Postlaryngectomy Dysphagia Caused by an Anterior Neopharyngeal Diverticulum

Abstract

Anterior neopharyngeal diverticulum, which may occur after total laryngectomy, is a mucosalized pouch at the base of the tongue separated from the remaining pharynx by a posterior tissue band. The diverticulum has been alternatively called a pseudo–vallecula and the posterior tissue band a pseudoepiglottis because of the appearance on barium swallow. Kirchner and Scatliff described the neopharyngeal diverticulum as a cause of postlaryngectomy dysphagia in 1962. The dysphagia is characterized by a regurgitant quality similar to that found in patients with Zenker's diverticulum. On indirect examination, the pouch can be seen and often has food or mucus in it. In the setting of postlaryngectomy dysphagia, tumor recurrence must lead the differential diagnosis, 2 but indirect examination and barium swallow may reveal the presence of a significant diverticulum. In 30 of 34 postlaryngectomy patients Kirchner et al. 3 noted such a pouch varying in size from 1 to 30 cm. A diverticulum developed in all patients in this study who had postoperative fistulas and in 9 of 13 who did not have leaks. The authors postulated dehiscence of the pharyngeal closure at the tongue base as the cause of the diverticulum. Davis et al. 4 described a ‘pseudoepiglottis’ in 21 of 28 postlaryngectomy patients. They proposed that the closure technique may affect the incidence of diverticula, noting that all patients with vertical closures had pseudoepiglottis (average length, 18.4 mm), whereas 67% of patients with a ‘T closure’ had such a finding (average length, 9.6 mm). They postulated that the superior suture line folding on itself created the pseudoepiglottis. Biller commented that the cause might be related to the approximation of the constrictor muscles. 4 No patients in Kirchner's group had surgical treatment of their anterior neopharyngeal diverticulum, whereas two patients in Davis' group underwent laser excision with improvement. Other authors describe patients with a significant ‘vallecular pseudodiverticulum’ treated with external surgical repairs. 5 Sobol et al. 6 described three patients with neopharyngeal diverticula, two of whom were treated with an endoscopic division of the posterior wall of the diverticulum. We have recently used a simple transoral method, described below, to address this problem and describe two patients with dysphagia caused by an anterior neopharyngeal diverticulum and improvement after this correction.

Transoral Robotic Surgery Total Laryngectomy

“…The ideal pharyngotomy closure has been a subject of debate. In order to reduce the development of pharyngeal shelf and associated neopharyngeal diverticula [6], Davis et al [7] advocated the T-shaped pharyngotomy closure to improve postlaryngectomy swallowing function. Currently, pharyngotomy closure is routinely performed in a vertical, linear fashion, to minimize technical error as well as reduce blood supply at the corners of the T-shaped suture line, as postulated.…”

Transoral Robotic Surgery Total Laryngectomy: Evaluation of Functional and Survival Outcomes in a Retrospective Case Series at a Single Institution

“…This is a technically less demanding closure than previously described T-shaped closure techniques [14] and theoretically reduces the risks of pharyngeal shelf and neopharyngeal diverticula formation with associated poor swallowing outcomes [15]. All senior authors reporting on TORS-TL close the pharyngotomy in a horizontal orientation, with Lawson et al [9] also applying fibrin glue over the incision for watertight closure.…”

Anteriores Pseudodivertikel nach Laryngektomie

“…Als weitere Ursache von Schluckstörungen nach Laryngektomie ist die Ausbildung einer divertikelartigen Aussackung ventral eines querliegenden Narbensegels zwischen Zungengrund und Hypopharynxtrichter in Betracht zu ziehen [1][2][3][4]. Für diese Aussackung wurde wegen der Ähnlichkeit mit einem Zenker-Divertikel der Begriff des "anterior neopharyngeal diverticulum" [3] bzw.…”

“…Für diese Aussackung wurde wegen der Ähnlichkeit mit einem Zenker-Divertikel der Begriff des "anterior neopharyngeal diverticulum" [3] bzw. des "vallecular pseudodiverticulum" [4,10] geprägt.…”

“…Intraoperative Komplikationen oder Schwierigkeiten wurden bei keiner der 9 Schwellendurchtrennungen beobach- [3]. Diese gestattet zudem die Diagnose von weiteren Pathologien im Ösophagus [1,8].…”