Overview
Definition:
Zenker's diverticulum is an outpouching of the pharyngeal mucosa and submucosa through a weak area in the posterior hypopharyngeal wall, typically Killian's triangle (between the thyropharyngeus and cricopharyngeus muscles)
It is a pulsion diverticulum.
Epidemiology:
It is the most common esophageal diverticulum, typically affecting individuals in their 60s and 70s
There is a slight male predominance
Incidence is estimated at 1-2 per 100,000 population annually
It is rarely seen in younger individuals.
Clinical Significance:
Zenker's diverticulum is significant due to potential complications like dysphagia, regurgitation of undigested food, aspiration pneumonia, halitosis, weight loss, and rarely, esophageal cancer
It significantly impacts quality of life and requires surgical intervention when symptomatic.
Clinical Presentation
Symptoms:
Dysphagia, often described as difficulty swallowing solids more than liquids
Regurgitation of undigested food, sometimes hours after eating
Cough or choking, particularly with meals, due to aspiration
Halitosis (bad breath) due to stagnant food in the diverticulum
Unexplained weight loss
Hoarseness or throat discomfort.
Signs:
A palpable mass in the neck, especially when the patient strains or performs Valsalva maneuver
Auscultation may reveal gurgling sounds in the neck after eating
Poor dentition is often noted
Vital signs are usually normal unless aspiration pneumonia is present.
Diagnostic Criteria:
Diagnosis is typically confirmed with imaging studies
Clinical suspicion arises from characteristic symptoms
No formal "criteria" exist, but a combination of classic symptoms and radiological findings establishes the diagnosis.
Diagnostic Approach
History Taking:
Detailed questioning about onset, duration, and progression of dysphagia
Nature of regurgitated material (solids, liquids, undigested)
Any associated cough, choking, or aspiration events
Presence of halitosis, hoarseness, or weight loss
Past medical history, especially of GERD or previous neck surgery
Review of dentition.
Physical Examination:
Careful examination of the neck for any masses or pulsations
Auscultation for gurgling sounds
Oral cavity examination to assess dentition and oropharyngeal structures
Neurological examination to rule out motility disorders
Assessment for signs of aspiration pneumonia (fever, tachypnea, crackles).
Investigations:
Barium esophagogram is the gold standard for diagnosis, clearly delineating the diverticulum, its size, and location
Esophagoscopy (flexible or rigid) allows direct visualization but must be performed cautiously due to the risk of perforation
it is essential to examine the diverticular opening
Esophageal manometry may be performed to assess cricopharyngeal muscle function but is not typically routine for diagnosis.
Differential Diagnosis:
Achalasia, peptic stricture, esophageal cancer, Schatzki ring, external esophageal compression (e.g., vascular anomalies, enlarged lymph nodes), pharyngeal tumors, functional dysphagia, and other types of esophageal diverticula (e.g., epiphrenic)
Distinguishing features include the characteristic location and symptoms of Zenker's.
Management
Initial Management:
Dietary modifications to soft, pureed foods
Frequent small meals
Avoidance of very hot or cold foods
Improved oral hygiene
For asymptomatic patients, conservative management may suffice.
Medical Management:
Primarily symptomatic management
Antibiotics if aspiration pneumonia occurs
Acid suppressants (PPIs) if GERD is contributing to irritation, though not a primary treatment for the diverticulum itself.
Surgical Management:
Surgical excision of the diverticulum is indicated for symptomatic patients
Procedures include: 1
Diverticulectomy: Excision of the diverticulum with division of the cricopharyngeus muscle (myotomy)
Preferred for large diverticula
2
Diverticulopexy: Suspension of the diverticulum to the prevertebral fascia, usually with a myotomy
Suitable for smaller diverticula
Approaches can be cervical (open) or transoral endoscopic
Open cervical approach (left or right anterior neck incision) is most common
Transoral stapled diverticulectomy is a minimally invasive option.
Supportive Care:
Postoperative care involves pain management, monitoring for signs of bleeding or infection, gradual resumption of diet, and nursing support to ensure adequate hydration and nutrition
Monitoring for pulmonary complications is crucial.
Complications
Early Complications:
Bleeding, infection (wound or mediastinitis), pharyngeal or esophageal perforation, recurrent laryngeal nerve injury (leading to vocal cord paralysis), esophageal leak, aspiration pneumonia, pneumothorax, temporary fistula formation.
Late Complications:
Diverticulectomy site stenosis, recurrence of symptoms (if myotomy incomplete or diverticulum not fully addressed), persistent dysphagia, fistula formation, chronic cough, weight loss.
Prevention Strategies:
Meticulous surgical technique, careful identification of anatomical planes, adequate myotomy of the cricopharyngeus muscle, appropriate antibiotic prophylaxis, cautious use of endoscopic instruments, and diligent postoperative monitoring are key to preventing complications.
Prognosis
Factors Affecting Prognosis:
Age and comorbidities of the patient, size and complexity of the diverticulum, surgical approach used, and experience of the surgical team
Presence of aspiration pneumonia preoperatively can affect outcomes.
Outcomes:
Symptomatic relief is generally excellent after successful surgical intervention, with over 90% of patients reporting significant improvement in dysphagia and regurgitation
Long-term recurrence is uncommon with appropriate surgical technique.
Follow Up:
Postoperative follow-up typically involves clinical assessment at 1 week, 1 month, and then as needed
Speech therapy evaluation may be beneficial
Patients should be advised on dietary modifications and to report any persistent or recurrent symptoms promptly
Routine imaging is usually not required unless symptoms suggest recurrence or other pathology.
Key Points
Exam Focus:
Zenker's is a pharyngoesophageal pulsion diverticulum at Killian's triangle
Classic symptoms include dysphagia, regurgitation, and halitosis
Barium esophagogram is diagnostic
Surgical excision with cricopharyngeal myotomy is the standard treatment
Risks include recurrent laryngeal nerve injury and perforation.
Clinical Pearls:
When suspecting Zenker's, consider asking if patients bring up undigested food hours after a meal, not just during eating
Be cautious during esophagoscopy to avoid perforation
A single, complete cricopharyngeal myotomy is crucial for preventing recurrence
Transoral approaches are gaining traction.
Common Mistakes:
Misdiagnosing Zenker's as simple GERD or dysphagia without proper investigation
Performing an incomplete myotomy, leading to symptom recurrence
Failing to consider aspiration as a complication
Overly aggressive esophagoscopy that results in perforation
Ignoring the importance of dentition in patients with regurgitation.