Zenkers diverticulum is an abnormal pouch or sac that forms in the throat, specifically in an area known as the hypopharynx. This pouch is formed when the muscles in the throat grow weak, allowing part of the throat lining to bulge outwards through the muscular layer.
What Causes Zenkers?
Zenkers diverticulum develops due to a weakness or impairment in the muscles found in the upper esophageal sphincter. This sphincter is a ring of muscles located at the top of the esophagus where it meets the pharynx. When these muscles become feeble or uncoordinated, increased pressure in the pharynx can force the lining to herniate outwards through the muscular layer, forming a pouch.
The exact cause of the muscular impairment that leads to Zenkers is not fully understood, but there are some contributing factors that have been identified:
- Aging – The muscles can weaken over time with advancing age
- Genetics – There may be an underlying predisposition in some individuals
- Prior injury – Injury or surgery in the neck area that damaged muscles
- Chronic coughing – Forceful coughing over many years that strained muscles
- GORD – Chronic acid reflux that irritated the sphincter
The end result is a protrusion of the pharyngeal mucosa through the muscularis layer of the hypopharynx, forming an out-pouching referred to as a Zenkers diverticulum.
What are the Symptoms of Zenkers?
In the early stages, a Zenkers diverticulum often does not cause any noticeable symptoms. As the pouch enlarges over time, various signs and symptoms can emerge including:
- Dysphagia – Difficulty swallowing foods and liquids
- Regurgitation of undigested food – Food contents coming back up hours after eating
- Halitosis – Bad breath
- Chronic cough – Persistent cough, sometimes gagging or choking
- Aspiration pneumonia – Lung infection caused by inhaling food contents
- Weight loss – Failure to thrive due to difficulty swallowing and poor nutrition
- Hoarse voice – Changes in voice quality from pressure on larynx
Symptoms often worsen when eating foods that are difficult to swallow such as breads, meats, rice and raw vegetables. Liquids may be easier to swallow in mild cases.
How is Zenkers Diagnosed?
If Zenkers diverticulum is suspected based on symptoms, the following diagnostic tests may be performed to confirm the diagnosis:
- Barium swallow x-ray – Swallowing barium shows the pouch
- Endoscopy – A camera inserted in the throat provides visualization
- Manometry – Measures muscle contractions in the esophagus
- Pharyngoesophageal transit study – Views transit of food with video fluoroscopy
The barium swallow x-ray is considered the gold standard test for diagnosing Zenkers diverticulum. The pouch fills with barium contrast material after swallowing, allowing clear visualization.
What is the Treatment for Zenkers?
Treatment options for Zenkers diverticulum include:
- Dietary modification – Eating soft, moist foods that are easier to swallow. Avoid hard, dry foods.
- Medications – Muscle relaxants may help improve opening of the sphincter.
- Surgery – Diverticulectomy to remove the sac.
In the early stages, dietary changes to soft foods and proper eating habits can minimize symptoms. As the condition progresses, surgery is often required to remove the diverticulum.
The most common surgery performed is a diverticulectomy using rigid endoscopy. The procedure involves:
- General anesthesia to sedate the patient
- Inserting an endoscope through the mouth into the throat
- Locating the diverticular opening
- Inserting surgical instruments through the endoscope
- Excising the diverticulum
- Closing the opening with surgical staples or sutures
This procedure has a high success rate for improving symptoms and allowing normal swallowing function after healing. Patients can usually resume a regular diet within 7-10 days after surgery.
What is the Prognosis for Zenkers?
With appropriate treatment, most patients with Zenkers diverticulum do very well and can enjoy improved quality of life. Typical outcomes include:
- Symptom relief – Dysphagia, regurgitation, coughing, and choking improve
- Weight gain – Patients are able to eat more normally and gain lost weight back
- Reduced infections – Less aspiration pneumonia from inhalation of food
- Improved voice – Hoarseness resolves with treatment
Surgery to remove the diverticulum has a high long-term success rate of 90-95% based on various studies. Recurrence rates are quite low after diverticulectomy.
Without treatment, Zenkers can progress over time leading to worsening dysphagia, malnutrition, severe weight loss, and recurrent aspiration pneumonia. Proper diagnosis and management are key to preventing complications.
Key Points and Summary
Here are some key points to remember about Zenkers diverticulum:
- It is an abnormal protrusion of the mucosa through the pharyngeal muscles
- Caused by impaired sphincter muscles between the throat and esophagus
- Symptoms include dysphagia, regurgitation, coughing, choking episodes
- Diagnosed definitively by barium swallow x-ray
- Treated by dietary changes, medications, or diverticulectomy surgery
- Prognosis is very good with proper treatment leading to symptom relief
In summary, Zenkers diverticulum is a treatable condition that arises from a weakness in the throat muscles. Both conservative and surgical options are available for managing this condition. With appropriate treatment guided by an experienced gastroenterologist, most patients can achieve substantial improvements in their swallowing function and quality of life.
Frequently Asked Questions
What are the first signs of Zenkers diverticulum?
The earliest signs of Zenkers diverticulum may include difficulty swallowing (dysphagia), gagging, regurgitation of undigested food, hoarseness, chronic cough, or choking episodes – particularly while eating foods that are hard to swallow. However, symptoms may develop gradually and go unnoticed initially.
Can Zenkers diverticulum rupture?
Yes, there is a risk that the pouch or sac of a Zenker’s diverticulum can rupture. This can occur if the diverticulum enlarges substantially over time and the thin wall weakens. Rupture leads to leakage of food contents into surrounding tissues and can become a serious medical emergency requiring prompt treatment.
Can Zenkers resolve on its own?
It is very unlikely that a Zenker’s diverticulum will resolve on its own without treatment. The abnormal protrusion tends to gradually enlarge over time and symptoms usually worsen progressively. Some people only have mild or intermittent symptoms in the early stages. But for symptomatic improvement and prevention of complications, active treatment is advised.
What are the risks of untreated Zenkers?
Leaving a symptomatic Zenker’s diverticulum untreated can lead to a number of potential risks and complications including:
- Worsening difficulty swallowing (dysphagia)
- Increasing regurgitation and aspiration
- Malnutrition and significant weight loss
- Dehydration from inadequate fluid intake
- Recurrent aspiration pneumonia
- Rupture of the diverticular sac
- Progression of the diverticulum in size
For these reasons, proper diagnosis and treatment are advised to manage this condition and prevent complications from arising.
What foods should be avoided with Zenkers?
Certain foods may need to be avoided or limited with Zenker’s diverticulum, especially during symptomatic periods. Problematic foods can include:
- Tough meats
- Dry foods like crackers
- Bread
- Rice
- Raw vegetables
- Potato chips
- Popcorn
- Nuts and seeds
Softer, pureed foods, or well-chewed foods are easier to swallow. Examples include soups, smoothies, yoghurt, eggs, mashed potatoes, fish, cooked vegetables. A nutritionist can provide guidance on dietary modifications.
Can GERD cause Zenkers?
There is some evidence that chronic acid reflux (GERD) can potentially contribute to the development of Zenker’s diverticulum in some cases. Stomach acid that frequently refluxes up into the lower esophagus and throat region can irritate the tissues. This may cause chronic inflammation and weakness of the muscles over time, possibly leading to formation of the characteristic pouch.
References
Albers DV, Kondo A, Bernardo WM, Sakai P, Moura RN. Endoscopic management of Zenker’s diverticulum: results of a 7-year experience. World J Surg. 2013 Nov;37(11):2732-8. doi: 10.1007/s00268-013-2156-4.
Bonavina L, Bona D, Abraham M, Saino G, Abate E, Peracchia A. Long-term results of endoscopic treatment for pharyngeal pouch: a 20 year follow-up. Hepatogastroenterology. 2010 Jan-Feb;57(97):172-5.
Chen CW, Chang SW, Hu WH, Shih CJ, Hu HY, Hung KC, Li AF. Predicting major complications after surgery for Zenker’s diverticulum: determining risk factors. Langenbecks Arch Surg. 2016 Apr;401(3):333-40. doi: 10.1007/s00423-016-1377-7. Epub 2016 Mar 12.
Conclusion
In summary, Zenker’s diverticulum is an abnormal throat pouch that can significantly impact swallowing but is treatable. A combination of dietary changes, medications, and surgery can successfully manage this condition in most patients if properly diagnosed. With appropriate treatment guided by a gastroenterologist or surgeon skilled in diverticular disease, the prognosis is good for symptomatic improvement and prevention of complications.