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AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Joel A Ernster, MD, Active Staff, Penrose-St Francis Healthcare System; Active Staff, Memorial Health System; Clinical Instructor, University of Colorado Health Sciences Center
Joel A Ernster is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Rhinologic Society, Colorado Medical Society, and Triological Society
Editors: Lanny Garth Close, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Karen Hall Calhoun, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Missouri; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
Zenker diverticulum, pharyngeal diverticulum, ZD, Zenker diverticula, Killian triangle, cricopharyngeus muscle, CP muscle, diverticulectomy, open diverticulectomy, endoscopic diverticulectomy, CP myotomy, diverticulopexy, diverticulotomy
Zenker diverticulum (ZD) was first described in 1769 by Ludlow. Zenker and von Ziemssen further characterized this entity in 1877. Although this condition was described in the literature numerous times between 1769 and 1877, Zenker's description was the most thorough, and his name has since been attached to it.
History of the Procedure
In 1866, Wheeler was the first to successfully perform surgical intervention. In 1917, Mosher described the first endoscopic approach.
Problem
Zenker diverticula are pulsion diverticula of the hypopharynx that occur primarily in older individuals, resulting in a life-altering and potentially life-threatening process. Zenker diverticula may be addressed by successful reliable surgical techniques.
Frequency
Zenker diverticulum occurs more commonly in certain parts of the world. It is observed most often in northern European countries and in countries whose population has a northern European heritage (eg, United States, Canada, Australia). Zenker diverticulum is rarely observed in Japan and Indonesia. Prevalence in high-risk countries is 2 cases per 100,000 people. Zenker diverticulum has a male-to-female ratio of 1.5:1 and is observed almost exclusively in older individuals.
Etiology
Zenker diverticula occur in a muscular dehiscence that is present most commonly between the oblique muscle fibers of the inferior constrictor muscle and the transverse fibers of the cricopharyngeus (CP) muscle. This area is known as the Killian triangle. Other areas of muscular dehiscence occur between the oblique and transverse fibers of the CP muscle (ie, Killian-Jamieson area) and between the CP muscle and the esophageal muscles (ie, Laimer triangle). More inferiorly positioned Zenker diverticula may occur in one of these latter sites (see Image 1). Zenker diverticula may be staged in 1 of the following 3 systems, as assessed by means of barium swallow videofluoroscopy: - Lahey system
- Stage I: A small mucosal protrusion is present.
- Stage II: A definite sac is present, but the hypopharynx and esophagus are in line.
- Stage III: The hypopharynx is in line with diverticulum, and the esophagus is indented and pushed anteriorly.
- Morton system
- Small sacs are less than 2 cm in length.
- Intermediate sacs are 2-4 cm in length.
- Large sacs are greater than 4 cm in length.
- van Overbeek system
- Small sacs are less than 1 vertebral body in length.
- Intermediate sacs are 1-3 vertebral bodies in length.
- Large sacs are greater than 3 vertebral bodies in length.
Zenker diverticula extend into the left neck 90% of the time. This is likely due to the slight convexity of the cervical esophagus to the left side and to the more laterally positioned carotid artery on the left side, creating a potential space for the sac.
Pathophysiology
Although Zenker proposed a pulsion mechanism affecting the pharyngeal mucosa above the CP muscle, no consensus exists regarding a unifying concept of the pathophysiologic cause of Zenker diverticulum. The specific abnormality of the CP muscle has not been elucidated. Hypothetical abnormalities include the following:
- Abnormal timing of deglutition resulting in closure of the CP muscle when ideally it should be opening
- Incomplete CP muscle relaxation
- Elevated resting tone of the entire upper esophageal sphincter (UES)
- Loss of CP muscle elasticity
- CP muscle myopathy or denervation atrophy
- CNS injury with a focal spastic CP muscle
- CP muscle spasm in response to gastroesophageal reflux disease (GERD)
Studies to investigate the mechanism are scant. Cook histologically examined the CP muscle obtained at the time of diverticulectomy and found abundant fibrosis within the muscle. Whether this finding is a cause or a result of Zenker diverticulum is uncertain. Kern determined that older individuals exhibit less anterior excursion of the larynx and hyoid with deglutition than younger subjects, resulting in higher hypopharyngeal intrabolus pressures in older subjects.1 Whether this leads to Zenker diverticulum over time is speculative. van Overbeek suggested an anthropometric explanation. He felt individuals with longer necks had a larger Killian triangle, which predisposed them to formation of Zenker diverticulum.2
Clinical
The combination of the following symptoms is nearly pathognomonic for Zenker diverticulum: - Dysphagia
- Regurgitation of undigested food hours after eating
- Sensation of food sticking in the throat
- Special maneuvers to dislodge food
- Coughing after eating
- Aspiration of organic material
- Unexplained weight loss
- Fetor ex ore
- Borborygmi in the neck
Symptoms may last from months to years. The most common life-threatening complication is aspiration. Other complications include massive bleeding from the mucosa or from fistulization into a major vessel, esophageal obstruction, and fistulization into the trachea. Squamous cell carcinoma (SCC) within Zenker diverticulum is extremely rare, occurring in 0.3% of Zenker diverticula worldwide. A Mayo Clinic review suggests an incidence of 0.48% in the United States. Approximately 50 cases of invasive SCC and carcinoma in situ are reported in the literature. This possibility should be considered when evaluating patients with cervical metastatic SCC with an unknown primary cancer.
Zenker diverticula require intervention only if they produce symptoms. In general, small (ie, <2 cm) lesions found incidentally require no intervention. However, some surgeons contend that since these lesions are likely to become larger with time, intervention ought to be considered in younger, healthier asymptomatic patients with Zenker diverticula. Small lesions are satisfactorily treated with a CP myotomy with or without an invagination procedure. Intermediate and large diverticula (ie, 2-6 cm) are best managed by open diverticulectomy with CP myotomy or by endoscopic diverticulotomy. Very large diverticula (ie, >6 cm) are best managed with excision with CP myotomy or a diverticulopexy with CP myotomy, depending on the health of the patient. On one occasion, the authors placed a gastrostomy as the sole form of intervention for an ill 95-year-old patient with a 20-cm Zenker diverticulum.
See Etiology.
The overall health of people in this generally older population of patients may not allow a significant surgical undertaking. Recognition of this problem is essential in designing the ideal treatment plan. However, the range of effective treatment options allows treatment for essentially all symptomatic patients.
From an anatomic perspective, the most common open procedure (diverticulectomy with CP myotomy) has no contraindications. The endoscopic approach (diverticulotomy) may not be performed if the patient has significantly reduced cervical extension or marked trismus.
Imaging Studies
- The criterion standard of confirmatory evaluations is the barium swallow with videofluoroscopy. This study provides information about size, location, and character of the mucosal lining of the Zenker diverticulum (see Image 2). Certain radiographic features of the diverticulum neck may predict the likelihood of success of the endoscopic stapling approach. These features were reviewed by Tsikoudas.3
Diagnostic Procedures
- Flexible endoscopic evaluation of swallowing (FEES) provides information that may suggest the presence of a Zenker diverticulum, but this test has not supplanted the barium swallow in most surgeons' practices. Pooling in the esophageal introitus may be ascertained in individuals with Zenker diverticulum by using cream or other readily visible forms of food in various consistencies. This test may help select patients for whom barium swallow is appropriate.
- Rigid or flexible esophagoscopy is essential before surgical management to assess the nature of the mucosa of the Zenker diverticulum and to exclude the presence of SCC or carcinoma in situ. Care must be taken with rigid esophagoscopy to avoid perforating the Zenker diverticulum.
- Esophageal or hypopharyngeal manometry does not add to the clinical workup.
Histologic Findings
A Zenker diverticulum is lined with stratified squamous epithelium with a thin lamina propria. No muscular layer exists. Fibrosis surrounding the diverticulum is common. The fibrotic tissue surrounding the diverticulum may limit the spread of any extravasated material from the diverticulum during endoscopic procedures and therefore reduce the likelihood of local abscess formation.
Medical therapy
As with cricopharyngeal achalasia, botulinum toxin may be used to provide temporary relief of dysphagia symptoms. Symptomatic patients who are poor surgical risks and have small Zenker diverticula may be treated satisfactorily by this method.
Surgical therapy
Current surgical therapeutic options include the following: - Cricopharyngeal (CP) myotomy alone: This procedure was described in several reports during the 1970s as a sole form of intervention for Zenker diverticulum. The rationale for and the benefits of the procedure are generally well recognized; however, this procedure is most commonly combined with other more definitive procedures.
- Diverticulum invagination or imbrication with CP myotomy: This surgical approach was first described in 1866 by Keyart. It is a reasonable option for small or intermediate-sized symptomatic Zenker diverticula that cannot be managed with an endoscopic approach. With this technique, the diverticulum is pushed into the hypopharynx, and the muscle and adjacent fibrous tissue are oversewn. A CP myotomy is usually combined with this technique.
- Diverticulopexy with CP myotomy: This approach was first described in 1966. With this procedure, the Zenker diverticulum is mobilized and positioned in a superior nondependent position higher in the neck. The Zenker diverticulum is generally sewn to the sternocleidomastoid muscle. Older patients with very large Zenker diverticula (>6 cm) who cannot tolerate a diverticulectomy are the best candidates for this approach. It may be performed with the patient under local anesthesia if necessary. A CP myotomy is usually performed as well.
- Diverticulectomy with CP myotomy: Wheeler described the first successful diverticulectomy in 1892. It is now considered the standard approach, particularly in the United States.
- Endoscopic diverticulotomy with cautery, laser, or stapler
- In 1917, Mosher first described an endoscopic approach but abandoned it because of complications. This approach was reintroduced by Dohlman and Seiffert in 1958.4 Although these authors reported few complications, other surgeons experienced complications such as mediastinitis and abscess formation, and the technique did not gain widespread acceptance. A cautery unit was used to perform the diverticulotomy.
- During the 1980s, the carbon dioxide laser and potassium-titanyl-phosphate (KTP) laser were used to perform the incision. The carbon dioxide laser technique remains a favored procedure in both Europe and the United States. This technique is particularly useful for small (<2 cm) and moderate (2-4 cm) diverticula because a stapler may not be able to satisfactorily grasp the "party wall" between the esophagus and diverticulum. The risk of cervical emphysema is higher with the laser technique over the stapling technique. The laser technique, however, has the distinct advantage over the stapling technique because of the ease of transection of the "party wall." The stapler is bulky and is difficult to insert, particularly in small female patients.
- The endoscopic stapling technique has been reported multiple times, first by Collard et al in 1993.5 This technique consists of adhering the mucosal edges by stapling them together while cutting across the "party wall" at the same time. It has become the preferred endoscopic approach for most American and British surgeons. Few complications have been reported with this procedure. Patients with good flexibility, favorable dentition, and larger diverticula are the best candidates.
- Flexible endoscopic diverticulotomy with laser or needle-knife techniques are in the development stage.
Preoperative details
The 2 most commonly performed surgical procedures are the diverticulectomy with CP myotomy and the endoscopic diverticulotomy with a stapler. - Diverticulectomy with cricopharyngeal myotomy: Precede this procedure by a direct laryngoscopy and rigid esophagoscopy, principally to assess the mucosa. Many surgeons find placement of a Foley catheter in the Zenker diverticulum helpful to facilitate locating the Zenker diverticulum later in the procedure. Other maneuvers include placing a Maloney dilator or nasogastric (NG) tube in the esophagus to facilitate later dissection.
- Endoscopic diverticulotomy with stapler: Proper instrumentation is essential for the performance of this technique.
- Three different-sized Weerda laryngoscopes, including the diverticuloscope (anatomic differences require different scopes)
- Hopkins endoscopes (0 and 30°, 4 mm)
- Dental protection
- Vascular 35-mm stapler, preferably with an articulating arm
Intraoperative details
- Diverticulectomy with cricopharyngeal myotomy
- Make a through transverse incision at the level of the cricoid, extending laterally to the SCM muscle.
- Retract the SCM muscle and carotid sheath contents laterally; retract the thyroid and thyroid cartilage medially, and turn them slightly away from the dissection.
- The recurrent laryngeal nerve (RLN) is not routinely identified.
- Perform the dissection on the diverticulum if readily apparent; if the sac is not apparent, begin dissection posteriorly in the midline at the level of the inferior constrictor muscle extending inferiorly until the sac is encountered.
- Then, transect the sac neck either sharply or with a stapler/cutter device.
- Perform CP myotomy.
- If the sac neck is sharply transected, perform closure with 3-0 or 4-0 absorbable suture placed in a Connell closure with 2-3 layers.
- Place an NG tube.
- Place a nonsuction drain.
- Diverticulotomy with stapler
- Intubate the patient with an endotracheal (ET) tube smaller than standard (ie, 6-mm outside diameter [OD] tube for 70-kg patient).
- Place dental protection on the upper and lower dentition.
- Inspect the larynx and postcricoid region with an anterior commissure laryngoscope.
- Position and suspend an appropriate-sized Weerda laryngoscope.
- Inspect mucosa of the sac.
- Define the partition or "party wall" between the sac and the esophagus and ascertain the size of the sac.
- Hopkins endoscopes are used to guide the stapler into place.
- Place the straight part of the stapler (containing the staples and blade) in the esophagus; place the angled part (anvil) in the sac (see Image 3).
- Engage the device, simultaneously stapling and cutting the partition. Release and remove the device (see Image 4).
- Perform a second stapling if residual partition remains.
Postoperative details
- Diverticulectomy with cricopharyngeal myotomy
- Place an NG tube for 3-4 days.
- If a stapler/cutter such as a GIA device is used, an NG tube may not be necessary.
- Start alimentation slowly.
- Closely monitor temperature; obtain a chest radiograph.
- Diverticulotomy with stapler
- Administer ice chips the night of the procedure and a soft diet the following day.
- Closely monitor temperature; obtain a chest radiograph.
- This may be safely performed on an outpatient basis.
- Postoperative radiologic assessment of the surgical site with barium swallow videofluoroscopy must be interpreted with understanding of the surgical intent. Findings that indicate a successful result include the following:
- Reduced height of the partition wall
- Easy passage of barium into the esophagus
- Reduced height of barium in the residual sac
Diverticulectomy with cricopharyngeal myotomy
- Mortality (0-9.5%)
- Morbidity (4-47%)
- RLN paralysis
- Esophageal stenosis
- Mediastinitis
- Pharyngocutaneous fistula
- Hematoma
- Esophageal perforation
Endoscopic stapling diverticulotomy
- Mortality (0-1%)
- Morbidity (10-31%)
- RLN paresis/paralysis
- Bleeding
- Mediastinitis
- Dental injury
- Esophageal perforatio
- Diverticulum perforation (This can occur when placing the angled end of the stapler in a small- to moderate-sized sac while it is stretched tautly by the Weerda diverticuloscope. Repairing this perforation with endoscopically placed sutures has been reported, but open drainage remains the preferred approach.)
- Cervical emphysema
Diverticulectomy with cricopharyngeal myotomy - Advantages
- Removes the diverticulum
- Provides tissue for pathologic review
- Highly effective
- Disadvantages
- Longer surgical intervention
- Longer hospitalization
- Delayed alimentation
- Immediate symptom relief (90-100%)
- Long-term symptom recurrence (2-33%): Gutschow compared the success rates with "open" versus endoscopic techniques.6 He found that in sacs that measured less than 3 cm the open technique achieved 98% long-term success while the endoscopic approach achieved only a 57% rate. With sacs larger than 3 cm, the success rate was 97% and 88%, respectively.
Endoscopic diverticulotomy with stapler - Advantages
- Short surgical procedure
- Easily repeated
- Quick return to oral alimentation
- Short hospitalization
- Less tissue trauma
- Highly effective
- Disadvantages
- Unable to perform in some patients
- Does not remove the diverticulum
- No tissue for pathologic review
- Immediate symptom relief (94-100%)
- Long-term symptom recurrence
- Stapling technique (0-47%): According to Gutschow, the recurrence rate with any endoscopic approach is greater if the sac is smaller.6
- Recurrences may be successfully managed with a repeat endoscopic or an "open" approach; when performing the open approach, the surgeon needs to recognize the altered anatomy present as a result of the prior endoscopic procedure.
- Cautery or laser technique (1-79%; varies widely by reporting site)
A complete understanding of the etiology of Zenker diverticulum (ZD) formation is not available. Further studies focused on the function of the CP muscle are likely to be fruitful. The procedure of choice for Zenker diverticula 2-4 cm in length (the most common size) is different for different surgeons. The final role for endoscopic procedures (with the laser or stapler) awaits further analysis and longer-term follow-up studies.
| Media file 1:
Posterior view of the hypopharynx and proximal esophagus showing the Killian triangle (dehiscence between the inferior constrictor muscle and cricopharyngeus [CP] muscle), Killian-Jamieson area (dehiscence between oblique and transverse fibers of CP muscle), and Laimer triangle (dehiscence between CP muscle and esophageal muscle). |
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| Media file 2:
Images obtained during barium swallow videofluoroscopy demonstrating an intermediate-sized Zenker diverticulum. |
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| Media file 3:
Endoscopic view of partition between the esophagus (anteriorly) and the Zenker diverticulum (posteriorly); the stapler is in place in the lower view. |
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Media type: Photo
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| Media file 4:
Endoscopic view of the stapled and cut edges of the partition between the esophagus and the Zenker diverticulum. |
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Media type: Photo
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Zenker Diverticulum excerpt Article Last Updated: Jan 17, 2008
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