Zenker’s diverticulum (ZD) is an uncommon condition involving the formation of a pouch at the junction of the throat and the upper esophagus. This abnormal outpouching collects food particles and saliva, which can lead to symptoms that interfere with swallowing. Though relatively rare, ZD is a progressive and treatable condition that primarily affects older adults.
Anatomy and Formation of Zenker’s Diverticulum
ZD forms in the hypopharynx, the lower part of the throat just above the esophagus. This area contains a natural weak point in the muscular wall known as Killian’s triangle. The pouch is considered a “false” diverticulum because it involves only the mucosal and submucosal layers, not the full muscular layer.
The formation begins with the cricopharyngeal muscle, which acts as the upper esophageal sphincter. This muscle must relax during swallowing to allow food to pass into the esophagus. If the muscle fails to relax fully or contracts too forcefully, it creates high pressure in the pharynx above it. This pressure pushes the inner lining of the throat outward. The tissue herniates through Killian’s triangle, gradually creating a sac-like structure that collects food and secretions.
Identifying the Common Symptoms
The symptoms of Zenker’s diverticulum are directly related to the pouch’s ability to trap and retain food. The most common complaint is dysphagia, or difficulty swallowing, which typically begins with solid foods before progressing to liquids. This often presents as a sensation that food is “sticking” in the throat.
A distinct symptom is the regurgitation of undigested food, which can happen long after a meal. Since the food has been sitting in the pouch and has not reached the stomach, it comes back up unchanged. This stagnant food material can also lead to chronic halitosis, or severe bad breath. Patients may also report a chronic cough, globus sensation, or unexplained weight loss.
Diagnostic Procedures and Associated Complications
Confirming a diagnosis of Zenker’s diverticulum relies primarily on a barium swallow study, also called an esophagram, often paired with videofluoroscopy. During this test, the patient swallows a contrast liquid that coats the digestive tract. X-ray images or video are taken during the swallow, clearly visualizing the contrast liquid filling the abnormal pouch. This procedure is highly effective because it directly demonstrates the size and location of the diverticulum. While upper endoscopy can be used, it carries a small risk of perforating the pouch wall and is sometimes avoided.
Leaving ZD untreated can lead to serious complications, the most concerning of which is aspiration pneumonia. This occurs when regurgitated contents spill into the airway and lungs, causing a severe infection. Other risks include malnutrition, ulceration and bleeding within the pouch, and the development of cancer within the lining.
Modern Treatment Options
Treatment for symptomatic Zenker’s diverticulum is primarily surgical, aiming to eliminate the pouch and address muscle dysfunction. Modern practice favors minimally invasive endoscopic repair as the first-line therapy. The choice of approach depends on the diverticulum’s size and the patient’s overall health status.
Endoscopic repair involves passing specialized instruments through the mouth to reach the pouch. The procedure focuses on dividing the septum, which is the muscular wall separating the esophagus from the diverticulum. This division, called a cricopharyngeal myotomy, cuts the overly tight cricopharyngeal muscle. This eliminates the high-pressure zone and merges the pouch with the main swallowing channel.
For very large or complex pouches, an open surgical approach may be necessary. This traditional method involves an incision in the neck to access the pouch. The pouch is then either removed entirely (diverticulectomy) or inverted and secured (diverticulopexy), always combined with a cricopharyngeal myotomy.