Pharyngoesophageal (Zenker) Diverticulum

• • Dysphagia, pressure symptoms, and gurgling sounds in the neck

  • Regurgitation of undigested food, halitosis

  • Manual emptying of the diverticulum by the patient

Epidemiology

• • Diverticula are acquired lesions that result from the protrusion of mucosa and submucosa through a defect in the musculature due to high pressures generated during swallowing (pulsion type, most common) or from the pulling outward of the esophagus from inflamed peribronchial mediastinal lymph nodes (traction type)

  • Diverticula arise posteriorly in the midline—above the cricopharyngeus muscle and below the inferior constrictor of the pharynx; the sac projects laterally

  • Pulsion diverticula are 3 times more common in men than in women; most patients are over age 60

  • The body of the esophagus often shows abnormal motility; an associated hiatal hernia is common and abnormal reflux is present in about 33% of patients

Symptoms and Signs

• • Dysphagia: Related to the size of the diverticulum

  • Undigested food is regurgitated into the mouth, especially when the patient is in the recumbent position

  • The patient may manually massage the neck after eating to empty the sac

  • Swelling of the neck

  • Gurgling noises after eating

  • Halitosis and a sour metallic taste in the mouth

Imaging Findings

• • A smoothly rounded blind pouch is visible on fluoroscopic exam

  • Esophagoscopy is hazardous because the instrument may enter the ostium of the diverticulum and lead to perforation

• • Esophageal manometry and pH measurements will show if the diverticulum is associated with an abnormal response of the cricopharyngeus muscle to swallowing (delayed opening of the sphincter) and the amount of gastroesophageal reflux

Rule Out

• • Malignant lesions

  • Achalasia of the cricopharyngeus muscle

  • Cervical esophageal webs (may also occur along with diverticula)

• • Radiographic contrast fluoroscopic esophagogram

  • Manometry

  • pH testing

When to Admit

• • Diverticular perforation with mediastinitis or abscess

  • Aspiration pneumonitis or pneumonia

  • Severe dysphagia prohibiting enteral intake

Surgery

• • Excision of the diverticulum and division of the cricopharyngeal muscle

  • Other options:

  • -Diverticulopexy

    -Oropharyngeally placed ligating and dividing stapler

Indications

• • All cases

  • If the patient also has significant gastroesophageal reflux, this should be corrected before the upper sphincter is divided, in order to avoid aspiration

Complications

• • Aspiration leading to pneumonitis

  • Diverticular perforation with mediastinitis or paraesophageal abscess

  • Mucosal ulceration and bleeding

Prognosis

• • Excellent

References