Throat / Larynx / Pharynx

The "throat" is the layman's term for the pharynx and larynx. The pharynx is the food passage and the larynx is the voice box but they are connected as evidenced by the fact that we put food into our throats, and also inhale air through it to breathe. The pharynx and larynx work together to stop food/drink from going down into the lungs and to stop air going into the stomach. It is thus a separation area.

The larynx part of the throat consists of a triangular box of specialised cartilages covered by delicate lining. It is essential in providing an airway to breathe through, a separator to protect the lungs from swallowed food /liquid , and lastly in providing voice for communication.

The pharynx part of the throat consists of a muscular tube consisting of 3 layers of muscles much like 3 polystyrene cups sitting one inside the other. Each layer or "cup" of muscles is open in front where they joins with the mouth, the back of the tongue and the larynx or voice box. The lowest part of the 3rd layer or "cup" is the cricopharyngeus which acts as a sphincter at the top of the gullet (oesophagus).

What is normal swallowing?

There are 3 phases in swallowing: oral, pharyngeal, and oesophageal.

The oral phase is voluntary and starts when you push food with your tongue backwards into the throat. The rest of the swallow is automatic or involuntary and involves the pahryngeal and oesophageal phases. There is an automatic process that begins at the back of the tongue and progressively travels down the throat (pharynx) and gullet (oesophagus) into the stomach. This process is a sequential wave of relaxation followed by contraction creating a travelling "squeeze" that pushes the food before it and down the food passage. Relaxation of the food passage muscles before the "squeeze" wave accommodates the food bolus which essentially travels down within the travelling wave of relaxed muscles.

In the pharyngeal phase the larynx is lifted up (watch your adam's apple raise when you swallow) and is tucked up under the tongue base. At the same time the larynx is closed by the epiglottis acting like a lid to shut it off as the food passes by. The vocal cords are also brought together so that any liquid or food that gets past the epiglottis cannot go further into the airway. After the food goes past, the larynx lowers to it's normal position, the epiglottis tips up again and the vocal cords open so that you can breathe again. This phase is therefore quite quick.

The oesophageal phase is a continuation of the waves of relaxation and squeeze from the pharynx but is generally slower.



Pharyngeal pouch surgery

Pharyngeal pouch surgery is required when there is a hold-up of food in the throat after swallowing due to a pouch.  The aims of surgery are

  • to divide the tight and incoordinate cricopharyngeal muscle 
  • to eliminate the pouch
  • to restore normal swallowing 

Pharyngeal pouch surgery is done under a general anaesthetic so that the patient is asleep and unaware during the operation. Generally the operation commences by gently inserting a telescope through the mouth in order to examine the throat in general, then to inspect the pouch and to ensure that the lining is healthy i.e. no cancers. When the operation is done externally which is Dr McIvor's preferred method, the pouch is then packed with gauze to make it more obvious and a small tube is placed in the oesophagus to stretch and better define the tight cricopharyngeal muscle.

An incision is made in the lower neck on the left side as pouches tend to veer to the left. A gentle dissection is performed down to the pouch which is readily identified behind the larynx and trachea. Having gauze packing within the pouch facilitates this. The pouch is then dissected to display the underlying tight muscle which is cut without making a hole in the internal throat lining. The gauze is removed via the mouth by the anaestetist and the pouch is either inverted (usually) or excised (when large). A small drain is then inserted and the wound closed with running sutures.

The photo to the left demonstrates the small incision for this surgery. It heals as a fine and usually barely visible scar.

The procedure takes about 1 hour but can be longer depending on its complexity.

The hospital stay is usually 1 day and planned time off work should be 7-10 days.


Pharyngeal pouch

A pharyngeal pouch is a pocket that balloons out the back of the pharynx or throat. It collects food and the patient becomes aware of a residue of food in the throat after swallowing. As it enlarges over months/years it collects more of each swallow. This produces an unpleasant sensation of having something stuck in the throat. Often food is brought up again hours after eating it. With time more food is trapped than is swallowed and the patient can begin to lose weight. Eating out can be embarrassing. Frequently coughing occurs after eating but this generally does not deliver the food out of the pouch. In extreme cases food trapped in the pouch can spill over into the windpipe (trachea) and cause chest infections.

Pharyngeal pouches usually present in people over 50 but occasionally can occur earlier. They generally develop because of an incoordination of the swallowing mechanism.

normal swallow

Usually when we swallow food, there is an automatic process that begins at the back of the tongue and progressively travels down the throat (pharynx) and gullet (oesophagus) into the stomach. This process is a sequential wave of relaxation followed by contraction creating a travelling "squeeze" that pushes the food before it down the food passage. Relaxation of the food passage muscles before the "squeeze" wave accommodates the food bolus which essentially travels down within the travelling wave of relaxed muscles.

Why do pouches develop?

A pouch develops because there is an incoordination between the squeeze wave and the preceeding wave of relaxation. The squeeze wave ends up forcing the food bolus into an area that has not relaxed in anticipation of the food. This area is at the site of the upper oesophageal sphincter otherwise known as the cricopharyngeus muscle. Why the cricopharyngeus does not relax in time for the food bolus is not always clear but it is often associated with gastro-esophageal reflux whereby acid from the stomach comes up into the throat causing a reflex constriction of the muscle. Also, as part of the aging process there can be a generalised incoordination right down the swallowing passage but most evident in the throat.

When the food bolus comes up against the constricted cricopharyngeus there is a bulging of the pharyngeal wall at its weakest point which is the back wall just above the cricopharyngeus. This area is known as "Killian's dehiscence" after the man who described it and is relatively weaker than other areas purley because it doesn't have as many muscle layers. So the back wall gets stretched with each swallow until there is a pocket or pouch which hangs down behind the oesophagus and which collects food easily (as it doesn't have a good muscle layer unlike the main channel). The build up of food after each swallow is uncomfortable and increasingly embarrasing.


A pharyngeal pouch is diagnosed from the history and a barium or videoswallow. The classic story is of food getting trapped in the throat after swallowing and of undigested food being brought up hours later. The diagnosis is clinched by a test whereby liquid barium is swallowed while video XRays are taken demonstrating the pouch ballooning out the back of the pharynx.

Pharyngeal pouch surgery

Surgery is advised when a pharyngeal pouch is diagnosed as it will increasingly become the preferred food channel and cause increasing difficulty in swallowing

When and where will the operation be done?

What must I do in the weeks before surgery? ( insurance, hospital, family, work)

What do I do on the day of surgery? and what shall I bring to hospital?

What will happen when I go to theatre?

What will happen when I get back to the ward?

Is it a safe operation and what are the side effects?

Dr McIvor has done a large number of pharyngeal pouch operations. After healing, patients are expected to swallow normally. The vast majority are able to swallow liquid on the evening of surgery and to commence a soft diet the following morning. However, as with all operations, there are some risks which Dr McIvor minimises as much as possible.The main risk (<5%) is the possibility of a small breech in the throat lining which could allow saliva, food or drink to soil the neck tissues and cause an infection or abscess. If a breech is suspected, feeding is delayed until the lining has healed. This may require a short period of antibiotics and feeding through a nasogastric tube (tube through the nose down to the stomach) to allow healing to occur. If an abscess forms then the wound will need to re-opened in the operating room under general anaesthesia, washed out, and drained. Complete healing will ensue.

A lesser risk is to the nerve (recurrent laryngeal nerve) to the larynx (voice box) on that side (<5%)This is almost certain to be temporary. It causes a weak breathy voice but as stated above it is expected to recover completely over a few weeks.

Occasionally patients become more aware of acid reflux symptoms after the procedure and require antireflux medication such as losec. This is because they already have reflux before the procedure which contributes to the tight throat cricopharyngeal muscle and pouch formation. The tight cricopharyngeus reduces the amount of acid coming up into the throat but in doing so restricts swallowing. Once the muscle is cut during the operation, in these patients the acid may be perceived coming into the throat. Typically these patients respond to medication such as losec (omeprazole) but a small number need the attention of a gastroenterologist to solve the reflux problem.

Rarely (<1%) there may be a collection of blood in the wound which may require return to theatre and drainage.

Will it affect my voice ?

Dr McIvor has done a large number of pharyngeal pouch operations.  However, as with all operations, there are some risks which Dr McIvor minimises as much as possible.

Occasionally there is bruising or stretching of the nerve (recurrent laryngeal nerve) to the larynx (voice box) on that side (

Will I have neck stiffness or pain?

You will feel some discomfort in the lower neck and throat but you will be given some medication to help ease this. Pain relief may be given in different ways, such as injections, liquid medicine or tablets. Most patients say the discomfort is not as bad as they expected, and after the first day are up and walking around.

Following discharge Dr McIvor prescribes paracetamol and an anti-inflammatory for 5 days which suffices for any discomfort.  After a few weeks you should be back to a good standard of neck and throat function

Will I have a scar?

The incision is either in a skin crease or a zig-zag vertical line which heals to leave a fine scar.

What are the costs for pharyngeal pouch surgery?

There are generally 3 costs for any procedure:  surgeon’s fee, anesthetist’s fee, hospital fee. These are given separately by the surgeon, the anaesthetist, and the hospital and are to be paid separately. 

Dr McIvor’s secretary will give or post to you an estimate for all three of these costs.  It is important that you discuss this with your insurance company prior to coming into hospital. 

The hospital account is to be paid at the time of discharge from the hospital. The anaesthetic and surgeon fees should be settled on receipt of the account through the post or at the post-operative appointment.


What will I look like after surgery and what will I be able to do?

  1. You will have a scar in the lower left side of your neck . This will be covered by a small white dressing so that it is not visible. 
  2. You will have a small drain from your wound to collect wound fluid which naturally occurs following your surgery. The drains are small plastic tubes which are inserted into the neck at the end of your operation. The long length of tubing outside the neck is attached to a plastic collection bottle into which the fluid drains. Wound drains help to speed up wound healing and reduce infection.
  3. The drain is not painful can be carried around with you. It will usually be removed by a nurse the day after your operation when the drainage is minimal.   Drain removal is not painful.
  4. You will feel some discomfort in your throat mainly when swallowing but you will be given some medication to help ease any pain and discomfort. Pain relief may be given in different ways such as injections, liquid medicine or tablets. Most patients say it was not as bad as they expected.
  5. For your own safety it is important that you do not get out of bed on your own immediately following your operation as you may be drowsy and weak. At first when you need to use the toilet a member of staff will need to assist you with a commode or bedpan. You will soon be able to walk to the bathroom yourself.
  6. You will have a nurse call bell within easy reach so that you can seek help from the ward staff as needed.
  7. Following your operation you may not feel very sociable so it is wise to restrict visitors.


Will I have a sore neck?

When you wake from the anesthetic you will find that the skin of your neck is quite numb as the anesthetist inserts a lot of local anesthetic around the surgical area once you are asleep and prior to the operation.  This not only provides good pain relief but reduces the amount of intravenous pain relief he needs to give during the operation.  This helps to minimize the side effects of strong pain relief such as nausea and constipation.

You will be given medication to take home to relieve any discomfort.  Please take it as described on the packet and take care not to exceed the recommended dose.

Your wound area may appear swollen and hard to touch, with some numbness, which will gradually resolve as healing takes place.

When will I be able to eat and drink?

If Dr McIvor is happy with that the lining of the throat is intact then he may allow you to drink on the evening of surgery and then to commence a soft diet the following morning. This is the situation in the vast majority of cases. He will re-evaluate you in the morning and if he is happy then he will allow you to continue on the soft diet until he sees you in his clinic at one week.


What care do I need to take regarding my neck wound?

Keep your neck wound clean and dry.  There will be a paper tape over the wound to protect the wound.

After your skin tapes are removed at your one week appointment and the scar is healing well you can rub a small amount of unscented moisturising cream on the scar so it is less dry as it heals.  Vitamin A, Vitamin E, Bio-oil , or Aloe Vera are effective. Take care not to knock your wound and remember to keep the wound dry if it becomes wet after bathing or showering by patting it dry with a clean towel.

The pressure of rubbing the cream in will also help to soften the scar.

If the wound area becomes increasingly painful, red or swollen or you notice any discharge then please seek medical advice from Dr McIvor or your GP.

What rest do I need and when should I return to work?

You will need to take it easy while your neck wound is healing. This means avoiding strenuous activity and heavy lifting for a couple of weeks. The wound area will gradually feel less stiff and you will soon be able to enjoy your normal activities.

You will probably need to take 7 to 10 days off work (or sometimes longer) depending on your occupation and the nature of your work.   Dr McIvor can issue you with a note for this period and then you should see your GP if more time is required.

What about my medications and tablets?

Please continue to take the medication you have been prescribed and ensure that you have a good supply. If you are unsure about any of the tablets you need to take, please check this with a nurse before you go home. Repeat prescriptions can be obtained from your GP.


What follow-up will there be?

Following your discharge you will need to be reviewed in the clinic to check how your wound is settling down and also your swallowing. You will usually receive the date and time for this appointment through the post or by phone from Dr McIvor’s secretary. Please contact Dr McIvor’s secretary (09 4887349)if you do not receive one shortly following discharge.




Throat cancer / Laryngeal cancer

"Throat" is the layman's term for the voicebox (larynx), and the gullet (pharynx and upper oesophagus). Cancers here are not common as far as all malignancies go, but we see about 70 new cases each year in Auckland.

The following is a set of characteristics that we tend to see with these cancers but they can occur at any age from teen-ager to centurian, in either gender, and in those with no obvious risk factors. Patients with the symptoms or signs listed below should be investigated.


Cancer of the throat is most common in those older than 40 years. However it can present in any adult age group.

Risk factors

There is an asociation with smoking and excessive alcohol intake although many patients appear to have no such risk.


Throat cancer usually presents because of a lump or non-healing ulcer in the throat.  This can be perceived in various ways according to its location:

Visible swelling or ulcer
Those high in the throat, eg the tonsil, may be seen when the mouth is open.

Pain or discomfort
A non-healing ulcer may be felt as an irritation, discomfort or pain in the throat, usually to one side.  It may also be felt in the ear of the same side due to irritation of a throat nerve that also supplies sensation to the ear.

Difficulty swallowing

A throat tumour may progressively interfere with swallowing, initially with solids and then progressively with liquids and saliva.   At the start, there may be a discomfort on swallowing and then some foods may catch or stick.  After a while, some solids may have to be regurgitated and the person moves onto a pureed diet.  Progressively fluids become a problem and there is weight loss.

The above scenario is different from  a common problem called “globus” which is the feeling of something in the throat when swallowing saliva.  With globus, there is no discomfort or hold-up when swallowing solids or drinking.  It occurs only when the person is performing a dry swallow i.e nothing but a bit of saliva in the throat.  Globus is clearly different from the scenario of a throat tumour pictured above.

Change in voice or hoarseness
Tumours on the vocal cords will give a progressive alteration in voice as distinct from a change that is there some days and not on others and with no progression.  Hoarseness is the sole symptom of an early vocal cord cancer – therefore any persisting change in voice for 3 weeks or longer must be investigated.

Difficulty breathing and airway noise (stertor/stridor)
Tumours will gradually grow and occupy space that is important for breathing.  As they do so, sound is created as air passes through the narrowed channel.  In the upper throat e.g. the tonsil, this may sound like breathing with a potato in one’s mouth or throat and the voice quality may seem like one is talking with a "hot-potato" in the mouth.  Typically there is a slightly harsh breathing sound called “stertor”

In the voice box, there is already a normal narrowing in the airway at the level of the vocal cords which are very fine structures designed to vibrate voluntarily as one expels air.  This is how voice is produced.  With tumours in the voice-box or larynx, progressive airway narrowing causes involuntary noise during breathing that can have a tonal quality called “stridor”.  This sound can be on breathing in, or breathing in and out.  Airway noise occurring only when breathing out generally comes from the lower airway (in the chest) e.g. asthma.

Often there will be some blood tinging of saliva or sputum but not necessarily.

Neck lump
An enlarged lymph node is frequently the only thing noticed by a person who has developed a throat cancer.  This may be because the tumour has not ulcerated enough to hurt, is not big enough to interfere with swallowing or breathing, and is not affecting the vocal cords.  Many tumours are in this category and first bring attention to themselves by spreading to a lymph node in the neck.



The throat needs to be thoroughly examined and this usually requires inspection through a flexible scope in the clinic

any non-healing ulcer or lump that is visible through the mouth e.g. on the tonsil, can be biopsied in the clinic under local anaesthetic.  Those further down the throat require general anaesthesia and rigid endoscopy.

CT scan 
of the throat and neck to determine the extent of tumour involvement and also whether the neck nodes are enlarged.  Often the chest will also be scanned.