Zenker Diverticulum


Article Author:
Zeid Nesheiwat


Article Editor:
Catiele Antunes


Editors In Chief:
Silvio de Melo Jr.
Vittorio Giuliano
Truptesh Kothari


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/9/2019 10:24:57 PM

Introduction

Zenker's diverticulum is a type of diverticulum that develops in the hypopharynx, typically between the cricopharyngeus (CP) muscle and the inferior pharyngeal constrictor muscle. It only involves the mucosa and submucosal layers and does not involve the muscular layer, hence making it a false diverticulum. It may also occur in other parts of the esophagus, such as between the oblique and transverse fibers of the CP muscle, known as Killian-Jamieson area, and between the CP muscle and the esophageal muscles, known as Laimer triangle.[1][2][3]

Etiology

The etiology of Zenker's diverticulum is not fully understood, but most of the hypotheses revolve around the abnormal structure and physiology of the cricopharyngeus muscle. Professional believe that abnormal pressure during swallowing causes dehiscence of this muscle leading to the formation of a Zenker’s diverticulum. Therefore, this diverticulum is an acquired mucosal herniation between the horizontal and oblique fibers of the cricopharyngeus muscle.[4]

Epidemiology

It is a rare disorder of the esophagus, primarily seen in elderly individuals, peaking between the seventh and ninth decades of life. Occurs rates range from 0.01% to 0.11% of the population. It is more common in men than in women. Zenker’s diverticulum rate varies in different parts of the world being more common in northern Europe, United States of America, and Canada and rarely occurs in Japan and Indonesia. However, the true incidence is difficult to ascertain due to a significant number of patients who do not seek treatment. Zenker’s diverticulum is rare before the age of 40.[5]

Pathophysiology

Although there are multiple theories regarding the pathophysiology and development of Zenker's diverticulum, no clear consensus exists. It is understood that a Zenker's involves impaired cricopharyngeal compliance, usually due to fibrotic changes, what causes increased intrabolus pressure with swallowing. As a result of this, the hypopharyngeal pressure increases, leading to herniation at the weak point just above the cricopharyngeus.

Histopathology

Histological examination of a Zenker’s diverticulum is rarely done. Microscopic evaluation of the pouch usually shows a sac containing stratified squamous epithelium, and the submucosa lining often shows fibrous tissue. Rarely, ulcerations or evidence of cancer, squamous cell or carcinoma in situ, may be present.

History and Physical

The development of this diverticulum leads to retention of food particles which leads to complaints of regurgitation, halitosis, aspiration, and difficulty swallowing. Patients with Zenker's diverticulum will typically present with a long history of dysphagia followed by a sensation of food stuck in the throat. Up to 98% of patients have the primary complaints of dysphagia. Other common symptoms include recurrent coughing, fetor ex ore (halitosis), and unexplained weight loss. Rarely, a visible lump might be seen in the neck.

Evaluation

Barium swallow with videofluoroscopy provides information regarding its size, location, and character of the mucosal lining, and diagnoses the condition. Upper endoscopy, which includes both flexible and rigid assessment, are also used and typically essential in the surgical evaluation. Staging of the Zenker's diverticulum is imperative to the overall evaluation. There are 3 staging systems: Lahey, Morton, and Van Overbeek staging systems. Only one of the 3 may be used. The staging is typically reliant on the size of the pouch in which the bigger the size, the higher the staging.[6]

Treatment / Management

Only symptomatic lesions need treatment; lesions less than 2 centimeters rarely require any treatment. In some cases of Zenker's diverticulum associated with achalasia, botulinum toxin may help relieve symptoms of dysphagia. For all other large Zenker's diverticulum, surgery is indicated. However, since Zenker's diverticula occur in the elderly population, great care is required in selecting patients for surgery. The Zenker's diverticulum can be treated by an open procedure or via an endoscopic approach. During surgery, it is vital to divide the cricopharyngeus muscle to relieve the elevated pressure zone and eliminate the pouch of the diverticulum. A 1-cm myotomy is adequate in most cases. Recently lasers have been used during upper endoscopy to resect the diverticulum instead of staples. Overall, lasers have been shown to have fewer recurrences and faster improvement in symptoms compared to the use of staplers. Open surgery usually is more invasive and requires longer hospitalization but does provide rapid symptom relief and low rates of recurrence. Complications of surgery include injury to the laryngeal nerve, bleeding, esophageal perforation, and trauma to the oral cavity.[3][4][7]

Differential Diagnosis

Although rare, cancers, such as squamous cell carcinomas may be present in conjunction with a Zenker's diverticulum. This is imperative to rule out during an assessment. One must ask about smoking history and consumption of very hot or very cold liquids (teas, coffee). Other differential diagnoses that one must think about is achalasia, GERD or Barrett esophagus, esophagitis (radiation, immunocompromised, STI), stroke in the acute setting, and ulcerations due to retention of food. It is important to be thorough in the evaluation of these patients.

Staging

The Lahey, Mortons, and Van Overbeek staging systems are used for evaluation of a Zenker's diverticulum. These staging systems are used to describe the degree of the Zenker's diverticulum, usually in the sense of pouch size. Barium swallow with videofluoroscopy is the radiographic methods used for staging.

Prognosis

The prognosis for these patients is dependant on which surgical procedure was performed. Patients who undergo diverticulectomy with cricopharyngeus myotomy, immediate symptoms relief occurred in 90% to 100% of patient. The long-term symptoms recurrent rate is 2% to 33%. Mortality occurs in zero to 9.5% of these patients while morbidity, which includes mediastinitis, esophageal stenosis, recurrent laryngeal nerve damage, pharyngocutaneous fistula, hematoma and esophageal perforation occurs in 4% to 47% of patients who underwent this procedure. In patients who received treatment via endoscopic diverticulectomy with a stapler, the immediate symptoms relief occurred in 94% to 100% of patients. The long-term symptoms recurrence rate ranges from zero to 47%. Mortality occurs in zero to 1% and morbidity, which includes recurrent laryngeal nerve damage, bleeding, mediastinitis, dental injury, esophageal perforation, diverticulum perforation, and cervical emphysema occurred in 10% to 31%. Prognosis is varied and dependent on multiple factors that include patients age and comorbidities.

Complications

Complications of this disease are varied and dependant on the surgical approach taken, patient age and comorbidities. Since this disease is mainly a disease of the elderly, the prognosis is typically poor, and recurrence rates are high. Patients and clinicians need to aware of potential complications which include recurrent laryngeal nerve paralysis, mediastinitis, esophageal perforation/stenosis, cervical emphysema, among others.

Postoperative and Rehabilitation Care

Proper follow-up is imperative to minimizing post-operative complications and infections.

Deterrence and Patient Education

Patients must be aware of the benefits and risk of Zenker's diverticulum and the potential usefulness of surgery.

Enhancing Healthcare Team Outcomes

A multidisciplinary approach to zenker diverticulum

Zenker diverticulum usually presents in the middle-aged and elderly population with symptoms of dysphagia and regurgitation. The condition is progressive and can lead to aspiration, halitosis, chronic cough, and hoarseness. Patients admitted with a diagnosis of Zenker diverticulum need to be looked after a multidisciplinary team of healthcare professionals because there are many treatment options. There is no data to show that one treatment is better than the other. Hence, the nurse should educate the patient and family about the disease, its outlook, and management. At the same time, the nurse should take aspiration precautions by avoiding a supine position. A speech consult should be obtained to determine the risk of aspiration and a dietary consult to determine what type of foods are safe. Because many of these patients are frail and weak, a physical therapy consult may help increase exercise tolerance and ambulation.  After the surgery, the patient should be closely monitored by the nurse for dysphagia and aspiration. Only a team approach can lower the morbidity associated with Zenker diverticulum. [8][9](Level V).

Outcomes

Even though there are several methods to manage Zenker diverticulum, the outcomes after all of these treatments are safe and effective. Almost all patients report an improvement in immediate symptoms. Unfortunately, there are no randomized trials or long-term studies to determine which is the most effective procedure and which is durable. The key is to have an experienced surgeon or endoscopist. The low prevalence of this disorder may make it difficult to conduct large randomized trials; hence the choice of treatment remains one of personal choice. [10][11][12](Level V)


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    Contributed by Scott H. Plantz, MD, FAAEM
Attributed To: Contributed by Scott H. Plantz, MD, FAAEM

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Zenker Diverticulum - Questions

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Which is false about pharyngeal pouches?



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During repair of Zenker diverticulum in the neck, what structure is commonly encountered in the groove between the trachea and esophagus?



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Which is a common presentation of patients with Zenker diverticulum?



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Which of the following statement is correct regarding the repair of a Zenker diverticulum?



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Which of the following causes a Zenker diverticulum?



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Which muscle is frequently divided during surgery on a patient with Zenker diverticulum?

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A 60-year-old male complains of regurgitation of undigested food eaten days earlier. He also has dysphagia with solids on occasion. Halitosis is the only physical finding. Which of the following is the most likely diagnosis?



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Which surgical procedure for Zenker diverticulum is least likely to relieve symptoms and has the highest risk of recurrent symptoms?



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Which of the following is least often seen in patients with Zenker diverticulum?



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A 72 year old presents with a several month history of dysphagia and a cough. He says he has lost 12 pounds over the past 2 months. He denies smoking or alcohol. His health has otherwise been good except for his hypertension, which he controls with a diuretic. Physical exam is unremarkable. You suspect that the patient may have Zenker diverticulum. The imaging test of choice to make the diagnosis is which of the following?



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Which of the following is rarely a feature of Zenker diverticulum?



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What is the importance of Killian triangle?



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What is the most common cause of Zenker diverticulum?



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What pathophysiology is associated with the finding in the barium swallow below?

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A middle-aged male was being worked up for vague abdominal pain and underwent many investigations. During the barium swallow, an incidental finding was noticed (See below). The patient had no other symptoms, was on no medications, had no allergies, denied any trauma, and stated that he was otherwise in good health. Also, the blood work was within normal limits. The patient was referred to a surgeon who recommended surgical treatment. Which of the following procedures is associated with the highest rates of recurrence?

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If a patient with a history of Zenker diverticulum presents with pneumonia, coverage must be for which bacterial class?



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While walking past the radiology suite, you note a barium swallow study shown in the following image. The majority of patients with this pathology will present with which complaint?

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A 65-year-old male presents with a 3-year history of a chronic cough and regurgitation after eating. He states that he has difficulty swallowing and feels as though there is a lump in his throat. More recently he has noticed that his breath smells bad even though he brushes his teeth three times per day. Injury to the nerve supplying the muscle most likely involved in this disease process could present with which of the following symptoms?



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Zenker Diverticulum - References

References

Achille G,Castellana M,Russo S,Montepara M,Giagulli VA,Triggiani V, Zenker Diverticulum: A Potential Pitfall in Thyroid Ultrasound Evaluation: A Case Report and Systematic Review of Literature. Endocrine, metabolic     [PubMed]
Tabola R,Lewandowski A,Cirocchi R,Augoff K,Kozminska U,Strzelec B,Grabowski K, Zenker diverticulum: Experience in surgical treatment of large diverticula. Medicine. 2018 May     [PubMed]
Ciuc D,Birlă R,Panaitescu E,Tanţău M,Constantinoiu S, Zenker Diverticulum Treatment: Endoscopic or Surgical? Chirurgia (Bucharest, Romania : 1990). 2018 Mar-Apr     [PubMed]
Ishaq S,Sultan H,Siau K,Kuwai T,Mulder CJ,Neumann H, New and emerging techniques for endoscopic treatment of Zenker's diverticulum: State-of-the-art review. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society. 2018 Jul     [PubMed]
Hoffmann M,Fazel A,Mews KG,Ambrosch P, 32 years of experience with CO{sub}2{/sub} -LASER-assisted treatment for Zenker's Diverticulum - an update of 227 patients treated in Kiel. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology     [PubMed]
Henry MA,Lerco MM,Tagliarini JV,Castilho EC,Novaes FT,Lamonica VC, Pharyngoesophageal diverticulum: evaluation of treatment results. Revista do Colegio Brasileiro de Cirurgioes. 2013 Mar-Apr     [PubMed]
Tenorio L,Palacios F, [Efficacy and safety of the endoscopic management of Zenker diverticulum with IT-Knife 2 device]. Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru. 2017 Jul-Sep     [PubMed]
Shapiro J, Oropharyngeal dysphagia: pathophysiology, clinical assessment and management. Revista de gastroenterologia de Mexico. 1994 Apr-Jun     [PubMed]
Wasserzug O,Zikk D,Raziel A,Cavel O,Fleece D,Szold A, Endoscopically stapled diverticulostomy for Zenker's diverticulum: results of a multidisciplinary team approach. Surgical endoscopy. 2010 Mar     [PubMed]
Mazza M,Bergamini AN,Parise P,Cossu A,Adamenko O,Elmore U,Rosati R, Treatment of Zenker's Diverticulum With Endoscopic Stapled Esophago-divertisculostomy (ESD): Analysis of Long-term Outcome. Surgical laparoscopy, endoscopy     [PubMed]
Desbeaux A,Gronnier C,Piessen G,Vanderbeken M,Ruolt N,Triboulet JP,Mariette C, Same-day discharge in benign esophageal surgery: a prospective cohort study. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus. 2017 Apr 1     [PubMed]
Jones D,Aloraini A,Gowing S,Cools-Lartigue J,Leimanis M,Tabah R,Ferri L, Evolving Management of Zenker's Diverticulum in the Endoscopic Era: A North American Experience. World journal of surgery. 2016 Jun     [PubMed]

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