What is Zenker Diverticulum?
Zenker’s diverticulum is a specific kind of pouch that forms in the upper part of your throat, typically between two muscles called the cricopharyngeus and the inferior pharyngeal constrictor muscle. This pouch only involves the inner lining and the layer right beneath it, but not the muscle layer, which makes it a “false” pouch or diverticulum. This pouch can also form in other parts of the esophagus or food pipe- between the oblique and transverse fibers of the cricopharyngeus muscle (which is known as the Killian-Jamieson area), and between the cricopharyngeus muscle and the esophageal muscles (known as Laimer triangle).
What Causes Zenker Diverticulum?
The cause of Zenker’s diverticulum, a pouch that can form at the junction of your throat and esophagus, isn’t entirely known. However, most theories suggest it has something to do with the abnormal structure and functioning of a muscle in your throat called the cricopharyngeus muscle. Experts think that unusual pressure while swallowing can cause this muscle to split apart, leading to the creation of a Zenker diverticulum. So, this pouch is considered a condition that people acquire, not one they are born with. It’s a sort of hernia, which is to say, a part of the body pushes through a weak spot in a muscle wall.
The diverticulum, or pouch, forms in a specific area between two parts of the cricopharyngeus muscle. This area is often called the Killian triangle.
Risk Factors and Frequency for Zenker Diverticulum
Zenker diverticulum is a rare condition that affects the esophagus, most often seen in elderly people, especially between the ages of 70 and 90. It is more commonly found in men than in women. This condition primarily occurs in northern Europe, the US, and Canada, while it’s quite rare in countries like Japan and Indonesia. However, due to many people not seeking treatment, it’s hard to accurately calculate how often it occurs. It also doesn’t usually appear before the age of 40.
- Zenker diverticulum is a rare esophagus disorder.
- It’s mainly seen in elderly individuals, particularly between the ages of 70 and 90.
- The condition is more common in men.
- It’s most often found in northern Europe, the US, and Canada, and it’s rare in Japan and Indonesia.
- Getting accurate numbers is challenging because many people don’t seek help for it.
- Zenker diverticulum rarely occurs before age 40.
Signs and Symptoms of Zenker Diverticulum
Zenker diverticulum is a medical condition that happens when a small pouch forms and collects food particles in the throat. This can lead to several issues like feeling as if food is stuck in the throat, bad breath, coughing, and unexplained weight loss. Some people might even notice a lump in their neck. These symptoms can occur over an extended period, sometimes lasting months or even years.
- Feeling of food stuck in the throat
- Bad breath
- Coughing
- Unexplained weight loss
- Visible lump in the neck (rare)
- Symptoms lasting for months or years
Testing for Zenker Diverticulum
If you have been experiencing issues with swallowing, your doctor may suggest a barium swallow test with videofluoroscopy. This test is like an X-ray and helps your doctor understand where any issues are, how big they may be, and what the inner lining of your throat looks like. It can also help diagnose your condition.
You also might have a procedure called an upper endoscopy. This is when a thin, flexible tube with a light and a camera lens at the end is passed into your throat to take a close look inside. This test is key to get a good understanding of your throat, particularly if surgery might be needed.
Your doctor will also need to ‘stage’ any diverticulum (a pouch-like opening or cavity in the throat) found. There are three different staging systems but typically, only one will be used. The stage depends on the size of the pouch – the bigger the pouch, the higher the stage.
Endoscopy can also show if any scarring (also called fibrosis) is present around the diverticulum. This can help prevent the formation of local abscesses – pockets of pus that can cause infections. The test can also identify any food that might be pooling in the pouch.
Treatment Options for Zenker Diverticulum
Only Zenker diverticulum symptoms that are causing discomfort or complications need to be treated. Zenker diverticulum is a small pouch that can form at the back of your throat, and generally, small pouches less than 2 centimeters don’t require any treatment. When linked with a condition called achalasia, a type of muscle disorder, injecting botulinum toxin, a type of drug, might relieve symptoms like difficulty in swallowing, also known as dysphagia.
In cases where the Zenker diverticulum is larger, surgery may be recommended. Because Zenker diverticulum is more common in elderly people, we have to carefully consider who would benefit from surgery.
When surgery is chosen, it can either be done as an open procedure, involving a larger cut, or as an endoscopic approach which uses a more advanced technique involving smaller cuts. The aim of surgery is to cut a tight muscle in your throat called the cricopharyngeus muscle to alleviate pressure in this area and get rid of the pouch.
However, simply cutting the muscle may not completely get rid of symptoms, hence, the muscle cut should be combined with a more comprehensive procedure to have a more effective result.
In recent times, lasers have been used during endoscopy to cut out pouch rather than using staples. Generally, lasers have shown to have less recurrence of the pouch and quicker symptom relief than staplers. Open surgery, on the other hand, might require a longer hospital stay but could rapidly relieve symptoms with less likelihood of the pouch returning. Surgery complications could include injury to your voice box nerve, bleeding, perforation of your food pipe, the esophagus, and injury to the mouth.
There are two key procedures to treat Zenker diverticulum:
1. Diverticulectomy with myotomy: This is a definitive procedure that removes the pouch entirely. It gives immediate relief from symptoms and has a low chance of symptoms coming back. However, it requires more time, patient admission, and suspend eating until the surgical area has healed. It has risks including injury to the laryngeal nerve (voice box nerve), esophageal stenosis (narrowing of the food pipe), fistula (abnormal connection) formation, esophageal perforation, and mediastinitis (infection of the space between the lungs).
2. Endoscopic diverticulectomy with stapler: This is a short procedure that allows for early resumption of diet and a shorter hospital stay. While it is generally safe and effective, it might not be suitable for all, as it does not remove the pouch and may not provide tissue for further examination. If symptoms recur, the procedure might be done again. It also has similar risks as the one above.
What else can Zenker Diverticulum be?
Zenker’s diverticulum is a medical condition where a small pouch forms in the throat, and occasionally, other illnesses like cancer, specifically squamous cell carcinomas, might be present along with it. It’s not very common, but it’s essential for doctors to check for this during an examination. This includes asking about the patient’s smoking history and whether they regularly consume very hot or very cold drinks like tea or coffee.
Doctors also need to consider other diseases that can have symptoms similar to Zenker’s diverticulum. These could include:
- Achalasia, a condition where the food pipe (esophagus) has trouble moving food into the stomach
- GERD or Barrett esophagus, conditions related to acid reflux
- Esophagitis, which is inflammation in the esophagus that could happen due to radiation therapy, a weakened immune system, or sexually transmitted infections
- Strokes occurring in the acute setting
- Ulcerations, which can happen from food being retained in the throat
It’s crucial that these patients are evaluated thoroughly for proper diagnosis and treatment.
What to expect with Zenker Diverticulum
The recovery outcomes for patients depend on the type of surgical procedure performed. In the case of patients who have undergone a surgery called “diverticulectomy with cricopharyngeus myotomy,” immediate relief from symptoms is achieved in 90% to 100% of cases. However, the long-term recurrence rate (the chance that symptoms might return) is between 2% and 33%. There is a mortality rate of up to 9.5%, while complications such as inflammation of the esophagus or injury to nerves, among other things, can occur in 4% to 47% of the patients.
For patients treated with another procedure called “endoscopic diverticulectomy with a stapler,” immediate symptom relief occurs in 94% to 100% of patients. The long-term recurrence rate of symptoms ranges from zero to 47%. There is a mortality rate of up to 1%, and possible complications, including nerve damage, inflammation, dental injury, and perforation (tearing) of the esophagus, occur in 10% to 31% of patients.
The prognosis, or future outlook for patients varies and depends on multiple factors including the patient’s age and other underlying health conditions.
Possible Complications When Diagnosed with Zenker Diverticulum
The complications from Zenker’s diverticulum, a condition usually found in the elderly, can vary based on the type of surgery used, the age of the patient and any other existing health conditions. Unfortunately, given that this condition is more common in older individuals, the outlook is generally not good and there is a high chance of it recurring.
One of the major complications of Zenker diverticulum is aspirating or inhaling food or liquids into the lungs. Additional complications may include bleeding, the formation of an abnormal connection with the windpipe, and blockages in the esophagus.
It’s important for patients and their healthcare teams to be aware of other possible complications including:
- Nerve paralysis in the larynx, which is part of the throat
- Mediastinitis, a serious infection in the space between the lungs
- Tears or narrowing in the esophagus
- Cervical emphysema, a condition characterized by air trapped under the skin of the neck area
Recovery from Zenker Diverticulum
It’s really important to have regular check-ups after surgery to reduce the chances of complications and infections.
Preventing Zenker Diverticulum
It’s important for patients to understand the advantages and potential risks associated with having a Zenker’s diverticulum condition, and how surgery could possibly be helpful. Zenker’s diverticulum is a pouch that can form at the junction of the throat and the esophagus, which can cause problems when swallowing. Surgery is often considered to manage this condition, but like any medical procedure, it comes with its own set of benefits and risks.
