Understanding pharyngeal pouch: Symptoms and treatments

In his latest online article, Professor Martin Anthony Birchall gives us his insights into pharyngeal pouch. He talks about the typical symptoms and clinical presentations associated with it and how it differs from other conditions, the main risk factors, what diagnostic techniques or tools are used to confirm the presence of the pouch, the available treatment options and potential complications.

What are the typical symptoms and clinical presentations associated with pharyngeal pouch and how does it differ from other conditions affecting the client?

An infrequent condition known as Zenker's diverticulum, commonly referred to as a pharyngeal pouch, occasionally occurs. This condition emerges due to alterations in our swallowing process, although the precise mechanisms behind it remain unclear. Nevertheless, it results in the formation of a small protrusion at the upper throat, capable of trapping food and liquids, thereby causing swallowing difficulties. Additionally, there may be instances of food regurgitation, particularly when reclining at night due to the pouch's compression, leading to coughing and spluttering.

Severe cases may even lead to chest infections and weight loss due to impaired swallowing. Notably, there can be a distinct gurgling sound, especially on the left side or after meals, as food remains trapped for extended periods in these pouches. Halitosis, or bad breath, can also occur because of the prolonged presence of food, sometimes lasting for days or even weeks. These symptoms are commonly observed in older individuals, though there is a rising trend in people in their 50s and 60s, as opposed to the previously more common occurrence in individuals in their 70s and 80s.

What are the main risk factors underlying and underlying causes that contribute to the development of pharyngeal pouches and how can they be effectively identified and addressed?

The underlying reasons for the development of pharyngeal pouches or Zenker’s remain a mystery to us. One theory suggests that the presence of stomach acid flowing into the oesophagus, the food pipe, may trigger an exaggerated protective response, causing increased constriction at the upper oesophageal region to prevent acid from reaching the mouth or throat. However, this theory is not a perfect explanation, as we lack a comprehensive understanding of why this phenomenon occurs. Additionally, the factors contributing to its occurrence more frequently in males and predominantly on the left side, rather than the right, remain elusive.

What we do understand is that, for some inexplicable reason, individuals experience spasms or an inability to relax at the upper oesophageal sphincter. Consequently, when food is swallowed, this sphincter remains closed, leading to the buildup of pressure in the back of the throat and the development of a hernia-like protrusion. Gradually, this protrusion enlarges over time, transforming from a small ledge to a small pool and eventually forming a full-fledged pouch. While the exact causes remain unclear, the fundamental physiological issue lies in the tightness of the muscle at the upper throat, and this is where our focus and treatment efforts are directed.

What diagnostic techniques or tools are commonly used to confirm the presence of a pharyngeal pouch and what additional investigations may be necessary to assess its size, location and potential complications?

When there's a suspicion that someone might have a pharyngeal pouch, our typical initial screening procedure involves a test known as a barium swallow. During this test, a radiopaque liquid, visible on x-rays, is ingested. The radiographer, an x-ray technician, then captures images at various points throughout the swallowing process to track the movement of the liquid. This method is highly effective in clearly delineating the presence of a pouch. While it's feasible to detect the pouch using alternative imaging techniques, the barium swallow has established itself as the gold standard for diagnosis over the years.

What are the available treatment options for managing a pharyngeal pouch and what factors should be considered when determining the most appropriate approach for each patient?

The management of pharyngeal pouches or Zenker’s diverticulum offers several options tailored to each patient's specific needs. For individuals with mild symptoms and no other complications, they may choose to live with the condition, as all surgeries come with potential risks. Those who are elderly, frail, or have multiple health issues that make surgery risky can opt for less invasive procedures. These may include endoscopic techniques to relax the tight throat muscle causing the problem, which can be repeated as needed. Alternatively, injections of botulinum toxin (Botox) can be considered to relax the muscle.

Surgical methods have evolved over the past decade. Traditional open surgery, involving a neck incision to remove the pouch, is now rarely used due to its associated risks and longer hospital stays. The preferred approach for most patients is endoscopic, where a tube is inserted into the throat to directly address the muscle tightness without removing the pouch. This method is highly effective, and the recovery is typically smoother. However, it carries a slight risk of tooth damage, bruising to the lips, mouth, and tongue, as well as a small chance of perforation.

For patients with anatomical challenges that make rigid endoscopy difficult, there are specialised gastroenterologists who use flexible telescopes to access the pouch with similar outcomes and fewer risks. As more experience accumulates in this field, flexible endoscopy is becoming a viable option for many patients. Ultimately, the choice of treatment should be personalised, with patients fully informed about the options to make the decision that suits their individual circumstances.

What are the potential complications associated with an untreated or recurrent pharyngeal pouch and how can an ENT specialist effectively monitor and support patients to minimize these risks?

Some individuals may choose not to undergo a procedure, especially if their symptoms are relatively mild. This decision is entirely reasonable. However, it's important to note that leaving an untreated pouch unaddressed can lead to progressively worsening swallowing difficulties, which can impact not only daily life but also social activities like dining out comfortably. In more severe cases, untreated pouches may lead to food and drink entering the lungs, resulting in a condition known as aspiration pneumonia. This, in turn, can be associated with weight loss, though it typically requires the condition to reach a considerable severity, which is rare in contemporary times. In managing patients with pharyngeal pouches or Zenker’s diverticulum, the optimal timing and type of treatment are determined collaboratively with the patient. It's essential to recognise that there is no one-size-fits-all approach to addressing this condition.

Professor Martin Anthony Birchall is a distinguished ENT specialist with over 35 years of experience. You can schedule an appointment with Professor Birchall on his Top Doctors profile.