A 65-year-old male presents with a history of progressive dysphagia, regurgitation of undigested food, and chronic cough, particularly at night. On barium swallow study, a large Zenker's diverticulum is identified. Which symptom is most directly related to the size of the Zenker's diverticulum?
Explanation:
Zenker's diverticulum (ZD) is an outpouching of the mucosa of the pharynx, typically occurring at the Killian triangle. The size of the diverticulum can significantly impact the clinical presentation. Larger diverticula are more likely to retain food, leading to the regurgitation of undigested food, which is a hallmark symptom directly related to the size of the diverticulum. Dysphagia is also commonly associated with ZD but is not as directly correlated with the size of the diverticulum as regurgitation is. Halitosis, weight loss, and nighttime coughing can occur but are less specific indicators of diverticulum size.
Further Reading:
Eisele DW, Smith RV. Zenker's Diverticulum. In: Flint PW, Haughey BH, Lund VJ, Niparko JK, Richardson MA, Robbins KT, Thomas JR, eds. Cummings Otolaryngology: Head and Neck Surgery. 6th ed. Philadelphia, PA: Elsevier; 2015: 1110-1120.
Chang CW, Chen YT, Lin CP, et al. Zenker's diverticulum: clinical experience in diagnosis and treatment at a single medical center. J Chin Med Assoc. 2013;76(3):149-153.
Cook IJ, Gabb M, Panagopoulos V, et al. Pharyngeal (Zenker's) diverticulum is a disorder of upper esophageal sphincter opening. Gastroenterology. 1992;103(4):1229-1235.
Additional Concepts:
Pathophysiology of Zenker's Diverticulum: ZD is believed to result from increased intraluminal pressure in the hypopharynx, leading to herniation of the mucosa through an area of muscular weakness.
Diagnostic Modalities: Barium swallow study is the gold standard for diagnosing ZD. Endoscopic evaluation can also be used for diagnosis and therapeutic planning.
Management Options: Treatment options include open surgical repair, endoscopic stapling, and the more recent peroral endoscopic myotomy (Z-POEM), which has shown promising results with lower morbidity and shorter recovery times.
Complications: Potential complications of untreated ZD include aspiration pneumonia, malnutrition, and, rarely, carcinoma arising within the diverticulum.