Zenker’s Diverticulum

Zenker’s Diverticulum
n engl j med 354;23 www.nejm.org june 8, 2006



Zenker diverticulum, a pulsion diverticulum of the hypopharynx, is a rare lesion that occurs in elderly populations. The condition results in a classic presentation of symptoms, with complications that include aspiration and pneumonia, and is managed by endoscopic and surgical repair.

 

Zenker diverticula are lined with stratified squamous epithelium with a thin lamina propria. No muscular layer exists. Fibrosis surrounding the diverticulum is common.

 

 

Zenker diverticula may be staged in 1 of the following 3 systems, as assessed by means of barium swallow videofluoroscopy:

Lahey system

Criteria of the Lahey staging system are as follows:

• 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

Criteria of the Morton staging system are as follows:

• 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

Criteria of the van Overbeek system are as follows:

• 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

The history strongly suggests the diagnosis of Zenker diverticulum. The combination of the following symptoms is nearly pathognomonic for the condition:

• Dysphagia - Most patients (98%) present with some degree of 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 (halitosis)
• Borborygmi in the neck