|Year : 2013 | Volume
| Issue : 3 | Page : 318-320
Pharyngocele opening in vallecula: An unusual presentation
Gundappa D Mahajan, James Thomas, Priya Shah, Rashmi Prashanth
Department of ENT, Padmashree, Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pune, India
|Date of Web Publication||5-Jul-2013|
Department of ENT, Dr. D.Y. Patil Medical College, Pimpri, Pune
Source of Support: None, Conflict of Interest: None
Pharyngocele is a benign anomalous pouch formed by hernial protrusion of the mucous membrane through a defect in the hypopharynx. Here we report a 58-year male presenting with large submandibular swelling with complaints of dysphagia and regurgitation. MRI suggested presence of a large pharyngocele. In view of size of swelling external surgical approach was considered as a therapeutic option for the management.
Keywords: Pharyngocele, vallecula, neck swelling, dysphagia
|How to cite this article:|
Mahajan GD, Thomas J, Shah P, Prashanth R. Pharyngocele opening in vallecula: An unusual presentation. Med J DY Patil Univ 2013;6:318-20
| Introduction|| |
Pharyngocele is a protrusion of mucosa into one of the two weak areas of the pharyngeal wall.  The superior area is at the junction of the superior and middle pharyngeal constrictor muscles. An entrance point is located at the inferior pole of the tonsil at the lateral side of vallecula. The inferior area is in between the middle and inferior pharyngeal constrictor muscles and the thyrohyoid membrane. The entrance point is on the base of pyriform fossa. The differential diagnosis of the complaint of dysphagia is extensive; however, a search of the literature gives the impression that pharyngocele as a cause of dysphagia is relatively infrequent, since only 55 well-documented cases have been reported in last 126 years. Frequently, pharyngocele can be demonstrated by the Valsalva maneuver. Surgical repair is indicated when the symptoms are severe. Standard pharyngeal mucous membrane closure similar to the procedure utilized in the repair of Zenker's diverticulum should result in resolution of the problem.
| Case Report|| |
A 58-year-old man presented to the ENT OPD with a large, painless, 6 cm × 8 cm swelling on right side of the neck since two years. He reported that the swelling was increasing in size through last two years. He also complained of progressive dysphagia and regurgitation of fluids and undigested food particles hours after a meal. Other symptoms like unprovoked aspiration, hoarseness of voice, weight loss and recurrent respiratory infections were absent. On clinical examination, swelling measuring 6 cm × 8 cm was found to be on the right side of the neck extending from submandibular area to middle one third of right sternocleidomastoid muscle in anterior triangle [Figure 1]. The swelling was soft and compressible giving rise to gurgling sound on palpation (Boyce's sign). It was increasing in size on Valsalva maneuver. Indirect laryngoscopy revealed pooling of saliva at right vallecula near glossoepiglottic fold. The vocal cord movements were normal. Fiber optic laryngoscopy was done but the opening in the vallecula could not be appreciated, which was confirmed only after passage of catheter retrogradely from the pouch intraoperatively. X-ray soft tissue of neck was suggestive of air-filled space in the neck, which was confirmed by neck sonography. The barium swallow reported presence of a diverticulum. MRI done for this patient showed well-defined lesion seen on the right side of the neck in submandibular region, which is distended with air and there is fluid level in the dependent portion of the lesion. The air is seen as hypointensity and fluid as hyperintensity on T2W image [Figure 2]. T2W coronal image showed the superoinferior extent of the lesion with a small opening distended with air in right pharyngeal mucosal space and the fluid-filled component is seen extending up to the right thyroid cartilage [Figure 3].
With above battery of investigations patient was posted for surgery under GA for transcervical exploratory diverticulectomy. The neck incision was made along anterior border of right sternocleidomastoid from level of hyoid to few centimeters above the clavicle. Subplatysmal flap was raised followed by retraction of sternocleidomastoid. Anterior belly of omohyoid muscle was divided inferiorly. The pharyngocele was identified and freed from surrounding structures up to its attachment near the pharyngeal constrictor muscle [Figure 4]. The whole sac was then excised. A catheter passed from the defect could be retrieved from the right vallecula confirming that the defect was in the superior and middle constrictor muscle of the pharynx. Pharyngeal defect was sutured in layers. Patient was fed postoperatively through a feeding tube for one week after which oral diet was resumed. Postop recovery was uneventful. On follow-up after six month patient was free of symptoms.
| Discussion|| |
Congenital or acquired pharyngocele is a rare disease characterized by a herniation of the pharyngeal mucosa through the muscle layers of the lateral wall of the pharynx. The first well-documented case of a pharyngocele was reported by Wheeler  in 1886, and the first roentgenographic study of a pharyngocele was published by Hankins  in 1944. While they may present at any age, most diverticula present in later life. Posterior pharyngeal diverticula are far more common than lateral pharyngeal diverticula, with the posterior pharyngeal pulsion diverticulum being the one most commonly encountered. The exact mechanism of pouch formation centers on altered pharyngeal muscle pressures and the area of weakness, but as yet there is no universally accepted theory. It most commonly occurs between sixth and eighth decades and is 2-3 times more frequent in men than women. Generally the pharyngocele does not present specific clinical signs or symptoms, which makes it necessary to resort to radiological examination for the diagnosis.  Progressive dysphagia, regurgitation of food after meals and aspiration suggest Zenker's diverticulum. Diagnosis is confirmed by barium swallow radiography, which can also define the size and position of the sac. Sonography is another method for diagnosing pharyngocele. Chevalier et al. reported a case of pharyngocele in a 25-year-male with left cervical mass diagnosed by sonography. This mass had sonographic properties of air and it communicated with and extended to the pyriform sinus deforming the left lamina of thyroid cartilage.  On barium esophagography, the diverticulum appears as an outpouching arising from the midline of the posterior or lateral wall of pharynx.  Differential diagnosis of pharyngocele should be made from laryngocele. Barium swallow during Valsalva maneuver makes the diagnosis of pharyngocele apparent. MRI is done to know the exact extent of lesion. Surgical repair is indicated when the symptoms are severe. As reviewed in literature the size of pharyngocele is usually small giving rise to pouches in the region of vallecula and pyriform fossa and the symptoms are less specific. This case was an unusual presentation because it opened in the vallecula and size was large and the patient had remarkable symptoms which were attributed to large pharyngocele.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]