Summary:
Zenker’s Diverticulum
Zenker’s diverticulum is a rare condition that affects between 0.01-0.11% of the population. It most commonly affects women and the elderly, and is least commonly reported in people of Middle and Far Eastern descent.
Zenker’s diverticulum was first described by Friedrich Albert von Zenker in 1877. In Zenker’s diverticulum, the esophageal mucosa herniates posteriorly between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscles. This region is a small triangular area that happens to be the weakest. When the cricopharyngeus muscle is contracting abnormally, there is discoordination of the swallowing process and a resulting increase in pressure on the mucosa of the pharynx, which leads to the eventual distention of the mucosa. This diverticulum can reach sizes of 15cm or more.
Diagram of a Zenker's Diverticulum Superimposed on an X-ray Image of the Neck
Radiographic Image of a Zenker's Diverticulum
Patients who have a Zenker’s diverticulum may have regurgitation of undigested food, halitosis, difficulty swallowing, changes in their voice, and possible mild to moderate weight loss. There are also some severe complications including aspiration and pneumonia. Even though the diverticulum can be fairly large, it is rarely palpable. Many patients in addition to the diverticulum have hiatal hernia, esophageal spasm, achalasia, and esophagogastroduodenal ulcerations.
The lab test of choice to determine if a Zenker’s diverticulum is present is a barium swallow. During this test, the patient drinks a preparation containing barium sulfate, which is a metallic compound that is visible on X-ray. Any possible abnormalities along the digestive tract will then be seen.
Currently there is no known medical treatment for symptomatic Zenker’s diverticulum. Therefore, the treatment of choice is surgical. However, in patients with diverticula that are less than 1 cm, or in patients with multiple medical problems, nonoperative measures may be taken. There are no absolute contraindications to operative management of a Zenker’s diverticulum. There are three different surgical procedures for this condition: 1. Diverticulectomy with cricopharyngeal myotomy, 2. Diverticulopexy with cricopharyngeal myotomy, and 3. Endoscopic myotomy. The diverticulectomy with cricopharyngeal myotomy is when the pouch is either sutured or stapled off and then removed. Additionally, the cricopharyngeus muscle is divided longitudinally. This is usually performed through an incision in the left neck. The diverticulopexy with cricopharyngeal myotomy is when the pouch is inverted and sutured to the coverings of the vertebrae. The pouch is not removed. Additionally, the cricopharyngeus muscle is divided longitudinally. This procedure is more commonly performed in the severely debilitated patient. In endoscopic myotomy an endoscope is placed in the pharynx with one part of a linear stapler in the pharynx and one part in the pouch. When the stapler is fired, the pouch is opened and incorporated into the wall of the esophagus. Additionally, when the stapler is fired, the cricopharyngeus muscle is divided.
Complications of these procedures are low, but may include vocal cord paralysis, wound infection, wound infection with fistula, and recurrence. The prognosis for these patients is fantastic; however, the key is early recognition, division of the cricopharyngeus muscle, and removal of the diverticulum.
