Zenker’s Diverticulum

Background

A Zenker’s diverticulum is a pouch that gradually develops in the throat and catches food when the person swallows. It is a rare condition which occurs in roughly 1 of 5000 people, usually in people in their late 60’s and 70’s.

The underlying problem is that the cricopharyngeous sphincter muscle at the top of the esophagus is too tight. As we swallow, this muscle normally relaxes to allow the food to be pushed into the esophagus by the muscles in the throat and the back of the tongue. When it doesn’t relax well, pressure builds in the segment of the throat between the muscles of the pharynx and the sphincter. There is a naturally weak area in the back of the throat just above the sphincter and the increased pressure causes this wall to bulge. As people age, this area gets weaker and the bulge stretches until it forms a pouch.

Symptoms

This pouch is what is called a Zenker’s diverticulum (also called a hypopharyngeal diverticulum), and it can collect food and liquids as it gets bigger. This process occurs gradually over time, and symptoms may progress as the pouch slowly enlarges. Typical symptoms include:

• Difficulty swallowing solids (and sometimes liquids)
• Regurgitating undigested food several hours after eating
• Choking, especially right after eating or when you first lie down.
• Lingering cough
• Bad breath
• Weight loss

Office examination and testing

Since these symptoms can also occur with conditions other than Zenker’s diverticulum, it is important that an appropriate workup is performed to identify their source. Workup begins with a complete ear, nose, and throat exam, which typically includes flexible laryngoscopy. This involves using a small camera to look down the nose and throat to get a good look at some of the harder-to-view structures in the throat and to make sure the larynx is working properly. The next test is a Videofluoroscopic Swallowing Study (VFSS), which is a radiologic test that records images of the throat as you swallow a barium contrast material. This allows us to assess the structure and movement of the throat when you swallow, and if a Zenker’s diverticulum is present, the size and location can be measured. We might also order a separate Barium Esophogram to help ensure that we understand your situation completely.

Treatment

Sometimes a Zenker’s diverticulum is found incidentally. If there are few or no symptoms, we may not need to do anything. Sometimes, we recommend treatment even with few symptoms so that you can have surgery while you are younger and more robust. Surgical risks in general increase with age. For a small or early diverticulum, simple procedures such as a dilation with or without a Botox injection can be very helpful. We provide these services as well.

For symptomatic or larger diverticula, surgery to address the pouch is the most effective and efficient treatment.

There are 2 main categories of surgery:

• Endoscopic: where the work is performed through your mouth without skin incisions.
• Open: Where the pouch is removed completely from the neck via an incision in the skin.

Endoscopic:

This is done through the mouth. I gently place a device through the mouth into the lower throat to allow me to see and work on the pouch and the cricopharyngeus muscle (the spincter). Depending on how much room there is to work, I use a stapler, a smaller device that seals and cuts the tissue with heat, or even a thin laser beam to cut the muscle and turn the pouch into a funnel into the esophagus. The pouch is not removed in this procedure. This is called the “rigid endoscopic technique” and is the most common technique performed for Zenker’s Diverticulum in the last 30 years. It is reliable, quick, and safe.

If there is not enough room to use the standard rigid instruments, I can use flexible instruments. Flexible techniques are not as reliable as the rigid techniques, but they do allow patients to get close to the same result without having to have an open procedure.

Open Surgery:

For the rare patient that we cannot safely perform either of the endoscopic techniques, the true gold-standard is open surgery. This tried-and-true procedure is very reliable and effective, especially for larger diverticula. The sphincter muscle is cut from the outside (instead of from the inside of the esophagus in the endoscopic techniques), and the pouch is removed completely in most cases. It has some additional risks common to all open procedures, and involves a longer hospital stay. Most of the time, we will be able to tell you before surgery if you’re going to need to have it done with an open approach.

Risks

Risks of not getting treated at all:

This is very patient specific. In early cases, the risks are low initially, but symptoms almost always gradually get worse. Some people choke on the material that comes up from the pouch, which can lead to repeated pneumonias. Rarely it can become a crisis of swallowing, with dehydration, malnutrition, or worse. When we review your tests and your symptoms, we will be able to help you understand whether it’s urgent or not.

Risks of surgery:

All of the procedures carry one major risk: perforation of the esophagus where spit and food can get out of the esophagus and into the chest cavity or neck. This is very serious and can lead to dangerous infections and even death. All of the procedures carry a similar level of this risk, but it is rare. Our specific incidence of this is less than 2%. Each procedure is conducted with this risk in the forefront of our minds.

Endoscopic risks:

Rigid technique: The rigid instruments rest on a custom tooth guard which we put over your upper teeth (or gums). Even with this precaution, the teeth can rarely be chipped or broken (or the gums can be bruised). The tongue is compressed some, and it can temporarily swell or have a change in sensation or taste. We have never had a patient who had a lasting tongue issue. There is a risk of bleeding, but it is usually easily controlled in this technique.

Flexible technique:

There is much less risk to the teeth, but it is not zero. There is a higher incidence of bleeding during the flexible technique because it is more difficult to manage than with the rigid instruments. More patients have residual symptoms than with the rigid technique. Some patients are willing to accept these risks in order to avoid having an open surgery.

Open technique:

Standard surgical risks apply, such as an infection in the area or bleeding after surgery. The main risk in the open surgery that is not often seen with the endoscopic techniques is that the nerve that goes to the left vocal cord can be compressed during the surgery, which can affect the voice temporarily or permanently. There are other procedures which can really help if this happens.

How to choose a doctor.

Several specialties treat Zenker’s diverticula. As this is a relatively rare condition with several treatment options, it is important to choose a doctor who does this often and who can use any of the available techniques. That doctor will be able to fully treat the problem AND care for any complications that may arise.

At Greenville ENT, we are skilled in the rigid and flexible endoscopic approaches and in the open approach if needed. Come see us and we’ll help you understand your options and which treatment would be best for you.

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