Endoscopic management of lateral pharyngeal pouch

How we do it: the intra-operative identification of a pharyngocele

A pharyngocele is an uncommon condition, where pharyngeal mucosa herniates through the thyrohyoid membrane. It can be difficult to locate when the patient is at rest. To locate the pharyngocele intra-operatively, a bag valve mask was used to inflate the herniated mucosa. We describe a cost-effective and simple way to locate the pharyngocele intra-operatively.

Bilateral Pharyngoceles (Branchial Cleft Anomalies?) and Endoscopic Surgical Considerations

A case report of bilateral pharyngoceles without a history of elevated intrapharyngeal pressures is used to support the hypothesis that pharyngoceles may be an adult manifestation of an internal branchial sinus anomaly. The development of a pharyngocele from a branchial sinus origin would suggest a predictable relationship to the hypoglossal, glossopharyngeal, and superior laryngeal nerves, which may influence the choice of surgical approach (open versus endoscopic) and the counseling of patients who are considering surgical correction.

Endoscopic staple diverticulostomy for Zenker's diverticulum: review of experience in 337 cases

OBJECTIVE

Surgical treatment of Zenker's diverticulum (ZD) has evolved over the previous 2 decades to a predominantly endoscopic approach. In this study, we review our experience with endoscopic staple-assisted diverticulostomy (ESD) for treatment of ZD from 2002 to 2011.

METHODS

Retrospective chart review of 359 primary and revision ESD procedures performed on 337 unique patients between September 2002 and December 2011. Data were tabulated for age, sex, size of diverticulum, time to symptom recurrence, complications, and relief of symptoms.

RESULTS

Of 337 attempted primary ESD procedures, 3.9% (N = 13) were aborted due to inadequate exposure. Of 324 patients who underwent primary ESD, 93.8% (N = 304) reported postoperative improvement of dysphagia symptoms. There was a 4.0% (N = 13) major complication rate. Patient-reported recurrence of symptoms occurred in 7.1% (N = 23) of primary ESD patients but was not significantly associated with diverticulum size (P = .9765). Twenty-one patients underwent revision ESD, with 95% (N = 20) of patients reporting improvement and 4.8% (N = 1) developing recurrent symptoms.

CONCLUSION

Primary and revision ESD were shown to have similar success at relieving the symptoms of ZD, with low procedure abandonment and perioperative complication rates. Further patient follow-up is needed to determine the durability of symptom improvement and ZD recurrence rate following ESD.

Pharyngoceles: a photo-anatomic study and novel management

OBJECTIVES/HYPOTHESIS

Pharyngoceles are outpouchings of the lateral pharyngeal wall through the thyrohyoid membrane. These entities are inconsistently documented in the literature given the varying terminology and poor anatomic description. Open surgical repair has been the mainstay of treatment for symptomatic pharyngoceles.

STUDY DESIGN

A systematic literature review was conducted to identify articles presenting cases of pharyngoceles. Two case reports supplement the data found.

METHODS

Through a PubMed search, articles were examined specifically for anatomical discussions, presenting symptoms, and management strategies. To this data, we add two cases of bilateral symptomatic pharyngoceles with full multimedia documentation, including one patient treated successfully with novel endoscopic suture pharyngoplasties.

RESULTS

Twenty-five articles were identified that described 59 cases of pharyngoceles, for a total of 61 patients reviewed. Few articles include descriptive anatomy and correlate in vivo examples, and none describe intraluminal pharyngocele structure in detail. Both patients at our institution had complete resolution of their symptoms, as determined by interviews and oropharyngeal motility studies.

CONCLUSIONS

Relatively few true pharyngoceles have been reported in the surgical literature. We offer the first detailed endoscopic anatomic description and formal evaluation of swallowing outcomes, as well as an anatomically-based endoscopic approach. These lesions may be amenable to endoscopic repair with minimal long-term morbidity.

Lateral laryngopharyngeal diverticula: a videofluoroscopic study of laryngopharyngeal wall in wind instrumentalists

CONTEXT: This paper analyze healthy musicians who play wind instruments. OBJECTIVE: To identify possible diverticular formations on the laryngopharyngeal wall produced by pharyngeal overpressure during the use of these instruments. METHODS: Through a videofluoroscopic method, 22 professional musicians had their pharynx analyzed in frontal face and profile, by swallowing 20 mL of barium sulfate solution and blowing against resistance. RESULTS: All the volunteers showed lateral laryngopharyngeal diverticula (3 unilateral and 19 bilateral) with areas ranging from 0.7 to 6 cm². Trumpet and clarinet players showed larger diverticula, on both the right and left sides. Any important complaints were noted spontaneously or after questions. In the barium-swallow analyses, the 41 diverticula previously identified in the blowing tests were not seen or appeared to be smaller, because of the free flux passage from the pharynx to the esophagus. Despite the existence of the other, less resistant areas on the laryngopharyngeal segment, no other protrusions could be found in this group of wind instrumentalists. CONCLUSIONS: The lateral laryngopharyngeal diverticula that occur in blow instrumentalists is distinct of diverticula produced by laryngopharyngeal overpressure determined by abnormally high resistance to flux passage from pharynx to esophagus. In musicians is the persistent and continuous pharyngeal overpressure induced by the resistance of the instrument's mouthpiece will strongly distend the anatomically less resistant areas of the pharynx, producing a large protrusion. Laryngopharyngeal overpressure without abnormal resistance to flux passage explain the way blow instrumentalists protrusions did not appear as full sacs in a barium-swallow test, despite their larger dimensions. As final conclusion the musician-acquired diverticula must be considered as an "occupational overuse syndrome".

Lateral laryngopharyngeal diverticulum: anatomical and videofluoroscopic study

The aims were to characterize the anatomical region where the lateral laryngopharyngeal protrusion occurs and to define if this protrusion is a normal or a pathological entity. This protrusion was observed on frontal contrasted radiographs as an addition image on the upper portion of the laryngopharynx. We carried out a plane-by-plane qualitative anatomical study through macroscopic and mesoscopic surgical dissection on 12 pieces and analyzed through a videofluoroscopic method on frontal incidence the pharyngeal phase of the swallowing process of 33 patients who had a lateral laryngopharyngeal protrusion. The anatomical study allowed us to identify the morphological characteristics that configure the high portion of the piriform recess as a weak anatomical point. The videofluoroscopic study allowed us to observe the laryngopharyngeal protrusion and its relation to pharyngeal repletion of the contrast medium. All kinds of the observed protrusions could be classified as "lateral laryngopharyngeal diverticula." The lateral diverticula were more frequent in older people. These lateral protrusions can be found on one or both sides, usually with a small volume, without sex or side prevalence. This formation is probably a sign of a pharyngeal transference difficulty associated with a deficient tissue resistance in the weak anatomical point of the high portion of the piriform recess.

Characterization of monoclonal antibody to the Epstein-Barr virus BHRF1 protein, a homologue of Bcl-2

A monoclonal antibody (MAb), designated 3E8, was produced against the Epstein-Barr virus BHRF1 which is a viral homologue of the anti-apoptotic protein Bcl-2. The MAb recognized the BHRF1 protein in extracts from EBV-containing cell lines after activation and EBV-negative cell lines transfected by the BHRF1 gene. Epitope mapping by Western blot analysis revealed that the antibody bound region encompassing amino acid residues 28-33 of the BHRF1. In addition to immunoblotting, the MAb could be applied widely in detection of the BHRF1 in many assays, including immunofluorescence assay, immunohistochemistry, enzyme-linked immunosorbent assay and immunoprecipitation. Most of all, when used in immunoprecipitation experiments, the MAb 3E8 showed a better effect than the existing anti-BHRF1 MAbs since radioactive isotopes were not required to intensify signals of its target antigen. Based on its great use in a variety of immunological reactions, it is a powerful tool to elucidate the biological functions of BHRF1.

The Cellular Protein PRA1 Modulates the Anti-apoptotic Activity of Epstein-Barr Virus BHRF1, a Homologue of Bcl-2, through Direct Interaction

The Epstein-Barr virus-encoded early protein, BHRF1, is a structural and functional homologue of the anti-apoptotic protein, Bcl-2. There is accumulating evidence that BHRF1 protects a variety of cell types from apoptosis induced by various external stimuli. To identify specific proteins from normal epithelial cells that interact with BHRF1 and that might promote or inhibit its anti-apoptotic activity, we screened a yeast two-hybrid cDNA library derived from human normal foreskin keratinocytes and identified a cellular gene encoding human prenylated rab acceptor 1 (hPRA1). The interaction of hPRA1 with BHRF1 was confirmed using glutathione S-transferase pull-down assays, confocal laser scanning microscopy, and co-immunoprecipitation. Two regions of PRA1, amino acids 30-53 and the carboxyl-terminal 21 residues, are important for BHRF1 interactions and two regions of BHRF1, amino acids 1-18 and 89-142, including the Bcl-2 homology domains BH4 and BH1, respectively, are crucial for PRA1 interactions. PRA1 expression interferes with the anti-apoptotic activity of BHRF1, although not of Bcl-2. These results indicate that the PRA1 interacts selectively with BHRF1 to reduce its anti-apoptotic activity and might play a role in the impeding completion of virus maturation.

Diagnosis and management of cricopharyngeal achalasia and other upper esophageal sphincter opening disorders

Recent literature on disorders of the upper esophageal sphincter is reviewed, including discussion of advances in measurement, diagnosis, treatment, and management. The etiology of upper esophageal sphincter disorders is summarized, along with its pathophysiology, with reference to gastroesophageal reflux disease. Medical and surgical options for improving pharyngeal clearance and minimizing aspiration are also discussed, as is the use of percutaneous esophageal gastrostomy feeding tubes.