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Case 67: Halitosis

A 72 year old woman presents complaining of bad breath. She also finds that food she has eaten hours earlier occasionally refluxes into her mouth.

1. What does the xray show?

This barium swallow demonstrates a pharyngeal pouch. This is a pulsion diverticulum at the junction of the pharynx and upper oesophagus.

2. What other clinical features would you ask about and look for?

The history may include pain and dysphagia related to cricopharyngeal spasm. Regurgitation when the patient is supine may lead to aspiration, chronic cough or lung abscess.

There may also be a lump in the neck which typically presents on the left. Rarely a carcinoma may develop within the pouch and therefore regional nodes should be assessed.

3. What are the options for management?

This problem usually occurs in the elderly and a conservative approach may be justified in the infirm or demented patient. Operative options include an open procedure through the left neck. A cricopharyngeal myotomy is performed and the sac excised or plicated. Endoscopic management is increasingly popular. This is easiest in the edentulous patient where exposure of the pharynx may be excellent. An endoscopic linear stapler-cutter is used to simultaneously divide the cricopharyngeus and open the pouch into the oesophagus.

4. What is the underlying pathology and key to successful treatment?

The underlying problem is cricopharnygeal spasm leading to high intraluminal pressures above the upper oesophageal sphincter. This leads to progressive development of a diverticulum through the area of relative weakness in the posterior wall of the lower pharynx (dehiscence of Killian).