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Navigating Zenker’s Diverticulum: Pathophysiology & Workup

Julia Casazza • Updated Feb 14, 2024 • 67 hits

Zenker’s diverticulum is an acquired pharyngeal outpouching due to upper esophageal sphincter (UES) dysfunction. Affected patients are usually over sixty and complain of symptoms of regurgitation and/or problems swallowing. Zenker's diverticulum (ZD) workup should rule out related diverticula and, where desired, assist in surgical planning. Laryngologist Dr. Sarah Howell of University of Cincinnati recently spoke with BackTable’s Dr. Ashley Agan to explain what Zenker's diverticulum is, the cause, symptoms, diagnosis, and her approach to this condition.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• Zenker’s diverticulum occurs when esophageal mucosa herniates through the Killian-Jamieson triangle (an anatomic area between the fibers of the cricopharyngeus and inferior constrictors).

• Zenker’s diverticulum arises from increased intraluminal pressure in the context of upper esophageal sphincter (UES) dysfunction.

• As Zenker’s diverticulum are potential spaces, they can be missed on esophagogastroduodenoscopy (EGD). Administration of contrast material (air or barium) will visualize the diverticulum.

• Understanding patients’ Zenker’s diverticulum symptom burden and motivations for care are key in developing a surgical plan to treat ZD.

What is Zenker’s Diverticulum?

Zenker’s diverticulum is a herniation of the esophageal mucosa through the Killian-Jamieson triangle (an anatomic area between the fibers of the cricopharyngeus and inferior constrictors). Zenker’s diverticulum rarely presents in patients under sixty. The common Zenker’s diverticulum symptoms are the regurgitation of food and difficulty swallowing. ZD differs from, but can be mistaken for, traction diverticulum, a condition in which all three layers of the esophagus form an outpouching due to traction on existing scar tissues.

[Dr. Ashley Agan]
We're going to cover Zenker's diverticulum. Maybe before we get into patient presentation and how you take care of these patients. Maybe just some definitions like for our listeners who maybe are a little rusty or don't know what a Zenker's diverticulum is. Can you talk about that?

[Dr. Rebecca Howell]
Sure. Zenker's diverticulum diagnosis is a swallowing disorder. In the upper esophagus, it's an abnormal outpouching of the esophagus that causes specific Zenker’s diverticulum symptoms. They arise typically in patients that are in their seventh decade. They're not usually seen in younger patients, it's a red flag if they are. It causes problems with both swallowing, but more specifically with regurgitation of food. Regurgitation of food or pills, I think is even more specific to this particular thing.
…
Because a lot of times, especially if they're in C spine, you can actually get what's called a traction diverticulum. Traction diverticulum means that outpouching is caused because there's some scar tissue which actually pulls on the esophagus and then pulls out all three layers. Whereas a Zenker's diverticulum is really just the herniation of the mucosa. This actually goes through what's called the Killian-Jamieson triangle. It's the upper esophageal segment but between the fibers of the cricopharyngeus muscle and the inferior constrictors.

It's a triangle that actually is a congenital dehiscence. How we like to think about these things, especially in Zenker's is that you have to have a CP or cricopharyngeus muscle dysfunction and a congenital dehiscence of this area.

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The Pathogenesis of Zenker’s Diverticulum

Zenker’s diverticulum is, at its most basic, an esophageal “plumbing problem” that presents with regurgitation and difficulty swallowing. The cause of a Zenker’s diverticulum is when the upper esophageal sphincter (UES) fails to relax during swallowing, and an increased intraluminal pressure causes herniation of the esophageal mucosa, forming a ZD. Causes of UES dysfunction include reflux, esophageal dysmotility, megaesophagus, and nutcracker esophagus.

[Dr. Ashley Agan]
That makes sense. Because in my mind, correct me if I'm wrong, the upper esophageal sphincter is not relaxing. When you're pushing that food bolus back, there's that area of weakness. That's just getting the pressure there pushes into that. Then over time basically a pouch develops there. Is that how to think of it?

[Dr. Rebecca Howell]
You're absolutely right. I explain to patients that the esophagus, it's all plumbing. I draw these very funny pictures for them of like lips, a straight tube, and then some wiggly lines that is the rest of the intestines. It's all plumbing. If you have a backup somewhere, then you're going to have symptoms above. Sometimes, and again, what I think will really be interesting in the long-term as we learn more and more about these patients, I think that the lower esophagus is probably affecting the upper esophagus.

One of the things that, again, I think in thinking of these Zenker’s patients, sometimes they come with what people will look at as a CP bar. A CP bar, a cricopharyngeal bar is a radiologic finding, which shows 50%-- this is from Ekberg and Olsson. They found that if you have a 50% reduction in the diameter, then it's called a CP bar, which is simply a radiologic finding. It's not a diagnosis. You have to actually have dysphagia symptoms then to say that you have a cricopharyngeal muscle dysfunction.

That's important because if you look at the lower esophagus, sometimes that muscle becomes tighter or that valve becomes tighter because you have really bad acid reflux, or you have really bad dysmotility, or you have a megaesophagus or nutcracker esophagus, something. You have some other dysmotility that's lower down that's actually causing your body to tighten up that valve so that you're not refluxing all the time. The CP muscle, I think, in the upper esophageal sphincter, it's a tricky muscle because it's not always just as it seems.

Zenker’s Diverticulum Diagnosis & Clinical Examination

Workup of any patient with a swallowing problem should begin with flexible fiberoptic laryngoscopy (FFL). Zenker’s diverticulum isn’t always apparent on a scope exam. In cases where ZD is present on scope exam, it is often posteriorly oriented. Due to tracheal anatomy, the diverticulum may appear to have a slight leftward tilt. Similarly, ZD can be missed on esophagogastroduodenoscopy (EGD), as it is a potential space that requires insufflation of air or barium contrast to visualize.

The “sign of the rising tide” suggests ZD-associated UES dysfunction and refers to frothy secretions that emerge in the hypopharynx following speaking. If present, accompanying problems with cord motion can be investigated using stroboscopy.

[Dr. Ashley Agan]
That can make it really tricky to figure out what's going on. You talked a little bit about the demographics of these patients, so tend to be older, maybe in their seventies. What's a typical patient that's coming to see you in your office? Maybe somebody who hasn't had the workup yet. Because I'm sure as the subspecialist, you probably get patients who are like already worked up. Let's say that you don't know what's going on and they're just coming in with dysphagia, what other things are key to be asking?

[Dr. Rebecca Howell]
That's a great question, Ashley. Any patient that comes in with a swallowing problem, I certainly think that a flexible laryngoscopy is very helpful. Sometimes a stroboscopy if you're looking for closure because again these patients are usually a little bit older. Sometimes that can be beneficial just for, again, the glottic closure. I think it's important, so even when you just look with a scope, one of the things that you'll notice or that I teach my residents to look at is just saliva or mucus, like pooling of secretions.

If you see a clean throat with absolutely nothing else compared to somebody who is full of spit, you know already that they've got a problem. They've got a swallowing problem. The thing that is unique to Zenker’s, and I believe it was Moradi that actually wrote this up several years ago, he called it the rising tide. One of the things that you will oftentimes see is these frothy secretions coming up out of the UES, especially as they voice.

As patients continue, I have them talk for a while. Sometimes we have them do some high-pitched E's or some glides. Because as they keep going, oftentimes you'll get this like rising frothy secretions that come out of the UES, then see in the pyriform sinus more often on the left than the right, which is also consistent with. Oftentimes when we see Zenker’s they're posteriorly oriented, but oftentimes they look or appear that they're on the left side and that's just due to the anatomy of the trachea, this occipital groove.

History Taking in Patients with Zenker’s Diverticulum

When meeting a patient with suspected ZD, Dr. Howell recommends asking why patients chose to seek care now. Understanding patients’ motivations helps her craft an appropriate treatment plan. Most Zenker’s diverticulum patients will complain of symptoms of regurgitation of food/medication (most common) or problems swallowing. Though aspiration pneumonia or weight loss are possible in advanced disease, most patients present long before these occur.

[Dr. Ashley Agan]
That can make it really tricky to figure out what's going on. You talked a little bit about the demographics of these patients, so tend to be older, maybe in their seventies. What's a typical patient that's coming to see you in your office? Maybe somebody who hasn't had the workup yet. Because I'm sure as the subspecialist, you probably get patients who are like already worked up. Let's say that you don't know what's going on and they're just coming in with dysphagia, what other things are key to be asking?

[Dr. Rebecca Howell]
That's a great question, Ashley. Any patient that comes in with a swallowing problem, I certainly think that a flexible laryngoscopy is very helpful. Sometimes a stroboscopy if you're looking for closure because again these patients are usually a little bit older. Sometimes that can be beneficial just for, again, the glottic closure. I think it's important, so even when you just look with a scope, one of the things that you'll notice or that I teach my residents to look at is just saliva or mucus, like pooling of secretions.

If you see a clean throat with absolutely nothing else compared to somebody who is full of spit, you know already that they've got a problem. They've got a swallowing problem. The thing that is unique to Zenker’s, and I believe it was Moradi that actually wrote this up several years ago, he called it the rising tide. One of the things that you will oftentimes see is these frothy secretions coming up out of the UES, especially as they voice.

As patients continue, I have them talk for a while. Sometimes we have them do some high-pitched E's or some glides. Because as they keep going, oftentimes you'll get this like rising frothy secretions that come out of the UES, then see in the pyriform sinus more often on the left than the right, which is also consistent with. Oftentimes when we see Zenker’s they're posteriorly oriented, but oftentimes they look or appear that they're on the left side and that's just due to the anatomy of the trachea, this occipital groove.

Podcast Contributors

Dr. Rebecca Howell

Dr. Rebecca Howell is the division chief of laryngology at University of Cincinnati in Ohio.

Dr. Ashley Agan

Dr. Ashley Agan is an otolaryngologist in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, March 28). Ep. 99 – Management of Zenker’s Diverticula [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.