Zenker’s Diverticulum

Author Credentials 

Michael A. Holliday, MD
Assistant Clinical Professor
Residency Program Director
Department of Head and Neck Surgery
University of California, Los Angeles
Los Angeles, CA 90024
maholliday@mednet.ucla.edu

Module Summary

Zenker’s diverticulum is a pulsion diverticulum through Killian’s triangle that develops after many years of increased intraluminal pressure in the hypopharynx. This results in dysphagia to solids, regurgitation, and occasionally weight loss, aspiration, and pneumonia, which is especially dangerous as this affects mostly patients over age 70. Treatment includes methods aimed primarily at dividing the cricopharygeus. This is increasingly performed transorally with rigid or flexible instrumentation and a “diverticulotomy” approach to join the ZD with the esophagus; however one should maintain a familiarity with open approaches for patients whose anatomy will not permit endoscopic treatment, or for especially large ZD. Serious complications include mediastinitis and pharyngocutaneous fistula, which are thankfully rare with current techniques and antibiotic therapy.
 

Module Learning Objectives 
  1. Recognize the signs and symptoms of Zenker’s diverticulum (ZD).
  2. Explain the pathophysiology of Zenker’s diverticulum.
  3. Describe the role of imaging studies in evaluating Zenker’s diverticulum.
  4. Summarize the options for treating Zenker’s diverticulum.
  5. Identify the advantages, disadvantages, and risks of surgical therapies for Zenker’s diverticulum.

Anatomy

Learning Objectives 
  1. Understand the anatomy and relationship of the pharyngeal constrictor muscles, cricopharyngeus (CP), and esophageal musculature. 
  2. Understand the oblique course of the inferior constrictors, and the resultant “Killian’s triangle” or “Killian’s dehiscence” between the constrictors and CP, through which the ZD protrudes.
  3. Understand that ZD is a pseudodiverticulum, in that the wall includes only mucosa and submucosa.
References 
  1. van Overbeek JJ. Pathogenesis and methods of treatment of Zenker's diverticulum. Ann Otol Rhinol Laryngol. 2003;112(7):583-93.
  2. Law R, Katzka DA, Baron TH. Zenker's diverticulum. Clin Gastroenterol Hepatol. 2014 Nov;12(11):1773-1782.

Pathogenesis

Learning Objectives 
  1. Understand that mucosal prolapse occurs through Killian’s triangle, causing ZD.
  2. Understand age as a contributing factor to ZD development due to loss of tissue elasticity.
  3. Understand that the proximate event in ZD development is controversial, but includes increased hypopharyngeal intraluminal pressures. This may be due to CP achalasia and/or fibrosis; reflux; dyscoordination between hypopharyngeal, CP and esophageal musculature; esophageal dysmotility; or may be idiopathic.
     
References 
  1. van Overbeek JJ. Pathogenesis and methods of treatment of Zenker's diverticulum. Ann Otol Rhinol Laryngol. 2003;112(7):583-93.
  2. Veenker EA, Andersen PE, Cohen JI. Cricopharyngeal spasm and Zenker's diverticulum. Head Neck. 2003;25(8):681-94.

Incidence

Learning Objectives 
  1. Know that prevalence is between 0.01% to 0.11%.
  2. Know that ZD is more common in Caucasian race, males, and age 70-90 years.
References 
  1. Watemberg S, Landau O, Avrahami R. Zenker’s diverticulum: reappraisal. Am J Gastroenterol 1996;91:1494-1498.
  2. van Overbeek JJ. Pathogenesis and methods of treatment of Zenker's diverticulum. Ann Otol Rhinol Laryngol. 2003;112(7):583-93.

Genetics

Learning Objectives 

Know that there may be a genetic predisposition to ZD, with several reports of familial cases of ZD in the literature.

References 
  1. Klockars T, Sihvo E, Mäkitie A. Familial Zenker's diverticulum. Acta Otolaryngol. 2009;128(9):1034-1036.
  2. van Overbeek JJ. Pathogenesis and methods of treatment of Zenker's diverticulum. Ann Otol Rhinol Laryngol. 2003;112(7):583-93.

Patient Evaluation

Learning Objectives 
  1. Understand the symptoms experienced by patients with ZD, including dysphagia to solids and liquids, regurgitation of undigested food, aspiration, globus sensation, chronic cough, weight loss, mucus in throat, “gurgling sound” in the neck.
  2. Understand the importance of physical exam in patients evaluated for ZD, particularly for surgical candidacy.
  3. Understand the role of flexible laryngoscopy to rule out mass lesions and evaluate hypopharyngeal abnormalities.
References 
  1. Bergeron JL, Long JL, Chhetri DK. Dysphagia characteristics in Zenker's diverticulum. Otolaryngol Head Neck Surg. 2013;148(2):223-8.
  2. Bloom JD, Bleier BS, Mirza N, et al. Factors predicting endoscopic exposure of Zenker's diverticulum. Ann Otol Rhinol Laryngol. 2010;119(11):736-41.
  3. van Overbeek JJ. Pathogenesis and methods of treatment of Zenker's diverticulum. Ann Otol Rhinol Laryngol. 2003;112(7):583-93.

Measurement of Functional Status

Learning Objectives 
  1. Understand the role of Modified Barium Swallow Study in patients suspected of having ZD.
  2. Understand the role of Fiber-optic Endoscopic Evaluation of Swallowing (FEES) in patients with ZD.
  3. Recognize patient-reported symptoms inventories, such as Functional Outcome Swallowing Scale (FOSS) and Eating Assessment Tool (EAT-10) for monitoring pre- and post-intervention function.
References 
  1. Bergeron JL, Long JL, Chhetri DK. Dysphagia characteristics in Zenker's diverticulum. Otolaryngol Head Neck Surg. 2013;148(2):223-8.
  2. Van Abel KM, Tombers NM, Krein KA, et al. Short-term Quality-of-Life Outcomes following Transoral Diverticulotomy for Zenker's Diverticulum: A Prospective Single-Group Study. Otolaryngol Head Neck Surg. 2016;154(2):322-7.

Imaging

Learning Objectives 

Understand the importance of functional swallowing exam, such as videofluoroscopic swallow study or pharyngoesophagram, in the evaluation of Zenker’s diverticulum.

References 
  1. Mantsopoulos K, Psychogios G, Karatzanis A, et al. Clinical relevance and prognostic value of radiographic findings in Zenker's diverticulum. Eur Arch Otorhinolaryngol. 2014;271(3):583-8.
  2. Shah RN, Slaughter KA, Fedore LW, et al. Does residual wall size or technique matter in the treatment of Zenker's diverticulum? Laryngoscope. 2016;126(11):2475-2479.

Treatment

Learning Objectives 
  1. Understand that treatment may not be indicated and observation may be more appropriate, particularly for patients with minimal or no symptoms.
  2. Understand that treatment for dysphagia, especially aspiration, may involve gastrostomy tube and nil per os, for patients who cannot undergo surgery.
  3. Understand that surgical treatment is reserved for patients who have significant symptoms and who are medically appropriate for surgery.
References 
  1. Veenker EA, Andersen PE, Cohen JI. Cricopharyngeal spasm and Zenker's diverticulum. Head Neck. 2003;25(8):681-94.

Medical Therapies

Learning Objectives 

Understand that there is no definitive role of medical therapy for ZD, but patients may have symptomatic improvement with treatment of reflux.

References 
  1. Veenker EA, Andersen PE, Cohen JI. Cricopharyngeal spasm and Zenker's diverticulum. Head Neck. 2003;25(8):681-94.

Surgical Therapies

Learning Objectives 

Understand that treatment (when indicated) may be generally divided into: 

  • Endoscopic approaches: Diverticulotomy and cricopharyngeal (CP) myotomy
  • General approach is to divide posterior CP and “parting wall,” which will enjoin the diverticulum with the esophagus
  • This can be performed via a variety of techniques
    • CO2 laser
    • Endoscopic stapler
    • Ultrasonic scalpel (e.g. Harmonic)
  • This is performed transorally via:
    • Rigid instrumentation (Weerda diverticuloscope, Holinger Benjamin diverticuloscope)
    • Flexible esophagoscopy – emerging intervention and favored by interventional gastroenterologists
  • Open approaches
    • Diverticulectomy with CP myotomy
    • Diverticulopexy with CP myotomy
References 
  1. Leibowitz JM, Fundakowski CE, Abouyared M, et al. Surgical Techniques for Zenker's Diverticulum: A Comparative Analysis. Otolaryngol Head Neck Surg. 2014;151(1):52-8.
  2. van Overbeek JJ. Pathogenesis and methods of treatment of Zenker's diverticulum. Ann Otol Rhinol Laryngol. 2003;112(7):583-93.
  3. Law R, Katzka DA, Baron TH. Zenker's diverticulum. Clin Gastroenterol Hepatol. 2014 Nov;12(11):1773-82.

Staging

Learning Objectives 

Understand that multiple staging systems have been devised, but none are widely used.

Case Studies

  1. An 89yo male presents at the urging of his daughter. Over the last few years, he has been eating more slowly, as he states he must chew very thoroughly in order to swallow his food. He also notes that he will often expectorate undigested food 1-2 days after eating it. On laryngoscopy, you notice pooling in the piriform recesses. What diagnosis do you suspect? What is the next step to confirm your suspicion? How do you proceed to treat what is diagnosed as a 2cm Zenker’s diverticulum? 
  2. An 85yo man presents to the office today for recurrence of dysphagia approximately 10 years after his Zenker’s diverticulum was treated endoscopically. He has gradually noted food “lodging” in his throat and copious phlegm, similar to his symptoms prior to surgery. You order a videofluoroscopic swallow study, which confirms a Zenker’s diverticulum. Is revision endoscopic diverticulotomy as effective as the first surgery? Will the next surgery be performed “open” as a “salvage surgery?”
     
References 
  1. Scher RL. Endoscopic staple diverticulostomy for recurrent Zenker's diverticulum. Laryngoscope. 2003;113(1):63-7.

Complications

Learning Objectives 
  1. Understand that severe complications of Zenker’s diverticulum and cricopharyngeal achalasia include:
    • Severe dysphagia with weight loss and malnutrition 
    • Severe dysphagia with recurrent aspiration pneumonia
  2. Understand that possible complications of treatment of Zenker’s diverticulum and CP achalasia include:
    • Bleeding, infection
    • Dental or oral mucosal injury
    • Pharyngocutaneous fistula
    • Mediastinitis
    • Recurrence of ZD and dysphagia
References 
  1. Leibowitz JM, Fundakowski CE, Abouyared M, et al. Surgical Techniques for Zenker's Diverticulum: A Comparative Analysis. Otolaryngol Head Neck Surg. 2014;151(1):52-8
  2. van Overbeek JJ. Pathogenesis and methods of treatment of Zenker's diverticulum. Ann Otol Rhinol Laryngol. 2003;112(7):583-93.
  3. Shah RN, Slaughter KA, Fedore LW, et al. Does residual wall size or technique matter in the treatment of Zenker's diverticulum? Laryngoscope. 2016;126(11):2475-2479.

Review

Review Questions 
  1. What muscles form the borders of the natural weak point through which a Zenker’s diverticulum develops?
  2. What is this area called?
  3. What are the main symptoms of ZD?
  4. What are the main options for treating ZD surgically?
  5. What imaging studies should be performed during the workup for ZD?
  6. What physical exam findings should be considered to predict likelihood of succeeding via rigid transoral approach?
  7. What are the most common and most serious complications of treatment for ZD?
References 
  1. van Overbeek JJ. Pathogenesis and methods of treatment of Zenker's diverticulum. Ann Otol Rhinol Laryngol. 2003;112(7):583-93.
  2. Bloom JD, Bleier BS, Mirza N, et al. Factors predicting endoscopic exposure of Zenker's diverticulum. Ann Otol Rhinol Laryngol. 2010;119(11):736-41.
Resources 

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