Conditions: Zenker’s Diverticulum
(Hypopharyngeal Diverticulum)
What is a Zenker’s (hypopharyngeal) diverticulum?
A Zenker’s diverticulum is a dead end out-pouchiung (or pocket) located at the top of the esophagus. This pocket can collect food, pills, or liquids in it that do not pass through the esophagus on to the stomach. The problems a Zenker’s diverticulum may cause are variable, and may include the following:
difficulty swallowing
regurgitation of swallowed materials, often hours after swallowing them. The material may be brought up to the mouth by a motion such as bending over, and it may appear chewed but not digested.
creation of a gurgling sound,
bad breath,
the need for repeated throat clearing,
weight loss/malnutrition, and
pneumonia due to aspiration of food or liquids into the lung. This may be life threatening.
Why Does a Zenker’s Diverticulum Form?
Zenker's diverticulum typically forms due to uncoordinated swallowing, where the thyropharyngeus muscle contracts to push the food bolus down, but the cricopharyngeus muscle does not relax as it should to allow the bolus to pass. These factors lead to increased pressure within the distal pharynx during swallowing. The elevated pressure causes the wall of the pharynx to herniate at a site of least resistance known as Killian's triangle, which is a weak spot between the two muscles. Over time, this diverticulum tends to enlarge, causing greater symptoms.
The pharynx and esophagus from behind. Click to enlarge.
How is a Zenker’s diverticulum diagnosed?
Many different causes of swallowing problems exist, and Zenker’s diverticulum is but one of them. A Zenker's diverticulum may be suspected after clinical evaluation for one or more of the above listed problems but diagnosis may be confirmed with certain imaging studies. A barium swallow study and/or a modified barium swallow study may be used to investigate swallowing problems and these studies are very good for demonstrating a number of different types of anatomic problems, including Zenker’s diverticuli. In some cases, endoscopy (such as with an EGD) may be performed to directly visualize the diverticulum and evaluate the surrounding tissue. Less commonly, a computed tomography (CT) scan, MRI, or other imaging modalities can suggest the presence of a Zenker’s diverticulum, though these studies are more useful in the identification and assessment of other conditions.
Examples of a Zenker’s Diverticulum Demonstrated by a Modified Barium Swallow Study:
Modified barium swallow study (side view) demonstrating a Zenker’s diverticulum. The video repeats, and on the second iteration, the Zenker’s diverticulum is marked with a “Z.”
Video from the same patient as above is shown with a subsequent swallow. The contrast material from the first swallow remains in the Zenker’s diverticulum. Another swallow is undertaken and most of the liquid passes down the esophagus, but some remains in the Zenker’s diverticulum. From this diverticulum pouch, some material can be seen refluxing up to the level of the larynx (voice box) as shown with arrows. In this case, a small amount of liquid passes through the larynx to the trachea, with potential to pass on to the lungs.
Normal barium swallow (in frontal view) without demonstration of a Zenker’s diverticulum.
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