Zenker's diverticulum

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Zenker's diverticulum
Other namesPharyngoesophageal diverticulum, pharyngeal pouch, hypopharyngeal diverticulum
ZenkerSchraeg.gif
Specialty Gastroenterology

A Zenker's diverticulum, also pharyngeal pouch, is a diverticulum of the mucosa of the human pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the esophagus). It is a pseudo diverticulum or false diverticulum (only involving the mucosa and submucosa of the esophageal wall, not the adventitia), also known as a pulsion diverticulum.

Contents

It was named in 1877 after German pathologist Friedrich Albert von Zenker. [1] [2]

Signs and symptoms

When there is excessive pressure within the lower pharynx, the weakest portion of the pharyngeal wall balloons out, forming a diverticulum which may reach several centimetres in diameter.

While traction and pulsion mechanisms have long been deemed the main factors promoting development of a Zenker's diverticulum, current consensus considers occlusive mechanisms to be most important: uncoordinated swallowing, impaired relaxation and spasm of the cricopharyngeus muscle lead to an increase in pressure within the distal pharynx, so that its wall herniates through the point of least resistance (known as Killian's triangle, located superior to the cricopharyngeus muscle and inferior to the thyropharyngeus muscle. Thyropharyngeus and cricopharyngeus are the superior and inferior parts of inferior constrictor muscle of pharynx respectively). The result is an outpouching of the posterior pharyngeal wall, just above the esophagus. [3]

While it may be asymptomatic, Zenker diverticulum can present with the following symptoms:

It rarely, if ever, causes any pain.

Esophageal webs are seen associated in 50% of patients with this condition.

Rarer forms of cervical esophageal diverticula are the Killian's diverticulum and the Laimer's diverticulum. Killian's diverticulum is formed in the Killian-Jamiseon triangle (between the oblique and transverse fibers of the cricopharyngeus muscle). Laimer's diverticulum is formed in Laimer's triangle (located inferior to the cricopharyngeus in the posterior midline above the confluence of the longitudinal layer of the superior esophageal circular muscle). Laimer's triangle is covered only by the circular layer of esophageal muscle.

Diagnosis

Lateral X-ray of a Zenker's diverticulum Zenker22015Lateral.JPG
Lateral X-ray of a Zenker's diverticulum
AP X-ray of a Zenker's diverticulum Zenker1.JPG
AP X-ray of a Zenker's diverticulum

A combination of the simple barium swallow and a thorough endoscopy will normally confirm the diverticulum. [4]

Treatment

If small (ie, <2 cm) and asymptomatic, no treatment is necessary. [5] Larger, symptomatic cases of Zenker's diverticulum have been traditionally treated by neck surgery to resect the diverticulum and incise the cricopharyngeus muscle. However, in recent times non-surgical endoscopic techniques have gained more importance (as they allow for much faster recovery), and the currently preferred treatment is endoscopic stapling [6] [7] (i.e. diverticulotomy with staples ). This may be performed through a diverticuloscope. Other methods include fibreoptic diverticular repair. [8]

Other non-surgical treatment modalities also exist, such as endoscopic laser, which recent evidence suggests is less effective than stapling. [9]

Epidemiology

Zenker's diverticulum mainly affects older adults. It has an incidence of 2 per 100,000 per year in the UK, but there is significant geographical variation around the world. [10]

Related Research Articles

Swallowing, sometimes called deglutition in scientific contexts, is the process in the human or animal body that allows for a substance to pass from the mouth, to the pharynx, and into the esophagus, while shutting the epiglottis. Swallowing is an important part of eating and drinking. If the process fails and the material goes through the trachea, then choking or pulmonary aspiration can occur. In the human body the automatic temporary closing of the epiglottis is controlled by the swallowing reflex.

<span class="mw-page-title-main">Friedrich Albert von Zenker</span> German pathologist and

Friedrich Albert von Zenker was a German pathologist and physician, celebrated for his discovery of trichinosis.

<span class="mw-page-title-main">Diverticulum</span> Medical or biological term for an outpouching of a hollow (or a fluid-filled) structure in the body

In medicine or biology, a diverticulum is an outpouching of a hollow structure in the body. Depending upon which layers of the structure are involved, diverticula are described as being either true or false.

<span class="mw-page-title-main">Middle pharyngeal constrictor muscle</span> Muscle in the neck

The middle pharyngeal constrictor is a fan-shaped muscle located in the neck. It is one of three pharyngeal constrictor muscles. It is smaller than the inferior pharyngeal constrictor muscle.

<span class="mw-page-title-main">Inferior pharyngeal constrictor muscle</span> Skeletal muscle of the pharynx

The inferior pharyngeal constrictor muscle is a skeletal muscle of the neck. It is the thickest of the three outer pharyngeal muscles. It arises from the sides of the cricoid cartilage and the thyroid cartilage. It is supplied by the vagus nerve. It is active during swallowing, and partially during breathing and speech. It may be affected by Zenker's diverticulum.

<span class="mw-page-title-main">Oropharyngeal dysphagia</span> Difficulty controlling the mouth or throat for swallowing

Oropharyngeal dysphagia is the inability to empty material from the oropharynx into the esophagus as a result of malfunction near the esophagus. Oropharyngeal dysphagia manifests differently depending on the underlying pathology and the nature of the symptoms. Patients with dysphagia can experience feelings of food sticking to their throats, coughing and choking, weight loss, recurring chest infections, or regurgitation. Depending on the underlying cause, age, and environment, dysphagia prevalence varies. In research including the general population, the estimated frequency of oropharyngeal dysphagia has ranged from 2 to 16 percent.

Esophageal dysphagia is a form of dysphagia where the underlying cause arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach, usually due to mechanical causes or motility problems.

<span class="mw-page-title-main">Keratosis pharyngis</span> Medical condition

Keratosis Pharyngis is a medical condition where keratin grows on the surface of the pharynx, that is the part of the throat at the back of the mouth. Keratin is a protein that normally occurs as the main component of hair and nails. It is characterized by the presence of whitish-yellow dots on the pharyngeal wall, tonsils or lingual tonsils. They are firmly adherent and cannot be wiped off. The surrounding region does not show any sign or inflammation or any other symptoms that make affect the rest of the body.

<span class="mw-page-title-main">Nutcracker esophagus</span> Medical condition

Nutcracker esophagus, jackhammer esophagus, or hypercontractile peristalsis, is a disorder of the movement of the esophagus characterized by contractions in the smooth muscle of the esophagus in a normal sequence but at an excessive amplitude or duration. Nutcracker esophagus is one of several motility disorders of the esophagus, including achalasia and diffuse esophageal spasm. It causes difficulty swallowing, or dysphagia, with both solid and liquid foods, and can cause significant chest pain; it may also be asymptomatic. Nutcracker esophagus can affect people of any age but is more common in the sixth and seventh decades of life.

<span class="mw-page-title-main">Killian's dehiscence</span>

Killian's dehiscence is a triangular area in the wall of the pharynx between the cricopharyngeus and thyropharyngeus which are the two parts of the inferior constrictors(also see Pharyngeal pouch). It can be seen as a locus minoris resistentiae. Similar triangular area between circular fibres of cricopharyngeus and longitudinal fibres of esophagus is Lamier'striangle or Lamier-hackermann's area.

<span class="mw-page-title-main">Aphagia</span> Medical condition

Aphagia is the inability or refusal to swallow. The word is derived from the Ancient Greek prefix α, meaning "not" or "without," and the suffix φαγία, derived from the verb φαγεῖν, meaning "to eat." It is related to dysphagia which is difficulty swallowing, and odynophagia, painful swallowing. Aphagia may be temporary or long term, depending on the affected organ. It is an extreme, life-threatening case of dysphagia. Depending on the cause, untreated dysphagia may develop into aphagia.

A tracheo-esophageal puncture is a surgically created hole between the trachea (windpipe) and the esophagus in a person who has had a total laryngectomy, a surgery where the larynx is removed. The purpose of the puncture is to restore a person’s ability to speak after the vocal cords have been removed. This involves creation of a fistula between trachea and oesophagus, puncturing the short segment of tissue or “common wall” that typically separates these two structures. A voice prosthesis is inserted into this puncture. The prosthesis keeps food out of the trachea but lets air into the esophagus for oesophageal speech.

<span class="mw-page-title-main">Foreign body in alimentary tract</span> Medical condition

One of the most common locations for a foreign body is the alimentary tract. It is possible for foreign bodies to enter the tract either from the mouth, or from the rectum.

<span class="mw-page-title-main">Pharynx</span> Part of the throat that is behind the mouth and nasal cavity

The pharynx is the part of the throat behind the mouth and nasal cavity, and above the esophagus and trachea. It is found in vertebrates and invertebrates, though its structure varies across species. The pharynx carries food to the esophagus and air to the larynx. The flap of cartilage called the epiglottis stops food from entering the larynx.

Cricopharyngeal spasms occur in the cricopharyngeus muscle of the pharynx. Cricopharyngeal spasm is an uncomfortable but harmless and temporary disorder.

<span class="mw-page-title-main">Killian–Jamieson diverticulum</span> Medical condition

A Killian–Jamieson diverticulum is an outpouching of the esophagus just below the upper esophageal sphincter.

<span class="mw-page-title-main">Guttural pouch</span>

Guttural pouches are large, auditory-tube diverticula that contain between 300 and 600 ml of air. They are present in odd-toed mammals, some bats, hyraxes, and the American forest mouse. They are paired bilaterally just below the ears, behind the skull and connect to the nasopharynx.

<span class="mw-page-title-main">Esophageal intramural pseudodiverticulosis</span> Medical condition

Esophageal intramucosal pseudodiverticulosis (EIPD) is a rare condition wherein the wall of the esophagus develops numerous small outpouchings (pseudodiverticulae). Individuals with the condition typically develop difficulty swallowing. The outpouchings represent the ducts of submucosal glands of the esophagus. It typically affects individuals in their sixth and seventh decades of life. While it is associated with certain chronic conditions, particularly alcoholism, diabetes and gastroesophageal reflux disease, the cause of the condition is unknown. Treatment involves medications to treat concomitant conditions such as reflux and esophageal spasm, and dilation of strictures in the esophagus.

<span class="mw-page-title-main">Human digestive system</span> Digestive system in humans

The human digestive system consists of the gastrointestinal tract plus the accessory organs of digestion. Digestion involves the breakdown of food into smaller and smaller components, until they can be absorbed and assimilated into the body. The process of digestion has three stages: the cephalic phase, the gastric phase, and the intestinal phase.

<span class="mw-page-title-main">Retrograde cricopharyngeal dysfunction</span> Medical condition

Retrograde cricopharyngeus dysfunction or R-CPD is a condition in which people are unable to burp. It is a lifelong problem that is usually first noted in adolescence, but has also been reported as early as infancy. Most people with this condition also complain of frequent bloating, "gurgling noises" from the throat, frequent flatulence and poor tolerance to carbonated beverages.

References

  1. synd/2461 at Who Named It?
  2. Zenker, FA; von Ziemssen, HW (1867). Krankheiten des Oesophagus. Leipzig: F.C.W. Vogel.
  3. van Overbeek, JJ (July 2003). "Pathogenesis and methods of treatment of Zenkr's diverticulum". Ann. Otol. Rhinol. Laryngol. 112 (7): 583–93. doi:10.1177/000348940311200703. PMID   12903677. S2CID   31405929.
  4. Bencini L, Moraldi L, Bartolini I, Coratti A (January 2016). "Esophageal surgery in minimally invasive era". World J Gastrointest Surg. 8 (1): 52–64. doi: 10.4240/wjgs.v8.i1.52 . PMC   4724588 . PMID   26843913.
  5. Nesheiwat, Zeid; Antunes, Catiele (2023), "Zenker Diverticulum", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   29763172 , retrieved 2023-11-07
  6. Sen, P; Bhattacharyya, AK (August 2004). "Endoscopic stapling of pharyngeal pouch". J Laryngol Otol. 118 (8): 601–6. doi:10.1258/0022215041917817. PMID   15453934. S2CID   32002606.
  7. Chang, CY; Payyapilli, RJ; Scher, RL (June 2003). "Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases". Laryngoscope. 113 (6): 957–65. doi:10.1097/00005537-200306000-00009. PMID   12782805. S2CID   6206165.
  8. Altman, JI; Genden, EM; Moche, J (May 2005). "Fiberoptic endoscopic-assisted diverticulotomy: A novel technique for the management of Zenker's diverticulum". Ann. Otol. Rhinol. Laryngol. 114 (5): 347–51. doi:10.1177/000348940511400503. PMID   15966520. S2CID   39747386.
  9. Miller, FR; Bartley, J; Otto, RA (September 2006). "The endoscopic management of Zenker diverticulum: CO2 laser versus endoscopic stapling". Laryngoscope. 116 (9): 1608–11. doi:10.1097/01.mlg.0000233508.06499.41. PMID   16954989. S2CID   45791555.
  10. Siddiq, MA; Sood, S; Strachan, D (August 2001). "Pharyngeal pouch (Zenker's diverticulum)". Postgraduate Medical Journal. 77 (910): 506–11. doi:10.1136/pmj.77.910.506. PMC   1742115 . PMID   11470929.