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Zenker diverticulum and pharyngo-oesophageal disease
Zenker is a pulsion pouch that protrudes backward through Killian dehiscence — between the oblique part (thyropharyngeus) and the horizontal part (cricopharyngeus) of the inferior constrictor — because the cricopharyngeus does not relax; diagnosis is by barium swallow, and treatment must include division of the cricopharyngeus muscle.
Why it matters in the exam
The typical patient is an older man with difficulty swallowing, regurgitation of undigested food hours after eating, bad breath, "gurgling" in the neck and cough or aspiration pneumonia. The diagnostic test is a barium swallow (oesophagogram); blind endoscopy or careless tube insertion can perforate the pouch. A water-soluble contrast swallow (Gastrografin) is done first when perforation is suspected, because barium leaking into the mediastinum is more harmful. Cancer inside the pouch is very rare.
Treatment: endoscopic division of the common wall between the pouch and the oesophagus (the "party wall", which contains the cricopharyngeus) with a stapler or CO2 laser through a rigid laryngoscope — suits medium pouches; a very small pouch is hard to divide with a stapler. A flexible alternative is endoscopic septotomy or Z-POEM. Open surgery — cricopharyngeal myotomy with excision or suspension of the pouch (diverticulopexy) — suits very small or very large pouches, and a patient whose pharynx cannot be exposed. After failure, revision can be done by the same approach or the other one. Complications: perforation, mediastinitis, recurrent laryngeal nerve injury and recurrence of the pouch.
Other pharyngo-oesophageal diseases the exam likes: pill oesophagitis appears at the natural narrowings — at the level of the aortic arch, near the left atrium and at the lower sphincter; eosinophilic oesophagitis appears in a young man with atopy or asthma, difficulty swallowing solids and food bolus impaction, with "rings" in the oesophagus, and is diagnosed by biopsy (15 or more eosinophils per high-power field); globus — a sensation of a lump in the throat without difficulty swallowing, sometimes with throat clearing, without a structural finding.
Key points
- Pulsion pouch through Killian dehiscence.
- Barium swallow for diagnosis.
- Division of the common wall or open myotomy.
- The cricopharyngeus must be divided.
- Eosinophilic oesophagitis: young atopic patient, biopsy.
Summary table
| Situation | Clue | Treatment |
|---|---|---|
| Zenker | Older man, regurgitation of undigested food, bad breath | Barium swallow; division of the common wall and myotomy |
| Suspected perforation | Pain, fever after a procedure | Gastrografin first, then barium |
| Very small or very large pouch | Hard for a stapler | Open approach with myotomy |
| Pill oesophagitis | Painful swallowing after a tablet | Aortic arch, left atrium, lower sphincter |
| Eosinophilic oesophagitis | Young atopic patient, food impaction | Biopsy: 15 or more eosinophils |
| Globus | Lump in the throat without difficulty swallowing | Reassurance, treat contributing factors |
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Sources
- Cummings Otolaryngology: Head and Neck Surgery, 7th edition (2021) — Zenker diverticulum: endoscopic and open management
- ESGE Guideline: Flexible endoscopic treatment of Zenker's diverticulum, 2022 — Indications and technique
- Scott-Brown's Otorhinolaryngology Head and Neck Surgery, 8th edition (2018) — Pharyngeal pouch
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.