Abstract
Postlaryngectomy dysphagia is a common occurrence and can be a source of emotional distress that results in a decrease in quality of life among a patient population that is already exposed to considerable morbidity. One etiologic source that is less commonly reported as a source for postlaryngectomy dysphagia, and perhaps overlooked, is an anterior neopharyngeal diverticulum. Herein, we describe a postlaryngectomy dysphagia caused by a neopharyngeal diverticulum masking as velopharyngeal insufficiency of liquids. The liquid dysphagia was immediately relieved via transoral endoscopic approach using the Harmonic scalpel to resect and simultaneously coagulate the posterior wall.
1
Introduction
Postlaryngectomy dysphagia is a common occurrence and can be a source of emotional distress that results in a decrease in quality of life among a patient population that is already exposed to considerable morbidity. In these instances, the head and neck surgeon must first rule out any recurrence of malignancy as the etiologic source for their dysphagia. Once the patient has been cleared of any recurrence, other sources must be entertained that include neopharyngeal/esophageal stenosis, neuromuscular dysfunction, and cricopharyngeal hypertonia . One etiologic source that is less commonly reported as a source for postlaryngectomy dysphagia, and perhaps overlooked, is an anterior neopharyngeal diverticulum . The diverticulum is a well-mucosalized pouch at the base of the tongue separated from the remaining pharynx by a posterior tissue band that can be easily visualized on an indirect mirror examination. The diverticulum has been alternatively called a pseudovellecula , and Kirchner and Scatliff described the neopharyngeal diverticulum as a cause for postlaryngectomy dysphagia as early as 1962.
The dysphagia is characterized by a regurgitant quality similar to that found in patients with a Zenker diverticulum. However, unlike a Zenker diverticulum, which is a pulsion diverticulum due to a hypertonic cricopharyngeus muscle, the pathophysiology of a neopharyngeal diverticulum has not been completely elucidated but is most likely related to the closure techniques at the time of surgery . Our clinical experience suggests that although the incidence of a neopharyngeal diverticulum is not infrequent, associated symptomatic dysphagia is uncommon. Treatment for the diverticulum is relatively simple and has been well described by Deschler using a transoral approach with monopolar cauterization to incise the posterior wall. Others have reported a similar transoral approach but instead use an endoscopic stapler to divide the posterior wall, similarly performed for a Zenker diverticulum .
One of the most common procedures performed for postlaryngectomy dysphagia is serial pharyngoesophageal dilatation, which can be an effective method in relieving symptoms of dysphagia mostly related to solid foods. In those patients in whom serial dilatations do not relieve symptoms, especially with thin liquids, the differential diagnosis for their dysphagia must include an anterior neopharyngeal diverticulum. Herein, we describe a postlaryngectomy dysphagia caused by a neopharyngeal diverticulum masking as velopharyngeal insufficiency (VPI) of liquids. The liquid dysphagia was immediately relieved via transoral endoscopic approach using the Harmonic scalpel to resect and simultaneously coagulate the posterior wall.
2
Case report
An 84-year-old man with a history of a T4N3c supraglottic carcinoma underwent a total laryngectomy with bilateral neck dissections. He had an uneventful postoperative course and was tolerating a general diet by postoperative day 10. At 6 months of follow-up, the patient began to complain of nasal regurgitation with thin liquids to the speech language pathologist who completed a videofluoroscopic swallow study (VFSS) demonstrating a pseudovallecula and possible pharyngoesophageal stenosis ( Fig. 1 ). He was subsequently referred back to the primary surgeon for treatment of his dysphagia. At that time, the clinicoradiographic impression was that a pharyngoesophageal stenosis was the etiologic source for his dysphagia. He underwent serial dilatations with no relief of thin liquid nasal regurgitation. Persistent symptoms were responsible for a significant deterioration in quality of life, and he was referred to the senior author’s (RWB) clinic for further management. Indirect mirror examination revealed a very impressive anterior neopharyngeal diverticulum. Nasal regurgitation mimicking VPI was immediately observed upon oral intake of thin liquids, despite an intact velopharyngeal musculature. Retrospective examination of his previous VFSS confirmed our clinical suspicion that the anterior neopharyngeal diverticulum was the cause for his nasal regurgitation, harboring liquids only to reflux then into his nasal cavity on repeat swallowing attempts.
The patient was taken to the operating room for transoral endoscopic stapling of his nasopharyngeal diverticulum. Direct laryngoscopy with suspension confirmed the pouch ( Fig. 2 ). Endoscopic stapling was attempted; however, the design of the stapler prevented reaching the distal portion of the pouch ( Fig. 3 ). Attempts at modification of the staplers were similarly unsuccessful. The use of the Harmonic scalpel was then used to cleave the most distal portion of the pouch with success ( Fig. 4 ). There were no complications, and the patient tolerated a clear liquid diet immediately, postoperatively, without any signs or symptoms of nasal regurgitation. At 2 months of follow-up, the patient continued to tolerate a liquid diet without significant regurgitation, and his quality of life has greatly improved.
