Barium esophagogram of a Zenker's diverticulopexy.

Zenker's diverticulum is the most recognizable diverticulum of the esophagus. It is a rare pulsion-type diverticulum in the area of Killian's dehiscence. Symptoms include dysphagia, hoarseness, aspiration, a globus sensation, regurgitation of food, collection of mucus in the throat, and coughing. Barium esophagography is the single most valuable tool for making the diagnosis. The only treatment for Zenker's diverticulum is surgery. Surgery can result in some unusual findings when esophagography is performed years later to evaluate a possible recurrence.

We counseled an 82-year-old man who had presented for possible endoscopic management of a recurrent Zenker's diverticulum. (1) His initial surgery had been performed 2 decades earlier; at that time, he underwent a cricopharyngeal myotomy and suspension of the diverticulum superiorly to the cervical fascia (diverticulopexy). The patient tolerated the procedure well, and he remained asymptomatic until 1 year prior to his presentation at our clinic, when mucus began to collect in his throat and he developed a husky voice.

During our evaluation, the patient denied any aspiration, dysphagia, weight loss, or cough. We ordered a new barium esophagogram, which showed that the bottom of the pouch was oriented in a cephalad direction (figure). This finding was consistent with the fact that he had undergone a previous diverticulopexy. Given the patient's minimal symptomatology, conservative management was recommended.

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A variety of surgical techniques have been described to surgically address Zenker's diverticulum. The two primary surgical approaches are endoscopic and transcervical. Endoscopic approaches involve dividing the common wall between the esophagus and diverticulum with a stapler or laser. (1,2) Transcervical approaches entail excising, inverting, or suspending the diverticulum and performing a cricopharyngeal myotomy. (3) Endoscopic approaches are considered to be superior, primarily be cause of convalescence and morbidity issues. Among the different endoscopic approaches described in the literature, staple diverticulostomy has become accepted as the ideal technique for surgically addressing Zenker's diverticulum. (1) It may also be used to treat recurrences. (4) A barium esophagogram obtained following endoscopic staple diverticulostomy will show a residual diverticulum because the pouch is not actually excised. (5) However, the residual tissue does not retain barium.

In our patient's case, barium esophagography provided us with the information necessary to provide counseling on a surgical approach. If surgery had been necessary for our patient, a transcervical approach would have been preferred because the diverticulum's inverted position would have made endoscopic visualization of the common wall difficult.

References

(1.) Chang C, Payyapilli R, Scher RL. Endoscopic staple diverticulostomy for Zenker's diverticulum: Review of literature and experience in 159 consecutive patients. Laryngoscope 2003; 113:957-65.

(2.) Chang CW, Burkey BB, Netterville JL, et al. Carbon dioxide laser endoscopic diverticulotomy versus open diverticulectomy for Zenker's diverticulum. Laryngoscope 2004; 114:519-27.

(3.) Westrin KM, Ergun S, Carlsoo B. Zenker's diverticulum--A historical review and trends in therapy. Acta Otolaryngol 1996; 116: 351-60.

(4.) Scher RL. Endoscopic staple diverticulostomy for recurrent Zenker's diverticulum. Laryngoscope 2003; 113:63-7.

(5.) Jaramillo MJ, McLay KA, McAteer D. Long-term clinico-radiological assessment of endoscopic stapling of pharyngeal pouch: A series of cases. J Laryngol Otol 2001;115:462-6.

Christopher Y. Chang, MD; Richard L. Scher, MD

From Fauquier Ear, Nose, and Throat Consultants. PLC, Warrenton, Va. (Dr. Chang), and the Division of Otolaryngology--Head and Neck Surgery, Duke University Medical Center, Durham, N.C. (Dr. Scher).