This article raised an eyebrow on the grounds that apparently more than one type of pharyngeal pouch exists! They differ in terms of aetiology, site and approach to treatment, therefore awareness of them is advised to ensure the appropriate surgical management. The authors explain the anatomical relations of a traditional Zenker’s diverticulum, through the cricopharyngeus and inferior constrictors. They then describe the weakness below the cricopharyngeus and where the recurrent laryngeal nerve enters the larynx, named the Killian-Jamieson area. Pouches that arise here are intimately related to the recurrent nerve and the authors therefore advocate an external diverticulectomy rather than endoscopic approach. Laimer’s diverticulums are those arising within the triangular area bound by the cricopharyngeus and the divergent longitudinal muscle fibres of the oesophagus. These diverticula are ‘true’ in nature and are caused by oesophageal dysmotility. The final type is traction diverticulum, usually from a nidus of inflammation or infection, or more recently noted following anterior approaches to the cervical spine. Again these pouches are best treated from the external approach due to the scarring which may not be amenable to endoscopic stapling. Due to these diverticulum all arising inferior to the cricopharyngeus, this also makes endoscopic approaches to dividing them more challenging. They are best diagnosed based on history (previous cervical surgery / infection) and barium swallow. This article was well written with supporting line drawings of the anatomical differences. Recognition of an alternative diagnosis to a Zenker’s, even if it is at endoscopy, is important as this may affect the decision to convert to an open procedure sooner. 

Not all pharyngeal pouches are created equal: management of “non-zenker” hypopharyngeal diverticula.
Johnson CM, Postma GN.
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Suzanne Jervis

FRCS (ORL HNS), Shrewsbury and Telford Hospitals, NHS Trust, UK.

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