Diseases of the pharynx

Nasopharynx

Enlarged adenoid

The most common cause of an enlarged adenoid (there is only one nasopharyngeal adenoid, despite the common use of the term ‘adenoids’) is physiological hypertrophy (Fig. 43.14). The size of the adenoid alone is not an indication for removal. It is often associated with hypertrophy of the other lymphoid tissues of Waldeyer’s ring. If excessive hypertrophy causes blockage of the nasopharynx in association with tonsil hyper­trophy, the upper airway may become compromised during sleep causing obstructive sleep apnoea. This condition is becoming increasingly diagnosed, and is important because it can cause sleep deprivation and secondary cardiac complica­tions. It has been implicated in some cases of a sudden infant death syndrome. The most common symptom is snoring, which is typically irregular, with the child actually ceasing respiration (apnoea) and then restarting with a loud inspiratory snort. The child is often restless and may take up strange sleeping positions as he or she tries to improve the pharyngeal airway. Surgical removal of the tonsils and adenoid is curative, but it is important to avoid sedative premedications and opiate analgesics postoperatively because they may further depress the child’s respiratory drive. Obstructive sleep apnoea may also occur in adults, where the obstruction may result from nasal deformity, a hypertrophic soft palate associated with an altered nasopharyngeal isthmus, obesity and general narrowing of the pharyngeal airway, or supraglottic laryngeal pathology. Surgery may be indicated following investigation by means of a sleep study, during which measurement of the patient’s sleep pattern and arterial oxygenation is undertaken.

Hypertrophy of adenoid tissue most commonly occurs between the ages of 4 and 10 years, but the adenoid tissue usually undergoes spontaneous atrophy during puberty, although some remnants may persist into adult life. The relationship of adenoid enlargement to recurrent secretory otitis media or recurrent acute otitis media is not entirely clear. It has long been thought that eustachian tube dysfunction results from either inflammatory oedema or interference with palatal elevation which opens the

eustachian tube. However, the exact relationship has not been determined and many children who have secretory otitis media do not always benefit from adenoid removal.

Adenoidectomy

Adenoid tissue can be removed alone or in conjunction with a tonsillectomy.

Indications are:

       obstructive sleep apnoea associated with postnasal obstruction;

postnasal discharge;

recurrent acute otitis media or prolonged serous otitis media usually longer than 3 months’ duration;

recurrent rhinosinusitis.

Operative technique. The adenoid tissue is removed with a guarded curette (Fig. 43.15) pressed against the roof of the nasopharynx and then carried downwards in a moderately firm sweeping movement bringing the excised adenoid into the oropharynx (Fig. 43.16). The guard on the curette secures the adenoid and prevents it from dropping inferiorly into the airway. A postnasal swab is placed into the nasopharynx until all haemorrhage has ceased. Reactionary or secondary haemorrhage during the recovery period may require the placing of a nasopharyngeal pack under a further anaesthetic. This can occasionally cause respiratory depression in children and adults, and they require strict observation while the pack is in place.

Tumours of the nasopharynx

Benign. There are two main types of benign tumour of the nasopharynx: the angiofibroma and the antrochoanal polyp.

Anglo fibroma. This is often termed ‘nasopharyngeal angio­fibroma’, but this is incorrect as the tumour arises in the area of the sphenopalatine foramen in the posterior part of the nasal cavity. However, it readily expands into the nasopharynx and, although the tumour is not malignant in that it never metastasises, it does spread relentlessly over the skull base expanding anteriorly into the nasal cavities displacing the nasal septum, compressing the posterior wall of the maxillary antrum and often entering it by bone erosion. Likewise, it may enter and expand the sphenoid sinus and spread laterally through the pterygopalatine fissure and onwards into the infratemporal fossa occasionally to reach the soft tissues of the cheek and orbit via the inferior orbital fissure. Inferiorly it may fill the nasopharynx, depress the soft palate and eventually appear within the oropharynx (Fig. 43.17).

Macroscopically there is a firm reddish-blue tumour covered with normal mucous membrane, but ulceration may occur if the tumour hangs into the oropharynx or becomes exposed anteriorly at the nostril. Microscopically it is composed of immature fibroblasts and blood vessels, and it remains benign even in its advanced stages. It should probably be regarded as a hamartoma. Clinically the tumour is confined to male patients commonly between the ages of 8 and 20 years, i.e. around puberty. It occasionally occurs in the 20s and 30s.

  It rarely regresses and usually causes progressive nasal obstruction, recurrent severe epistaxis, purulent rhinorrhoea and occasionally loss of vision due to compression of the optic nerve. Although the tumour is rare, these symptoms in a young boy should always arouse suspicion. The tumour occurs in many countries around the world but is most common in northern India. The reasons for this are unknown.

Standard clinical examination may easily reveal the tumour in the nasal cavity or nasopharynx, but CT scanning best demonstrates the extent of the tumour and its accompanying bony erosion. MRI scanning will further define the soft-tissue extent and with these two modern investigations angio­graphic evaluation is rarely indicated.

Biopsy should be avoided unless clinical and radiological examination is not clear. There should be definite reasons for undertaking biopsy, and matched blood must be in readiness and the surgeon prepared to deal with the haemorrhage.

Whilst radiotherapy has occasionally been advocated, sur­gical resection is by the far commonest management world­wide and requires an adequate exposure of the entire region either through a midfacial degloving approach or a lateral rhinotomy (Figs 43.18 and 43.19). Both of these approaches allow ligation of the feeding maxillary artery. A transpalatal approach may be used for the smaller tumours but this does not give full control of any potential bleeding.

Antrochoanal polyp. This relatively uncommon lesion is not a tumour but a simple mucosal polyp. It does not arise in the nasopharynx, but from the maxillary antrum, from which it prolapses into the nasal cavity and thence expands back­wards into the nasopharynx and occasionally down into the oropharynx (Figs 43.20 and 43.21). It also commonly occurs in young males, and therefore may mimic a tumour of the nasal cavity or nasopharynx. It is distinguished clinically from an angiofibroma by its avascularity, pale colour, its site of origin on endoscopic examination and imaging, as it is a simple mucosal polyp. Whilst it may be removed intra nasally by an avulsion snare, a portion often remains in the antrum producing recurrent symptoms and it requires complete removal via an endoscopic approach through the middle meatus or, occasionally, a Caldwell—Luc procedure to prevent recurrence.

Malignant. Nasopharyngeal carcinoma is an interesting squamous cell carcinoma with a very variable incidence. In most parts of the world the tumour is rare with an incidence of less than one person in 100 000 per year. However, it is a common tumour amongst southern Chinese, and this high-risk population has rates of 30—50 people per 100 000 per year. In the rest of China there are substantial variations in the incidence but, in general, the incidence decreases from south to north. Higher frequencies of nasopharyngeal carcinoma are also observed in emigrant southern Chinese populations in south-east Asia and elsewhere around the world, and it is also more common amongst Eskimo, the Kadazans in East Malaysia and parts of northern Africa. It is now well accepted that mechanisms leading to development of a cancer often involve a multi step process, and the aetiology of nasopharyngeal carcinoma is most likely to be multifactorial with no single cause adequately explaining the epidemiology of the disease. However, it is also clear that three well-defined major aetiological factors are involved in its development (Table 43.3). The exact mechanism as to how these factors act is not yet fully understood. The majority of squamous carcinomas of the nasopharynx is undifferentiated and the morphology of this tumour is characteristic. Only a few are well-differ­entiated squamous carcinomas, and these two lesions make up over 90 per cent of nasopharyngeal malignancy in endemic areas. Other rare epithelial tumours are adenocarcinoma and adenoid cystic carcinoma. B- and T-cell lymphomas also occur in this region and should not be confused with the more common undifferentiated carcinoma.

Nasopharyngeal carcinoma affects a younger age group of the population than almost any other head and neck neoplasm. In endemic regions at least 60 per cent of patients are under 50 years of age and this applies to both sexes.

Clinical features. Symptoms are closely related to the position of the tumour in the nasopharynx and the degree of distant spread which may be present. Early symptoms are often minimal in nature and thus liable to be ignored by both patient and doctor.

  Approximately half the patients will present with a mass in the neck. This percentage is even higher in patients under 21 years of age. It indicates that the tumour has already reached an advanced stage. Fine needle aspirate or a biopsy of a neck node showing undifferentiated carcinoma requires immediate thorough examination of the nasopharynx.

  The nasopharynx may look normal or only minimally asymmetric but contain submucosal nasopharyngeal carci­noma. Nasal complaints occur in one-third of patients and aural symptoms of unilateral deafness, as a consequence of eustachian tube obstruction and secretory otitis media, occur in approximately 20 per cent. Neurological com­plications with cranial nerve palsies due to disease on the skull base occur relatively late in the disease but are a poor prognostic factor.

A biopsy of the nasopharynx is mandatory if there is suspicion of nasopharyngeal malignancy.The traditional method of indirect examination with a mir­ror, although adequate in some patients, has been superseded by direct inspection carried out by a flexible or rigid nasendoscope. If topical anaesthesia is used, a biopsy may be taken. Serological investigation for Epstein—Barr virus-associated anti­genic markers, in combination with the clinical and histological examination, is valuable for the early detection of disease. Highly sensitive assays for antiviral antibodies, together with the newly discovered virus-associated serological markers, are assisting not only in the early detection but in the treatment and control of this disease. IgA antiviral capsid antigen (VCA) antibody has recently been evaluated in mass surveys in southern China and has been found to be an excellent screening method for the early detection of nasopharyngeal carcinoma in high-risk groups.

Imaging. Imaging is essential to determine the extent of the disease and to enable correct staging. In areas where CT and MRI are available plain film radiography of the nasopha­rynx and other ancillary methods, such as xerography and tomography, have now been superseded. A chest X-ray, how­ever, should still be performed. CT has a major role in determining the size and position of the tumour essential for radiotherapy planning and assessing the response to treatment, diagnosing recurrence and detecting complications.

Treatment. Primary treatment of nasopharyngeal carcinoma is radiotherapy. The majority of the tumours belongs to the radiosensitive undifferentiated squamous cell group. With the advent of CT, precise radiotherapy treatment plan­ning is now possible and brachytherapy (intracavitary and interstitial radiotherapy) and chemotherapy are increasingly added in the management plan. Elective external radio­therapy is given to the neck in all cases, even when no neck nodes are apparent. For early disease, 3-year disease-free survival rates of more than 75 per cent are now common. However, late disease has figures of only 30—50 per cent for 3-year disease-free survival. Although the benefit of modern radiotherapy is beyond doubt, the value of additional chemo­therapy remains debated, but it is likely that a combination of chemotherapy and radiotherapy will produce better loco regional control of the tumour. Surgery is reserved for recur­rent disease in neck nodes and the occasional removal of recurrent skull base disease which has not responded to additional radiotherapy or chemotherapy.

Oropharynx

Acute tonsillitis

This common condition is characterised by a sore throat, fever, general malaise, dysphagia, enlarged upper cervical nodes and sometimes referred otalgia. Approximately half the cases are bacterial, the most common cause being a pyogenic group A streptococcus. The remainder is viral and a wide variety of viruses has been implicated; in particular, infectious mononucleosis may frequently be mistaken for bacterial tonsillitis. On examination the tonsils are swollen and erythematous, and yellow or white pustules may be seen on the palatine tonsils, hence the name ‘follicular tonsillitis’. A throat swab should be taken at the time of examination and blood for Paul—Bunnell testing (Fig. 43.22).

Treatment. Paracetamol or similar analgesia may be admin­istered to relieve pain and gargles of glycerol—thymol are soothing. The condition is frequently sensitive to benzyl or phenyoxymethylpenicillin (penicillin V) and these are given until antibiotic sensitivities are known. Ampicillin is avoided as it may exacerbate the situation and precipitate a rash in patients with infectious mononucleosis. Most cases resolve in a few days.

Quinsy

This is the formation of an abscess in the peritonsillar region causing severe pain and trismus, and most usually associated with streptococcal infection (see Fig. 43.23). Trismus caused by spasm induced in the pterygoid muscles from the spreading infection may make examination difficult. This may be overcome by the instillation of local anaesthesia into the posterior nasal cavity (thereby anaesthetising the spheno­palatine ganglion) and directly into the oropharynx. This simple manoeuvre aids subsequent examination which should be carried out with good illumination and suction. A diffuse swelling of the soft palate just superior to the involved tonsil is seen displacing the uvula medially and, in more advanced cases, there may be an area of pus pointing underneath the thin mucosa.

Treatment. In the early stages where no distinct abscess is pointing, intravenous broad-spectrum antibiotics are indi­cated and may produce resolution. However, if there is frank abscess formation, incision and drainage of the pus can be carried out under local anaesthesia (Fig. 43.24). A small scalpel is best modified by winding a strip of adhesive tape around the blade so that only 1 cm of the blade projects. In teenagers and young adults the patient sits upright and an incision is made in the position shown in Fig. 43.24. This is approximately mid-way between the base of the uvula and the third upper molar tooth. This may produce immediate release of pus but, if not, dressing forceps are now pushed firmly through the incision directly backwards and, on opening, pus may then be encountered. In small children general anaesthesia may be required.

Chronic tonsillitis

Chronic tonsillitis usually results from repeat attacks of acute tonsillitis in which the tonsils become progressively damaged and provide a reservoir for infective organisms.

Tonsillectomy. Indications for tonsillectomy may be divided into absolute or relative (Table 43.5). When the size of the tonsils is contributing to airway obstruction or a malignancy of the tonsils is suspected, the decision to perform tonsillectomy is relatively straightforward. Complete tonsillectomy is preferable to wedge biopsies when squamous cell carcinoma is suspected, and bilateral tonsillectomy is performed in the case of suspected lymphoma as part of the staging process.

Considerable interest now focuses on the area of sleep apnoea and related problems. Patients should be admitted for formal sleep studies to establish the exact extent and site of the problem following which a variety of medical and surgical treatments may be deemed appropriate, one of which is tonsillectomy.

Recurrent acute tonsillitis is the commonest relative indication for tonsillectomy in children and adolescents, although it is important that these attacks are well documented and do not simply constitute a minor sore throat usually of viral origin and of short duration. Chronic tonsillitis more frequently affects young adults in whom it is important to establish that chronic mouth breathing secondary to nasal obstruction is not the main problem rather than the tonsils themselves.

Ideally, the procedure should be undertaken when the tonsils are not acutely infected, and it is important to discuss factors which may increase the tendency to bleed. Blood transfusion is rarely required but it is normal practice to perform a ‘group and save’ in children under 15 kg in weight.

Dissection tonsillectomy is carried out under general anaesthesia during which the patient lies supine with the head extended and with the surgeon sitting at the end of the operating table. The mucosa of the anterior faucial pillar is incised and the tonsil capsule identified. Using blunt dis­section the surgeon separates the tonsil from its bed until only a small inferior pedicle is left (Fig. 43.25). Usually a snare is used to separate it from the lingual tonsil. Ribbon gauze is placed in the tonsillar bed and pressure applied for some minutes following which bleeding points may be controlled by ligature or by bipolar diathermy. Following surgery, the patient is kept under close observation for any systemic or local evidence of bleeding with regular monitoring of pulse and blood pressure, and observation to see whether the patient is swallowing excessively (Fig. 43.26). The patient is kept nil by mouth for the first few hours in case an immediate (or reactionary) haemorrhage should necessitate a return to theatre. After this period the patient is encouraged to use the mouth and a normal diet rapidly instituted. Paracetamol is preferred to aspirin-containing analgesics. Patients are generally allowed home on the following day and are warned that they may experience otalgia due to referred pain from the glossopharyngeal nerve and that late (or secondary) haemorrhage may occur up to 10 days following the surgery, which would necessitate their immediate return to hospital.

Haemorrhage is obviously the most common complication, occurring in the immediate postoperative period (Table 43.6). Local pressure, hydrogen peroxide, gargles and general supportive measures may help in mild cases, but it is generally .wisest to return to theatre for definitive treatment particularly in younger patients. Blood loss is replaced with crystalloid whilst a cross-match is performed, and frequent observations of blood pressure, pulse and respiratory rate are made. Adequate analgesia is given without causing respiratory depression. With the patient seated upright in bed the mouth is examined under reasonable illumination to determine the site of bleeding and if possible to suction away clots from the tonsillar fossa. A swab soaked in 1 in 1000 adrenaline may be held against the bleeding area in a co-operative patient, but if this is not possible and/or the bleeding persists theatre should be alerted. Under general anaesthesia it may be possible to identify a bleeding spot, but often a more generalised ooze is observed and suturing of the tonsil bed combined with the   application of Surgicel and bipolar diathermy is often more successful than attempted placement of ligatures.

Late haemorrhage is generally secondary to infection and patients should be immediately commenced on intravenous antibiotics with aerobic and anaerobic cover. Significant or persistent bleeding may require a further general anaesthetic and under sewing of the surgical bed, which by this time will often be covered with slough and granulation tissue. Post­operative tonsillar haemorrhage must still be regarded as a serious and life-threatening complication and should not be underestimated, particularly in the younger patient.

Parapharyngeal and retropharyngeal abscess

Parapharyngeal abscess. The parapharyngeal abscess may be confused with a peritonsillar abscess but the maximal swelling is behind the posterior faucial pillar and there may be little oedema of the soft palate. The patient is usually a young child and there may be a severe degree of general malaise. With an obvious abscess pointing into the oropharynx, drain­age may be carried out with a blunt instrument or the gloved finger but general anaesthesia is frequently required and the expertise of a senior anaesthetist, good illumination and good suction are absolutely essential. A large parapharyngeal abscess may compromise both the airway and swallowing. In the earlier cases admission to hospital and the institution of fluid replacements coupled with intravenous antibiotics may produce resolution. The advanced cases also require intravenous antibiotics.

Acute retropharyngeal abscess

This is the result of suppuration of the prevertebral lymph nodes and, again, is most commonly seen in children with most of the cases occurring in those under 1 year of age. It is associated with infection of the tonsils, nasopharynx or oropharynx, and is frequently accompanied by severe general malaise, neck rigidity, dysphagia, drooling, a croupy cough, an altered cry and marked dyspnoea. Indeed, dyspnoea may be the prominent symptom, and may also be accompanied by febrile convulsions and vomiting.

These children should always be carefully examined, and an inspection of the posterior wall of pharynx may show gross swelling and an abscess pointing beneath the thinned mucosa. In countries where diphtheria still occurs, an acute retropharyngeal abscess may be confused with this but the presence of the greyish-green membrane aids differentiation. Occasional­ly, a foreign body, most commonly a fish hone which has perforated the posterior pharyngeal mucosa, will give rise to an abscess in this situation in older children and young adults.

These patients should be admitted to hospital and intravenous antibiotics instituted immediately. Surgical drainage of the abscess may not be necessary but, if so, requires experi­enced anaesthesia as on induction care must be taken to avoid rupturing the abscess. The airway is protected by placing the child in a head-down position whilst a pair of dressing forceps guided by the finger may be thrust into an obvious abscess in the posterior wall with the contents being evacuated. On other occasions an approach anterior and medial to the carotid sheath via a cervical incision may he required.

Chronic retropharyngeal abscess

This condition is now rare and most commonly the result of an extension of tuberculosis of the cervical spine which has spread through the anterior longitudinal ligament to reach the retropharyngeal space. In contrast to the acute retropharyngeal abscess, this condition occurs almost solely in adults and radiology usually shows evidence of bone destruction and loss of the normal curvature of the cervical spine. The spine may be quite unstable and undue manipulation may precipitate a neurological event. In addition to the retropha­ryngeal swelling seen intraorally, there may be fullness behind the sternocleidomastoid muscle on one side. A chronic retropharyngeal abscess must not he opened into the mouth, as such a procedure may lead to secondary infection. Drainage of the abscess may not be necessary if suitable treatment of the underlying tuberculosis disease is instituted. If it is necessary then it should he carried out through a cervical incision anterior to the sternocleidomastoid muscle with an approach anterior and medial to the carotid sheath to the retropharyngeal space. The cavity is opened and suctioned dry after taking biopsy material. Occasionally surgery is required to decompress the spinal cord if there is a progressive neurological deficit.

Glandular fever (infectious mononucleosis)

This systemic condition is usually caused by Epstein—Barr virus but similar features can be due to cytomegalovirus or toxoplasmosis.

Clinical features. The tonsils are typically erythematous with a creamy-grey exudate, and they appear almost confluent and usually symmetrical in contradistinction to a quinsy. In addition to the discomfort and dysphagia, the patient may drool saliva and have respiratory difficulty, particularly on inspiration. They commonly have a high temperature and gross general malaise with other notable cervical or gener­alised lymphadenopathy. Occasionally an enlarged spleen or liver may be detected. These features most commonly occur in teenagers and young adults, and diagnosis can be con­firmed by serological testing showing a positive Paul—Bunnell test, an absolute and relative lymphocytosis, and the presence of atypical monocytes in the peripheral blood.

Treatment. Analgesia and maintenance of fluid intake are important. A small number of patients requires admission to hospital if the airway is compromised and a short course of steroids may be helpful. If this is necessary it should only be carried out as an in-patient where the airway can be con­stantly monitored. Antibiotics are of little value and, indeed, ampicillin is contraindicated because of the frequent appearance of a widespread skin rash.

Human immunodeficiency virus

The human immunodeficiency virus (HIV) is the causative agent of acquired immunodeficiency syndrome (AIDS) which, although it was initially associated with intravenous drug users and homosexual males, is now spreading in many parts of the world to affect the heterosexual community. It can affect almost all of the head and neck structures at any point during the disease. The initial seroconversion may pre­sent with the symptoms of glandular fever which is followed by an asymptomatic period of variable length. In the pre­AIDS period, prior to the full-blown symptoms of the AIDS-related complex, many patients have minor upper respiratory tract symptoms which are often overlooked such as otitis externa, rhinosinusitis and a nonspecific pharyngitis. As the patient moves into the full-blown AIDS-related complex a persistent generalised lymphadenopathy is frequently found affecting the cervical nodes which is usually due to follicular hyperplasia. However, patients may also develop tumours such as Kaposi’s sarcoma, sometimes seen in the oral cavity, and high-grade malignant B-cell lymphoma affecting the cervical lymph nodes and nasopharynx. In addition, multiple ulcers may be found in the oral cavity or pharynx associated with herpes infection. Severe candida may affect the oral cavity pharynx or even larynx, and a hairy leucoplakia may affect the tongue (Fig. 43.27). There is also an increased incidence of squamous cell carcinoma of the oral cavity.

The globus syndrome

A wide variety of patients has a predominant symptom of a feeling of a lump in the throat (Latin: globus lump). The symptom most commonly affects adults between 30 and 60 years of age. This feeling is not true dysphagia as there is no difficulty in swallowing. Most patients notice the symp­tom more if they swallow their own saliva, i.e. a forced dry swallow, rather than when they eat or drink. The aetiology of this common symptom is unknown but some patients may have gastro-oesophageal reflux or spasm of their cricopharyngeus muscle. The symptom may be associated with the presence of a pharyngeal pouch, or tumours in the oropharynx, hypopharynx or upper oesophagus.

The original name of globus hystericus is unhelpful and although these patients may be anxious and at times introverted, they none the less require full examination to exclude local disease. Radiological and endoscopic investigation may be necessary to exclude an underlying cause.

Pharyngeal pouch

The pouch is a protrusion of mucosa through Killian’s dehis­cence, a weak area of the posterior pharyngeal wall between the oblique fibres of thyropharyngeus and the transverse fibres of cricopharyngeus at the lower end of the inferior constrictor muscle. These fibres, along with the circular fibres of the upper oesophagus, form the physiological upper oesophageal sphincter mechanism. Quite why the pouch forms is not yet clear even with modern video fluoroscopic and manometric studies. Many patients with pharyngeal pouches have been demonstrated to have normal relaxation of the upper oesophageal sphincter mechanism in relation to swallowing, but others have been shown to have incomplete pharyngeal relaxation, early cricopharyngeal contraction and abnormalities of the pharyngeal contraction wave. As the pouch enlarges the resistance of the vertebral column behind usually causes it to turn laterally to the left (Fig. 43.28).

Clinical features. Patients suffering from this condition are commonly more than 60 years of age and it is twice as common in women as in men.

In the initial phases when there is a small diverticulum the patients may present with globus-type symptoms of a feeling of something in the throat or minor difficulties and slight regurgitation on swallowing. A videofluoroscopic or barium swallow study may show abnormalities of the upper oesophageal sphincter in association with the small pouch. As the diverticulum enlarges patients may experience regurgita­tion of undigested food sometimes hours after a meal, partic­ularly if they are bending down or turning over in bed at night. They are sometimes awoken at night with a feeling of tightness in the throat and a fit of coughing. Occasionally they may present with recurrent unexplained chest infections as a result of small amounts of liquid and food being aspirat­ed from the pouch. As the pouch increases in size the patients may notice gurgling noises from the neck on swallowing and the pouch may become large enough to form a visible swelling in the neck. This swelling may increase when the patient drinks and, indeed, there may be increasing difficulty with swallowing associated with weight loss and cachexia.

Radiological examination. If a pharyngeal pouch is sus­pected, this is an extremely useful examination. A thin emul­sion of barium is given to the patient as a barium swallow (Fig. 43.29) or, better still, as part of a videofluoroscopic swallowing study. Care should be exercised in patients who cough on swallowing indicating they may have aspiration. Just a few millilitres of barium is sufficient to outline the pharynx pouch and upper oesophagus. The videofluoroscopic study gives additional information about the pharyn­geal contraction waves and the performance of the upper oesophageal sphincter. Occasionally there is an associated hiatus hernia at the lower end of the oesophagus and this should be excluded. A chest X-ray is important to exclude aspiration pneumonitis. Rigid oesophagoscopy or pharyngoscopy under general anaesthesia is unnecessary for diagnosis and may be dangerous. When the diagnosis is unsuspected. oesophagoscopy performed without realising the pathology may be associated with the tip of the oesophagoscope entering the pouch and perforating the fundus. Subsequent mediastinitis is associated with a high mortality.

Treatment. Surgery is indicated when the pouch is associated with progressive symptoms, and particularly when a prominent cricopharyngeal bar of muscle associated with abnormality of the upper oesophageal sphincter mechanism causes considerable dysphagia. In very elderly patients a decision to operate may be offset by the general condition of the patient. Preoperative physiotherapy and attention to the respiratory, cardiovascular and nutritional aspects of the patient are important. Preoperative chest physiotherapy and perioperative antibiotics are recommended. In the classical operation the opening to the pouch is first identified using a pharyngoscope and a nasogastric tube placed into the oesophageal lumen to allow postoperative nutrition. This initial endoscopy is often difficult because the normal oesophageal opening is small compared with the lumen of the pouch but it may be facilitated by using a Dohlmann’ s rigid endoscope which allows better visualisation. The naso­gastric tube allows identification of the oesophagus sub­sequently by palpation and facilitates the myotomy, in addition to allowing postoperative feeding. The pouch may be packed with ribbon gauze soaked in proflavin solution to aid identification of the neck of the pouch.

A lower neck incision along the anterior border of the left sternocleidomastoid muscle, or a transverse crease incision, is then used and the sternocleidomastoid muscle and carotid sheath are retracted laterally and the trachea and larynx medially. The middle thyroid vein is divided and, if necessary, the inferior thyroid artery is found and ligated well laterally. The retropharyngeal space is entered above the inferior corner of the thyroid cartilage, thereby avoiding risk of damage to the recurrent laryngeal nerve. The pouch is found medially behind the lower pharynx and is carefully isolated and dissected back to its origin at Killian’s dehiscence. It may then be excised and the pharynx closed in two layers or, if it is small, it may invaginated into the pharyngeal lumen before closing the muscle layers. In all cases a myotomy dividing the fibres of the cricopharygeus muscle and the upper oesophageal circular muscle fibres must be performed. The wound is usually closed with drainage and the patient fed through the nasogastric tube for 3—7 days.

Complications. This classic operation has been associated with wound infection, mediastinitis, pharyngeal fistula formation and stenosis of the upper oesophagus. Variations have been tried which include simply hitching up the pouch into a superior position without excising it, thus allowing the fundus and body to empty continuously into the oesophagus. This is unsatisfactory with the larger pouches. Endoscopic division of the bar of muscle forming the anterior wall of the pouch and the posterior aspect of the lumen of the oesoph­agus has been advocated for many years using Dohlmann’s instruments and, more recently, a laser applied via a special pharyngoscope. There is increasing evidence that both the open operative intervention and previous endoscopic tech­niques can be improved by using an endoscopic stapling technique, whereby a specialised staple gun is passed down a modified pharyngoscope which safely divides the anterior wall of the pouch and the posterior wall of the oesophagus. This completes a full myotomy and allows any food and fluid to drain from the pouch directly down the oesophagus. The staples provide an instant two-layer closure at the site of division, and this endoscopic technique is associated with very low morbidity and a high success rate for the relief of the patient’s symptoms. Low morbidity is particularly important in this elderly group of patients.

Sideropenic dysphagia

Prolonged iron deficiency anaemia may lead to dysphagia, particularly in middle-aged females. In addition, they may have koilonychia, cheilosis and angular stomatitis, together with lassitude and poor exercise tolerance. The dysphagia is caused by a postcricoid web, and these patients have a higher incidence of postcricoid malignancy. Prognosis of these post­cricoid tumours is very poor, requiring radical treatment with radiotherapy and major surgery, and it is therefore important to prevent this problem by recognition and treatment of the anaemia. The syndrome is associated with the names of Plummet and Vinson, and Patterson and Brown Kelly.