Signs and Symptoms

Patients typically complain of dysphagia, regurgitation of undigested food, a feeling of food sticking in the throat, a globus sensation, and a persistent cough (especially after eating). Signs or symptoms may include aspiration, unintentional weight loss, and halitosis. Occasionally, a soft swelling may be palpable in the neck, typically in the left side.

Differential Diagnosis

The differential diagnosis includes pharyngeal malignancy, esophageal malignancy, and dysphagia due to central nervous system (CNS) etiology.

History

A history is often suggestive of Zenker′s diverticulum. Questions should be asked pertaining to weight loss, regurgitation, halitosis, and signs or symptoms associated with aspiration, such as frequent choking and coughing. There is typically no pain except in the presence of carcinoma.

Physical Exam

A full head and neck exam should be performed. On laryngoscopy, signs of laryngitis and pooling of saliva in the hypopharynx secondary to underlying cricopharyngeal hypertrophy may be seen. Less commonly, undigested food particles may be seen.

Imaging

Video fluoroscopy with barium typically demonstrates the pouch, especially near the end of the second stage of swallowing. This test is usually diagnostic, and no further imaging exams are typically necessary. Of note, ensuring the unilaterality of the pouch during this exam is important.

Pathology

Zenker′s diverticulum is a herniation or false diverticulum of the esophageal mucosa posteriorly between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscles ( Fig. 5.4 ). Although rare, it is important to recognize that a small percentage of patients with Zenker′s diverticulum may have a squamous cell carcinoma in the pouch (0.5 to 1%).

Medical

In a medically infirm patient, botulinum toxin (Botox; Allergan, Dublin, Ireland) injections to the middle pharyngeal constrictor (formerly called oropharyngeus) muscle may be effective.

Surgical

Treatment is typically surgical and reserved for symptomatic patients or patients with aspiration and pneumonia. Surgical management of Zenker′s diverticulum entails division of the cricopharyngeus muscle to eliminate the potentially elevated pressure zone and elimination of the diverticular pouch as a reservoir of food and secretions. Surgical treatment may be endoscopic or open. Operative intervention is usually undertaken when the diverticulum is at least 3 cm in length.

Endoscopic treatment includes endoscopic identification of the pouch and stapler transection of the cricopharyngeal bar, or the common wall between the pouch and the cricopharyngeal introitus is divided to make a common lumen.

Open surgical techniques include open diverticulectomy, inversion, cricopharyngeal myotomy, or diverticulopexy in which the diverticulum is inverted and sutured to the prevertebral fascia. Open techniques are typically performed through a left neck incision.

Signs and Symptoms

Patients may relate very specific aspects of the swallowing reflex that are problematic for them, or they may simply have a generic complaint of trouble swallowing. Dysphagia is associated with symptoms including choking, gagging, globus, odynophagia, difficulty initiating swallow, drooling, aspiration, coughing, nasal reflux, and regurgitation. A history of pneumonia is concerning for chronic aspiration. Weight loss may be a sign of dysphagia significant enough to reduce caloric intake, or potentially a neoplastic process. Children with dysphagia may have similar symptoms but also prolonged feeding times, repeated swallow efforts, or unusual posturing during feeding.

Dysphagia may involve one or more of the phases of the swallowing reflex, including oral preparatory, pharyngeal, or esophageal phases. Specific symptoms may direct the examiner′s attention to one of these sites.

Differential Diagnosis

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  Neurologic disorder (e.g., myasthenia gravis, Parkinson′s disease [PD], amyotrophic lateral sclerosis [ALS], multiple sclerosis, cerebral palsy, mental retardation or developmental delay, muscular dystrophy, postpolio syndrome, cranial neuropathies)

  
  
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  Neurologic injury (e.g., cerebrovascular accident, traumatic brain injury, neurosurgical or skull base procedures with cranial neuropathies)

  
  
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  Obstruction (e.g., upper aerodigestive tract neoplasms, esophageal web, strictures, achalasia, foreign body, cricopharyngeal dysfunction, cervical spine osteophytes)

  
  
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  Other (e.g., xerostomia, gastroesophageal reflux disease [GERD], presbyphagia or presbyesophagus, neck irradiation, cleft lip/palate, hypopharyngeal diverticulum, tracheotomy)

Physical Exam

The physical exam should include all components of the upper aerodigestive tract. The oral cavity should be examined and note made of labial competence; salivary function; tongue mobility, symmetry, and strength; palatal motion; mucosal lesions or masses; and gag reflex. The pharyngeal examination should include mirror examination and/or flexible nasopharyngoscopy. In addition to examining for symmetry, mass effect, and mucosal lesion, the presence of pooled secretions is a key finding. Saliva and liquid or food residue in the vallecula, piriform recesses, and postcricoid area indicate either an obstruction of material passage somewhere between the cricopharyngeus and the stomach, or a sensory defect of the hypopharynx and larynx.

Laryngeal examination is a component of the pharyngeal evaluation. A “wet voice” may indicate retained secretions in the hypopharynx and laryngeal introitus. The sensation, general mobility, and ability to completely close the vocal folds should be assessed. Neck examination should note symmetry, contour, presence of masses, and presence of laryngeal elevation with swallow. Normal presence of laryngeal crepitus (easy mobility and click encountered on moving the larynx over the cervical spine) should be elicited. Cranial nerves (CNs) should be assessed, particularly those associated with the swallow mechanism: CNs V, VII, IX, X, and XII.