Zenker Diverticulum

Snapshot

• A 59-year-old man presents to the clinic for complaints of bad breath and recurrent coughing spells. He complains difficulty swallowing at times and is noted to have a moderately sized neck mass during physical examination.

Introduction

• False diverticulum (sac-like outpouching of only the mucosa and submucosa) of the esophagus 
  • true diverticulum contains all layers of the intestinal wall
• Epidemiology
  • incidence
    • prevalence of 0.01 – 0.11% in the U.S.A.
  • demographics
    • 1.5:1 male predominance
    • typically seen in middle-aged adults and older adults in 7-8^th decade of life
  • location
    • occurs at the upper part of the esophagus at Killian triangle (an area of muscular weakness between the cricopharyngeus muscle and lower inferior constriction)   
• Pathogenesis
  • Killian triangle is a natural area of weakness within the muscular wall of the esophagus and is more common in men
  • thought to result from chronic increased pressure on the weakened area due to either
    • high intrabolus pressures during swallowing
    • resistance to swallowing due to abnormalities of the upper esophageal sphincter
• Prognosis
  • ranges widely depending on health of patient and surgical approach
• disease itself is rarely life-threatening

Presentation

• Symptoms
  • dysphagia
  • regurgitation
  • choking
  • halitosis (bad breath)
  • chronic cough
• Physical exam
• palpable, fluctuant neck mass

Imaging 

• Barium swallow 
  • preferred method of diagnosis  
  • will demonstrate dye collection posterior to the esophagus
• Transcutaneous ultrasound
  • allows for differentiation from a thyroid/neck mass
  • good alternative for people who have difficulties swallowing barium
• Esophageal manometry 
  • not required for diagnosis
• may help delineating the pathogenesis of the diverticulum

Differential

• Achalasia
  • distinguishing factor
    • will demonstrate a bird’s beak on barium swallow
• Diffuse esophageal spasm
  • distinguishing factor
• will have characteristic findings on esophageal manometry

Treatment

• Conservative treatment
  • if diverticulum is small and asymptomatic, no treatment is necessary
• Operative
  • myotomy of cricopharyngeus muscle with diverticulum resection
    • indication
      • if the diverticulum is large and symptomatic
• endoscopic approach has better success rates compared to external approach

Complications

• Aspiration pneumonia
• Squamous cell carcinoma of the diverticulum
  • prevalence ranges from 0.3-7 %
• Ulceration and bleeding
• Increased risk of iatrogenic perforation