Overview
Definition:
Zenker's diverticulum is an outpouching of the pharyngeal mucosa and submucosa through a weak point in the posterior hypopharyngeal wall, specifically Killian's dehiscence, located between the oblique and transverse fibers of the cricopharyngeus muscle
It typically occurs in the elderly and can lead to significant symptoms due to retained food and secretions
The pathogenesis is thought to be related to increased intraluminal pressure in the pharynx or esophagus, often due to cricopharyngeal spasm or achalasia
It is the most common type of esophageal diverticulum.
Epidemiology:
Zenker's diverticulum has an estimated incidence of 1 in 100,000 population
It is most commonly diagnosed in individuals between their 60s and 80s, with a higher prevalence in men
It is a rare condition overall, but a significant cause of dysphagia in the elderly
Patients may be asymptomatic for many years.
Clinical Significance:
Zenker's diverticulum poses significant challenges in management due to its location and potential complications
Accurate diagnosis and appropriate treatment are crucial to alleviate symptoms, prevent malnutrition, and avoid serious complications like aspiration pneumonia, esophageal perforation, and malignant transformation
The choice between endoscopic and open surgical approaches requires careful patient selection and consideration of procedural risks and benefits for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Progressive dysphagia, often to solids first then liquids
Regurgitation of undigested food, sometimes hours after eating
Halitosis (bad breath) due to retained food
Neck mass or sensation of a lump in the throat
Coughing or choking, especially during meals, suggestive of aspiration
Weight loss due to reduced oral intake
Hoarseness may occur due to recurrent laryngeal nerve irritation.
Signs:
Palpable neck mass, particularly on the left side, which may gurgle on palpation (Brunner's sign)
Signs of malnutrition
Signs of aspiration pneumonia, such as fever, tachypnea, and decreased breath sounds
Oropharyngeal examination may reveal pooling of secretions or food debris
Vital signs may be normal unless complicated by aspiration pneumonia.
Diagnostic Criteria:
Diagnosis is primarily based on imaging
While no specific formal criteria exist, a diagnosis is confirmed by demonstrating an outpouching from the posterior hypopharyngeal wall above the cricopharyngeus muscle on barium swallow
Symptoms such as dysphagia, regurgitation, and halitosis are strongly suggestive and warrant investigation
Endoscopic visualization of the diverticulum and assessment of its neck are also critical.
Diagnostic Approach
History Taking:
Detailed history of dysphagia (onset, progression, nature of food involved)
Characterize regurgitation (timing, volume, contents)
Ask about associated symptoms like halitosis, cough, choking, hoarseness
Inquire about weight loss and nutritional status
Assess for any prior history of swallowing difficulties or esophageal disorders
Enquire about medical comorbidities that might impact surgical risk
Red flags include rapid onset of symptoms, significant weight loss, and signs of aspiration.
Physical Examination:
A thorough head and neck examination, including palpation of the neck for masses
Auscultation of the chest to detect signs of aspiration pneumonia
Oral cavity examination to assess for pooling of secretions or food
Palpation of the abdomen if malnutrition is suspected.
Investigations:
Barium swallow (esophagography) is the gold standard for diagnosis, clearly delineating the diverticulum's size, location, and neck
Esophagoscopy (flexible or rigid) allows direct visualization of the diverticulum, assessment of the mucosal integrity, and evaluation of the cricopharyngeus muscle
Esophageal manometry can identify underlying motility disorders like cricopharyngeal spasm, which may be contributing factors
Chest X-ray to rule out aspiration pneumonia.
Differential Diagnosis:
Other esophageal diverticula (epiphrenic, mid-esophageal)
Achalasia
Esophageal strictures (benign or malignant)
Pharyngeal tumors
Globus pharyngeus
Esophageal candidiasis
Eosinophilic esophagitis
Neurological dysphagia.
Management
Initial Management:
For asymptomatic or mildly symptomatic patients, conservative management with dietary modification (soft diet, smaller meals, thorough chewing) and lifestyle changes (avoiding lying down immediately after eating) may suffice
For symptomatic patients, definitive treatment is indicated
The decision between endoscopic and open surgery depends on diverticulum size, patient comorbidities, surgeon's expertise, and patient preference.
Medical Management:
Medical management is primarily conservative and focuses on symptom relief and preventing complications
Dietary modifications are key
No specific pharmacotherapy directly treats Zenker's diverticulum itself, but medications may be used for associated conditions like GERD or aspiration prophylaxis if severe
Nutritional support through feeding tubes may be required in cases of severe malnutrition or prolonged dysphagia.
Surgical Management:
Surgical options include open surgery (diverticulectomy with or without cricopharyngeal myotomy
diverticulopexy with myotomy) and endoscopic diverticulotomy
**Open Surgery:** Traditionally the preferred method, involving a cervical incision, dissection to the diverticulum, and either excision of the sac (diverticulectomy) or suspension of the sac (diverticulopexy), usually combined with a cricopharyngeal myotomy to relieve the underlying pressure
**Endoscopic Surgery:** Performed via the mouth using a rigid esophagoscope
The technique involves incising the common wall between the esophagus and the diverticulum, effectively widening the opening and allowing drainage
This is typically achieved by dividing the inferior edge of the cricopharyngeus muscle and the septum between the esophagus and the diverticulum using a stapler or a hook knife
This approach offers faster recovery and less morbidity but may be limited by diverticulum size or associated pathology.
Supportive Care:
Postoperative care includes monitoring for bleeding, infection, and aspiration
Nutritional support may be necessary
Speech therapy may be beneficial for patients with persistent swallowing difficulties
Long-term follow-up is important to assess for recurrence or complications.
Complications
Early Complications:
Bleeding, mediastinitis, vocal cord paralysis (recurrent laryngeal nerve injury), pharyngeal or esophageal perforation, infection, wound dehiscence (open surgery), pneumothorax, air embolism (rare, endoscopic).
Late Complications:
Recurrence of symptoms, persistent dysphagia, aspiration pneumonia, weight loss, stricture formation, potential for malignancy (rare, within the diverticulum).
Prevention Strategies:
Careful patient selection for each surgical modality
Meticulous surgical technique to minimize injury to adjacent structures
Adequate division of the cricopharyngeus muscle during myotomy
Prompt recognition and management of aspiration
Proper postoperative diet and rehabilitation.
Prognosis
Factors Affecting Prognosis:
Size and location of the diverticulum
Presence of associated motility disorders
Surgical technique used
Surgeon's experience
Patient's overall health status and comorbidities
Development of complications.
Outcomes:
Both endoscopic and open surgical approaches generally offer good outcomes with significant relief of symptoms and improved quality of life
Endoscopic diverticulotomy often leads to shorter hospital stays and quicker recovery
Open surgery may be preferred for very large diverticula or when malignancy is suspected
Recurrence rates are generally low but can occur, especially if myotomy is incomplete.
Follow Up:
Follow-up typically involves clinical assessment for symptom recurrence
Imaging may be repeated if symptoms return or if complications are suspected
Patients are advised to maintain good dietary habits and monitor for any new symptoms
Long-term vigilance for potential complications like aspiration or malignancy is important.
Key Points
Exam Focus:
Zenker's diverticulum is a pulsion diverticulum in Killian's dehiscence
The primary symptom is progressive dysphagia and regurgitation
Barium swallow is the investigation of choice
Treatment options are open cricopharyngeal myotomy with diverticulectomy/diverticulopexy vs
endoscopic diverticulotomy
Endoscopic approach is less invasive with faster recovery but may be limited by diverticulum size
Cricopharyngeal myotomy is crucial for long-term success by addressing the underlying functional obstruction.
Clinical Pearls:
Always consider Zenker's in elderly patients with progressive dysphagia and regurgitation, especially if halitosis is present
The sound of gurgling on palpation of a neck mass can be pathognomonic
Aspiration is a significant complication that needs to be actively screened for and managed
Inadequate cricopharyngeal myotomy is a common cause of persistent symptoms after surgery
For exam purposes, remember the location of Killian's dehiscence and the muscles involved.
Common Mistakes:
Misdiagnosing Zenker's diverticulum as reflux or a benign stricture
Performing endoscopy without adequate preparation or sedation, leading to incomplete visualization
Performing myotomy without adequate length or depth
Over-reliance on only one surgical technique without considering patient factors
Failure to address the cricopharyngeal muscle dysfunction
Not considering aspiration risk in patients with Zenker's diverticulum.