Pharyngoceles are rare and more often unilateral than bilateral 2-4. It is commonly associated with occupational exposure to increased intra-pharyngeal pressure 1,3 such as glass blowing or playing musical woodwind/brass instruments. It occurs more frequently in males than in females and usually arises during the fifth and sixth decades of life 2,4,5.
Raised intrapharyngeal pressure secondary to 1-7:
- playing woodwind or brass instruments
- glass blowing
- excessive cough
The majority of patients are asymptomatic 4,5. The primary manifestation is dysphagia 4-6 but other clinical features may include 4,6:
The two main factors involved in the pathogenesis of pharyngoceles are chronic elevation of intrapharyngeal pressure and pharyngeal wall weakness 3-6.
Most documented cases in the medical literature have an association with the repeated elevation of intrapharyngeal pressure. Patients are typically glassblowers or musicians who play woodwind or brass instruments 1-7.
Pharyngocoeles can arise from two areas of weakness on the lateral wall of the pharynx 4,5.
- between the superior and middle pharyngeal constrictor muscles
- between the middle and inferior pharyngeal constrictor muscles 4,5,7
Loss of muscle elasticity with aging and previous surgeries can contribute to the wall weakness 2-5. A minority of patients have congenital causes thought to be due to branchial cleft anomalies 2,3,7.
Pharyngocoeles may be seen on a transverse sonogram at the level of the ventricular folds 8 as a hyperechoic gas pocket which enlarges during a Valsalva maneuver 8. In pharyngoceles, gas communicates with piriform sinuses distinguishing it from laryngoceles which have gas communicating with laryngeal saccules 8. Identification of pharyngoceles on ultrasound can be difficult in the presence of thyroid calcification 8,9.
Plain radiograph / fluoroscopy
Pharyngocoeles are best identified on the frontal barium swallow x-ray during a Valsalva maneuver 2 before and after contrast administration. In bilateral pharyngoceles, a "bullfrog appearance" can be appreciated on frontal cervical x-rays 1.
CT and laryngoscopy are the diagnostic tools of choice 4,5,7. Similar to radiographs, it is best appreciated during a Valsalva maneuver after ingestion of positive oral contrast medium 7. It is typically seen as a parapharyngeal gas sac that communicates with the base of the piriform sinus or the lateral side of the vallecula 5.
Morphologically is similar to findings on CT. Dynamic real-time and 3D MRI can allow for better visualization of the anatomy, specific location and characteristics of the lesion 4,9.
Treatment and prognosis
Treatment is usually conservative involving healthy dietary habits, oral hygiene, avoiding activities that increase intrapharyngeal pressure and wearing a compressive neck wrap while doing those activities 2,3,6,7. Surgical excision may be indicated in severely symptomatic patients 2,3,5-7.
- 1. Hao Xiang, Jason Han, William E Ridley, Lloyd J Ridley. Bullfrog swallow: Bilateral pharyngocoeles. (2018) Journal of Medical Imaging and Radiation Oncology. 62: 59. doi:10.1111/1754-9485.07_12784 - Pubmed
- 2. José Maria Porcaro-Salles, João Marcos Arantes Soares, Alexandre de Andrade Sousa, Gustavo Meyer, Marco Homero de Sá Santos. Lateral pharyngeal diverticulum: A report of 3 cases:. (2011) Ear, Nose & Throat Journal. 90 (10): 489-92. doi:10.1177/014556131109001010 - Pubmed
- 3. Oishi Konari M, Zapater Latorre E, Mosquera Lloreda N, Basterra Alegría J. Pharyngocele. (2013) Acta otorrinolaringologica espanola. 64 (5): 369-70. doi:10.1016/j.otorri.2012.02.003 - Pubmed
- 4. Restrepo S, Villamil MA, Rojas IC, Palacios E. Pharyngocele: CT and MRI findings. (2003) Ear, nose, & throat journal. 82 (7): 492, 494. Pubmed
- 5. Duarte R, Miranda D, Pereira T, Gomes S, Vasconcelos M. Pharyngocele: CT findings - a case report. (2008) Eurorad. doi:10.1594/EURORAD/CASE.6608
- 6. Dr. Norair Adjamian, Dr. Lyndsay L. Madden, Dr. Libby J. Smith. Bilateral Massive Pharyngoceles:. (2018) Ear, Nose & Throat Journal. 97 (8): 230-232. doi:10.1177/014556131809700818 - Pubmed
- 7. Edmiston R, Hariri A, Karagama Y. The trumpet player with a swelling in the neck. (2015) BMJ case reports. doi:10.1136/bcr-2015-209487 - Pubmed
- 8. Chevallier P, Motamedi JP, Marcy PY, Foa C, Padovani B, Bruneton JN. Sonographic discovery of a pharyngocele. (2000) Journal of clinical ultrasound : JCU. 28 (2): 101-3. doi:10.1002/(sici)1097-0096(200002)28:2<101::aid-jcu9>3.0.co;2-p - Pubmed
- 9. Louisa Traser, Claudia Spahn, Bernhard Richter, Tobias Baumann, Martin Schumacher, Matthias Echternach. Real‐time and three‐dimensional MRI for diagnosis of pharyngoceles. (2014) Journal of Magnetic Resonance Imaging. 40 (1): 55. doi:10.1002/jmri.24400 - Pubmed