W. T. FARR1NGTONFIG. 4(a) Barium swallow (anterior view) demonstrating pharyngeal lumen (P) and lateral pharyngeal pouch (arrows); (b) barium swallow (lateralview) demonstrating mucosal irregularity within the neopharyngeal pouch.pharynx. Bougie dilatation of the stricture was performedand the patient allowed to eat and drink the following day.The patient was allowed home 48 hours post-operativelyand has been symptom-free since.FIG. 5Line drawing of operative technique lateral view: blade of Boyle-Davis gag (G) inserted into the pouch (P); tongue base (T), pseudo-epiglottis (shaded) and swab (S) within the pharynx, protecting theposterior pharyngeal wall from laser injury.Operative techniqueIn the three cases in which the diverticulum requiredsurgical treatment, the CO2 laser was utilized. Undergeneral anaesthesia, the pharynx was first inspected with apharyngoscope and the pouch then displayed using aBoyle-Davis gag. (It is important to select a blade of suf-ficient length to insert deep into the pouch, to allow visual-ization of the entire extent of the party wall between thepouch and the lumen of the pharynx). Using the CO, laserset on 10 W continuously, this bar of tissue was excisedflush with the deep extent of the pouch. To protect the pos-terior pharyngeal wall from laser injury, a moist swab wasplaced in the pharynx posterior to the bar of tissue to beexcised (Figure 5). The excised tissue was submitted forhistological examination.A slight modification to this technique was required forthe treatment of lateral diverticuluae. The blade of the gagwas inserted into the lumen of the neopharynx, alongsidethe party wall which was then divided as described aboveusing the laser. The patient was allowed to eat and drinkthe following day.DiscussionThe existence of neopharyngeal diverticuluae follow-ing laryngectomy is well documented (Kritchener et al.,1963; Davis et al., 1982; Nayar et al., 1984). Such diver-ticuluae may be demonstrated by direct or contrast exam-ination, with the posterior wall of the diverticulum beingtermed a 'pseudo-epiglottis'. The aetiology of thesepouches is however far from clear. Incoordination of theconstrictor muscles post-operatively has been advanced asone explanation (Kritchener et al., 1963), as has the typeof closure. In a study evaluating the hypopharynx of 28post-laryngectomy patients by barium swallow, thepseudo-epiglottis was present in all cases in which verticalclosure had been performed, compared to 67 per cent ofthose in whom a T-shaped closure had been undertaken.POST-LARYNGECTOMY NEOPHARYNGEAL DIVERTICULAE 483Complications including dysphagia, stricture formationand pharyngocutaneous fistulae were more common in thevertical closure group (Davis et al., 1982). Kritchener etal. (1963) also described an association of pharyngoc-utaneous fistulae with post-laryngectomy diverticulae.However, in a further study of 20 patients after laryngec-tomy, there was no association between the presence ofthe pseudo-epiglottis and post-operative complications(Nayar <?r a/., 1984).These studies demonstrate that post-laryngectomydiverticulae occur in 35 to 100 per cent of patients. It ishighly likely therefore that the frequency of their exist-ence is related to altered pharyngeal physiology post-operatively. Using manofluorography, it has been shownthat the swallowing mechanism of all laryngectomees isaltered post-operatively. The absence of a negative pres-sure within the pharyngo-oesophageal (PE) segmentresults in patients having to generate higher propulsivepressures than normal using the tongue as a piston. Thisraised pressure within the neopharynx may explain thehigh incidence of diverticulae and pharyngocutaneous fis-tulae post-laryngectomy. The presence of a stricture orother obstructive element would further increase the riskof these complications (McConnel et al., 1986; McConnelet al., 1988). A recent case report describes the finding of apouch in the sixth week post-laryngectomy. Although thereport does not attribute the pouch development to infec-tion, the stigmata of sepsis were clearly present. It mayhave been that timely intervention with intravenous anti-biotics prevented the development of a fistula from theapex of the pouch (Al-Saati et al, 1993).In our series, all patients had received radiotherapywhilst two patients developed early pharyngocutaneousfistulae. In both, the pouch was in such a position as to beat the proximal end of the fistula track. In the patient with alaterally based fistula, a lateral pouch developed. Thepatient with a parastomal leak developed an anteriorpouch. In this patient significant distal stricturing waspresent. A stricture was also present in one other patient.In three of our cases, closure was vertical, whilst no recordof the method of closure was found in the remaining case.Cricopharyngeal myotomy was performed in one patient.In the light of the available evidence, we suggest thatpost-laryngectomy diverticulae are pulsion diverticulae.Factors which increase the distal PE resistance such asoedema, absence of a cricopharyngeal myotomy or strict-ure, may contribute to the high incidence of such pouches.The relationship between such diverticulae, sepsis andpharyngocutaneous fistulae may also be causal.Complications of a neopharyngeal pouch as with otherdiverticulae include dysphagia, late regurgitation ofundigested food and foreign body sensation. Foreign bodyimpaction may also occur as illustrated by Case 3. Car-cinoma within a neopharyngeal diverticulum, unlike car-cinoma within a Zenkers diverticulum has not, to ourknowledge, been described yet although it is a theoreticalrisk (Burton and Lund, 1990; Saunders et al., 1993).The treatment of post-laryngectomy pouches has onlyrecently been described. As in our series, the diverticulumwas visualized using a Boyle-Davis gag. The bar of tissuewas however divided using Dohlman's apparatus (AlSaati et al., 1993). Alternatively, a staple gun or laserexcision can be used as for pharyngo-oesophageal diver-ticulae (Benjamin and Innocenti, 1991; Martin-Hirschand Newbegin, 1993). Our experience suggests that mostpatients can safely be allowed to eat and drink the fol-lowing day.As all four of our cases were seen within a three-monthperiod, it is probable that many more symptomatic casesexist than is generally recognized. Dysphagia however,may be attributed to an associated pharyngeal strictureand dilatation performed with partial symptomatic relief.In addition, as these diverticulae occur soon after laryn-gectomy (Davis et al., 1982), the patient may accept anyalteration of swallowing as a normal post-operativephenomenon. These factors combined with the high inci-dence of post-laryngectomy dysphagia strongly suggestthat patients with this symptom following laryngectomyshould be investigated further. Endoscopic or radiologicalexamination may be performed, but there is a poor corre-lation between these two methods in the assessment ofthese diverticulae (Nayar et al., 1984): this may bebecause instrumentation distorts the anatomy. Bariumswallow is therefore recommended as the investigation ofchoice.ConclusionsA large percentage of patients, perhaps the majority,develop a pouch within the neopharynx following totallaryngectomy. In spite of this, reports of symptoms attrib-utable to such diverticulae are rare. Four patients withcomplications directly related to their neopharyngealpouches are presented. The importance of contrast exam-ination in the investigation of upper gastrointestinalsymptoms following laryngectomy is emphasized.ReferencesAl-Saati, A., Mitchell, D. B., Toynton, S., O'Connor, A. F. (1993)Post-laryngectomy diverticulum — a case report. Journal ofLaryngology and Otology 107: 46-48.Benjamin, B., Innocenti, M. (1991) Laser treatment of pharyngealpouch. Australian and New Zealand Journal of Surgery 61:909-913.Burton, M. J., Lund, W. S. (1990) Pharyngeal pouch carcinoma: twounusual cases. Journal of Laryngology and Otology 104:821-823.Davis, R. K., Vincentt, M. E., Shapshay, S. M , Strong, M. S. (1982)The anatomy and complications of 'T* versus vertical closure ofthe hypopharynx after laryngectomy. Laryngoscope 92: 16-22.Kritchener, J. A., Scatliff, J. H., Dey, F. L., Shedd, D. P. (1963) Thepharynx after laryngectomy - changes in its structure and func-tion. Laryngoscope 73: 18-33.Martin-Hirsch, D. P., Newbegin, C. J. R. (1993) Autosuture GIAgun: a new application in the treatment of hypopharyngeal diver-ticulae. Journal of Laryngology and Otology 107: 723-725.McConnel, F. M., Mendelsohn, M. S., Logemann, J. A. (1986)Examination of swallowing after total laryngectomy using mano-fluorography. Head and Neck Surgery 9: 3—12.McConnel, F. M., Cerenko, D., Mendelsohn, M. S. (1988) Dys-phagia after total laryngectomy. Otolaryngologic Clinics of NorthAmerica 21: 721-726.Nayar, R. C , Sharma, V. P., Arora, M. M. (1984) A study of thepharynx after laryngectomy. Journal of Laryngology and Otology98:807-810.Saunders, M. W., Murty, G . E., Bradley, P. J. (1993) Pharyngealpouch carcinoma. Ear, Nose and Throat Journal 72: 149-150.Address for correspondence:Mr C. Hartley,39 Beech Road,Cale Green,Stockport,Cheshire SK3 8HD.

Post-laryngectomy neopharyngeal diverticulae

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Post-laryngectomy neopharyngeal diverticulae

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