Zenker's Diverticulum

In anatomy, Zenker's diverticulum is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the oesophagus). It was named in 1877 by German pathologist Friedrich Albert von Zenker.

Epidemiology

Zenker diverticulum mainly affects older adults.

Mechanisms and manifestations

In simple words, when there is excessive pressure within the lower pharynx, the weakest portion of the pharyngeal wall balloons out, forming a diverticulum which may reach several centimetres in diameter.

More precisely, while traction and pulsion mechanisms have long been deemed the main factors promoting development of a Zenker's diverticulum, current consensus considers occlusive mechanisms to be most important: uncoordinated swallowing, impaired relaxation and spasm of the cricopharyngeus muscle lead to an increase in pressure within the distal pharynx, so that its wall herniates through the point of least resistance (variously known as Killian's triangle, Laimer's triangle, or more accurately Killian-Laimer triangular dehiscence). The result is an outpouching of the posterior pharyngeal wall, just above the oesophagus.PMID 12903677 Pathogenesis and methods of treatment of Zenker's diverticulum, Ann Otol Rhinol Laryngol. 2003 Jul;112(7):583-93

While it may be asymptomatic, Zenker diverticulum often causes clinical manifestations such as dysphagia (difficulty swallowing), and sense of a lump in the neck; moreover, it may fill up with food, causing regurgitation (reappearance of ingested food in the mouth), cough (as some food may be regurgitated into the airways) and halitosis (smelly breath, as stagnant food is digested by microrganisms). It rarely causes any pain.

Diagnosis

A simple barium swallow will normally reveal the diverticulum. This may be coupled with oesophageal endoscopy.

Treatment

If small and asymptomatic, no treatment is necessary. Larger, symptomatic cases of Zenker's diverticulum have been traditionally treated by neck surgery to resect the diverticulum and incise the cricopharyngeus muscle. However, in recent times non-surgical endoscopic techniques have gained more importance (as they allow for much faster recovery), and the currently preferred treatment is endoscopic staplingPMID 15453934 Endoscopic stapling of pharyngeal pouch, J Laryngol Otol. 2004 Aug;118(8):601-6PMID 12782805 Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases, Laryngoscope. 2003 Jun;113(6):957-65 (i.e. closing off the diverticulum via a stapler inserted through a tube in the mouth). This may be performed through a fibreoptic endoscopePMID 15966520 Fiberoptic endoscopic-assisted diverticulotomy: a novel technique for the management of Zenker's diverticulum, Ann Otol Rhinol Laryngol. 2005 May;114(5):347-51. Other non-surgical treatment modalities exist, such as endoscopic laser, which recent evidence suggests it less effective than stapling.PMID 16954989 The Endoscopic Management of Zenker Diverticulum: CO2 Laser versus Endoscopic Stapling, Laryngoscope. 2006 Sep;116(9):1608-11

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Theron M Claude is editor of www.diseaseopedia.com, the webs most comprehensive medical encyclopedia. learn more: www.diseaseopedia.com