Question

What is Zenker's diverticulum? What is the aetiology and management of such cases?

Hint:

Endoscopic management is preferred for smaller Zenker's diverticula, while surgical excision is necessary for larger or recurrent cases.

Answer 1

Step 1: Definition of Zenker's Diverticulum:
Zenker's diverticulum is a pouch or sac-like protrusion that forms in the mucosa of the pharynx, usually in the posterior hypopharynx, specifically at the junction between the hypopharynx and the esophagus. It occurs due to increased pressure within the pharynx and weakness in the posterior wall. This diverticulum can cause swallowing difficulties and other related symptoms.

Step 2: Aetiology of Zenker's Diverticulum:
1. Increased Intra-esophageal Pressure: The primary cause of Zenker's diverticulum is the increased pressure in the esophagus due to dysfunction of the cricopharyngeal muscle. This muscle failure leads to an outpouching of the mucosa at the site of least resistance.
2. Cricopharyngeal Dysfunction: The cricopharyngeus muscle, located at the upper esophageal sphincter, typically relaxes during swallowing. If it fails to relax properly, increased pressure in the pharynx leads to the formation of a diverticulum.
3. Age-related Degenerative Changes: Zenker's diverticulum is more common in older adults, as the cricopharyngeus muscle weakens and the esophageal motility declines with age.

Step 3: Clinical Features of Zenker's Diverticulum:
1. Dysphagia (Difficulty swallowing): The most common symptom, caused by the obstruction of the pharyngeal lumen.
2. Regurgitation of Undigested Food: Food can collect in the diverticulum and be regurgitated, often several hours after eating.
3. Coughing and Choking: Occurs due to aspiration of food or saliva that collects in the diverticulum.
4. Halitosis (Bad Breath): The retention of food in the diverticulum can lead to bacterial overgrowth, resulting in foul-smelling breath.

Step 4: Management of Zenker's Diverticulum:
1. Conservative Treatment:
- Dietary Modifications: Soft or liquid diets may be recommended to minimize the risk of aspiration and choking.
- Swallowing Therapy: A speech therapist may help with improving swallowing techniques to reduce the risk of food regurgitation and aspiration.

2. Endoscopic Management:
- Endoscopic Diverticulotomy: A minimally invasive procedure performed using a flexible endoscope. It involves cutting the diverticulum and removing the mucosa to provide relief from symptoms.
- Laser Therapy: Laser can be used to excise the diverticulum, especially in smaller cases, offering a less invasive alternative to surgery.

3. Surgical Management:
- Open Surgery (Diverticulectomy): In severe or larger diverticula, surgery is required to remove the diverticulum. The procedure involves excising the diverticulum and repairing the pharyngeal wall.
- Cricopharyngeal Myotomy: In conjunction with diverticulectomy, a myotomy of the cricopharyngeal muscle can be performed to relieve the pressure and prevent recurrence of the diverticulum.