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Halitosis, or bad breath, is a common condition that can be caused by a variety of factors, including sulphur-producing bacteria in the mouth and throat, dry mouth, certain foods, and poor oral hygiene. One less common cause of halitosis is Zenker's diverticulum, a pouch that develops at the top of the oesophagus, also known as a pharyngeal pouch. This pouch can cause difficulty swallowing, regurgitation, and bad breath due to the retention of food particles and salivary secretions. The treatment for Zenker's diverticulum involves surgery to remove or open the pouch, and in some cases, an endoscopic approach is used.
| Characteristics | Values |
|---|---|
| Common Name | Pharyngeal Pouch |
| Synonyms | Zenker's Diverticulum, Killian's Dehiscence |
| Location | Dorsal wall between the pharynx and oesophagus |
| Muscle Involvement | Cricopharyngeus, Thyropharyngeus |
| Prevalence | 0.01% to 0.11% of the population |
| Age | Confined to those aged over 70 years |
| Gender | More common in males (5:1 ratio) |
| Symptoms | Dysphagia, regurgitation, aspiration, chronic cough, weight loss, halitosis |
| Treatment | Cricopharyngeal myotomy, Zenker’s per-oral endoscopic myotomy (Z-POEM), surgery |
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What You'll Learn
Zenker's diverticulum, a pouch at the top of the oesophagus, causes halitosis
Zenker's diverticulum, also known as a pharyngeal pouch, is a condition that causes a pouch to form at the top of the oesophagus. This occurs when the cricopharyngeus muscle at the top of the oesophagus does not relax, preventing food from moving into the oesophagus. As a result, constant pressure from this muscle creates back pressure on the wall of the throat, eventually pushing tissue through the throat wall to form a pouch.
The presence of this pouch can lead to various symptoms, including difficulty swallowing, regurgitation of food, and bad breath or halitosis. The pouch can trap food particles and salivary secretions, causing them to decay and result in halitosis. The severity of symptoms often depends on the size and location of the pouch. Larger pouches are more likely to affect an individual's ability to swallow and may require medical intervention.
Zenker's diverticulum is typically treated through surgery, which involves removing or opening the diverticulum. One common surgical approach is cricopharyngeal myotomy, where an incision is made at the level of the cricoid cartilage, and the pouch is identified and excised. More recently, Zenker's per-oral endoscopic myotomy (Z-POEM) has gained popularity as a safe and effective treatment option, utilising a submucosal tunnelling technique.
The condition predominantly affects middle-aged and elderly individuals, with a higher prevalence in males and those over 70 years of age. It is uncommon, with rates ranging from 0.01% to 0.11% of the population, and is more commonly found in Northern Europe.
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The cricopharyngeus muscle's role in the pathogenesis of the pouch
The cricopharyngeus muscle is located at the junction of the pharynx and oesophagus. It is generally thought to be responsible for the high-pressure zone of the pharyngoesophageal (upper oesophageal) sphincter. The cricopharyngeus muscle's failure to relax or expand is termed cricopharyngeus muscle dysfunction (CPD) and can cause dysphagia.
Zenker's diverticulum, also known as a pharyngeal pouch, is a condition where a pouch forms at the top of the oesophagus, causing difficulty swallowing. The cricopharyngeus muscle is recognised as playing a role in the pathogenesis of the pouch. The constant pressure from the cricopharyngeus muscle creates back pressure on the wall of the throat, which over time may push tissue through the throat wall to form a pouch.
The pouch can cause food regurgitation, aspiration, and halitosis. Symptoms of Zenker's diverticulum may vary depending on the size and location of the pouch. Treatment options depend on patient age, the presence of comorbidities, the size of the diverticulum, surgeon experience, and patient preference. For example, patients with mild or intermittent symptoms may be taught swallowing strategies such as the Mendelsohn manoeuvre or effortful swallowing. More severe cases may require surgery to remove or open the diverticulum.
The emphasis on treatment has shifted from diverticulectomy to cricopharyngeal myotomy to prevent recurrence. Cricopharyngeal myotomy involves passing a rigid endoscope, making an incision at the level of the cricoid cartilage, identifying the pouch, and excising it. Patients are fed via a nasogastric tube for a week postoperatively. Potential complications include recurrent laryngeal nerve palsy, cervical emphysema, mediastinitis, and cutaneous fistula.
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Surgical treatment options for the pouch
A pharyngeal pouch, also known as Zenker's diverticulum, is a rare condition that occurs when a pouch forms at the top of the oesophagus, causing difficulty swallowing. The condition is associated with several symptoms, including food regurgitation and bad breath or halitosis. The pouch develops due to a loss of muscle compliance in the area of the cricopharyngeus muscle, resulting in elevated pressure that pushes the tissue through the throat wall to form a pouch.
Surgical treatment options for the pharyngeal pouch include:
Open Zenker's Diverticulotomy with Cricopharyngeal Myotomy
This approach involves removing the pouch from the oesophagus and oversewing the stump. The cricopharyngeal muscle is also cut to minimise the chances of the pouch recurring. This method can be used for any size pouch and eliminates the small chance of cancer developing in the residual pouch wall. However, it has a longer operating time, a higher complication rate, and requires a longer hospital stay.
Endoscopic Approach
This method involves dividing the wall between the pouch and the oesophagus, creating a common pouch and dividing the scarred and thickened cricopharyngeal muscle. It is typically performed using a combination cutting and sealing device such as a stapler. While this approach is minimally invasive, it has higher recurrence rates.
Zenker’s Per-oral Endoscopic Myotomy (Z-POEM)
Z-POEM is a safe and effective treatment option for Zenker's diverticulum. It uses a submucosal tunnelling approach to visualise and completely cut the septum in the submucosal tunnel under the safety of the intact mucosa. This theoretically leads to lower rates of symptom recurrence compared to traditional flexible endoscopic septotomy (FES).
Pharyngeal Pouch Stapling
Also known as endoscopic staple diverticulostomy, this is a minimally invasive procedure performed under general anaesthetic. A unique double-lipped scope is placed in the patient's mouth, with one lip in the oesophagus and the other in the pharyngeal pouch. An auto-suture disposable surgical staple is passed through the endoscope to cut and seal the wall between the pouch and the oesophagus. Pharyngeal pouch stapling has a lower risk of associated complications compared to alternative minimally invasive approaches, such as laser treatment.
The choice of surgical treatment depends on various factors, including the patient's age, general health, suitability for anaesthesia, symptom severity, and the size of the pouch.
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The pouch's location in the pharynx
A pharyngeal pouch, also called Zenker's diverticulum, is a small bulge or pocket, similar to a hernia, that occurs in the pharynx. The pharynx is the part of the throat that connects the mouth, nose, and oesophagus, and it runs from behind the nose and mouth to the bottom of the neck. Zenker's diverticulum is a pouch that forms at the top of the oesophagus, making it difficult to swallow.
The pouch can lie in the midline, behind the pharynx, or to one side. It is typically located above the Cricopharyngeal muscle, which is a sphincter-like muscle at the upper end of the oesophagus. However, in some cases, it may also lie below this muscle. The exact location of the pouch can vary, and it may extend into the left neck, likely due to the slight convexity of the cervical oesophagus.
The size and location of the pouch can influence the symptoms experienced. For example, the pouch may not cause noticeable symptoms until it grows large enough to affect the ability to swallow food. Larger pouches may compress the cricopharyngeus muscle, leading to a sensation of something being stuck in the throat. Additionally, the pouch's proximity to the recurrent pharyngeal nerve can result in hoarseness if it is compressed.
The diagnosis and treatment of Zenker's diverticulum often involve various procedures and evaluations. A barium swallow with videofluoroscopy can provide information about the pouch's size, location, and character of the mucosal lining. Endoscopic evaluations, such as nasendoscopy or Flexible Endoscopic Evaluation of Swallowing (FEES), are also commonly used to visualise the pouch and surrounding structures. Treatment options include surgical procedures like Dohlman's procedure, cricothyromyotomy, and various approaches to dividing the pouch and/or the cricopharyngeal muscle.
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The pouch's rarity and prevalence in Northern Europe
The pharyngeal pouch, also known as Zenker's diverticulum, is uncommon, with rates ranging from 0.01% to 0.11% of the population. However, its incidence appears to be higher in Northern Europe than in other regions. The pouch is largely confined to individuals over 70 years old, with males outnumbering females by a ratio of 5:1.
Zenker's diverticulum is a pouch that develops at the top of the oesophagus, causing difficulty swallowing. It occurs when the cricopharyngeus muscle at the top of the oesophagus does not relax, preventing food from passing through. As a result, constant pressure from this muscle creates back pressure on the throat wall, pushing tissue through and forming a pouch or outpouching.
The symptoms of Zenker's diverticulum include food regurgitation, bad breath (halitosis), aspiration, chronic cough, and unexplained weight loss. These symptoms may be present for months or years, and their severity often depends on the size and location of the pouch. In some cases, a visible lump may appear in the neck.
The treatment for Zenker's diverticulum depends on the size of the pouch. Smaller lesions may not require any treatment, while larger ones typically necessitate surgery to remove or open the pouch. Traditional flexible endoscopic septotomy (FES) involves dividing the septum containing the cricopharyngeus muscle between the pouch and the oesophagus. More recently, Zenker's per-oral endoscopic myotomy (Z-POEM) has gained popularity as a safe and effective treatment option, offering a better ability to visualise and completely cut the septum.
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Frequently asked questions
A pharyngeal pouch is a pulsion diverticulum, or false diverticulum, located dorsally at the wall between the pharynx and oesophagus. This condition is also known as Zenker's diverticulum.
The exact cause of a pharyngeal pouch is unknown. However, it is believed to be caused by weakness of the muscular wall and malfunction of the upper oesophageal sphincter. The cricopharyngeus muscle, which is usually involved, does not relax to let food move into the oesophagus, leading to increased pressure and the formation of a pouch.
Symptoms of a pharyngeal pouch include difficulty swallowing, regurgitation of food, bad breath (halitosis), recurrent coughing, and unexplained weight loss. The severity of symptoms often depends on the size and location of the pouch.
The treatment for a pharyngeal pouch depends on the patient's age, health status, and preferences. Small pouches may not require any treatment. Larger pouches are typically treated with surgery, either through an open procedure or an endoscopic approach, to remove or open the pouch and relieve symptoms.
