A 68-year-old man reports 2 years of progressive dysphagia, halitosis, and nocturnal coughing with regurgitation of food eaten many hours earlier. He describes a gurgling noise on swallowing and a swelling on the left side of his neck that he can compress, after which it refills. What is the underlying anatomical defect?

• A Herniation through Killian's dehiscence between the thyropharyngeus and cricopharyngeus ✓
• B Failure of relaxation of the lower oesophageal sphincter
• C Traction diverticulum at the level of the carina
• D Mucosal web at the postcricoid region

Explanation

This is a pharyngeal pouch, a pulsion diverticulum of the hypopharynx protruding through Killian's dehiscence, the weak area between the oblique fibres of thyropharyngeus and the transverse cricopharyngeus. Incoordination of cricopharyngeal relaxation raises pressure above the sphincter and drives mucosa out, usually to the left. Regurgitation of stale undigested food, gurgling, halitosis and night aspiration are characteristic. Achalasia involves the lower sphincter, and traction pouches are rare and asymptomatic.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.