Cricopharyngeal Diverticulum: Open Repair



Cricopharyngeal Diverticulum: Open Repair


William R. Carroll

Kirk P. Withrow





DIFFERENTIAL DIAGNOSIS



  • Zenker’s diverticulum typically presents with dysphagia, regurgitation of undigested food, and occasionally, aspiration pneumonia. Causes for cervical dysphagia in adults may be grouped into three categories: internal, external, and motility. Internal disorders include inflammation and edema, stenosis, and neoplasm. External disorders produce extrinsic compression of the pharyngoesophageal segment and may include thyroid disease, adenopathy, abscess, and congenital cysts. Motility disorders include achalasia, stroke, esophageal spasm, myasthenia, and bulbar palsy.


PATIENT HISTORY AND PHYSICAL FINDINGS



  • Cervical dysphagia is the most common presenting symptom of Zenker’s diverticulum. Symptoms may be quite subtle and include chronic cough and unexplained weight loss. As the patient swallows, food and liquids preferentially enter the wide mouth of the diverticular pouch rather than passing through the inappropriately closed upper esophageal sphincter. As food and liquid accumulate, the patient develops a sense of neck fullness and may hear gurgling sounds in the lower neck. A pathognomonic type of regurgitation is common in which the patient regurgitates food minutes or even hours after eating that is completely undigested and not mixed with gastric contents. The pouch may fill and empty spontaneously during deglutition. When the pouch empties, the contents may spill into the airway, causing aspiration with coughing or pneumonia. The aspiration may be subtle and lead to recurrent respiratory infections and eventually chronic respiratory insufficiency. Death due to untreated Zenker’s diverticulum typically results from pulmonary complications.


  • Physical findings of Zenker’s diverticulum include neck fullness or a mass in the tracheoesophageal groove that may gurgle or decompress with palpation (Boyce’s sign). Audible gurgling may be detected over the same region with swallowing. Inspection of the hypopharynx may reveal pooling of secretions.1 The pouch is typically not visible unless the patient undergoes esophagoscopy.


IMAGING AND OTHER DIAGNOSTIC STUDIES



  • Barium swallow is usually needed to definitively diagnose Zenker’s diverticulum. The study characteristically reveals a diverticular sac originating just superior to the prominent and poorly relaxing cricopharyngeus muscle. Radiologists describe this prominent muscle as a cricopharyngeal “bar.”


  • Computed tomography (CT) or magnetic resonance (MR) imaging of the neck is unnecessary if barium swallow
    confirms a Zenker’s diverticulum. These studies would typically reveal a fluid-filled, cyst-like density adjacent to the level of the cricopharyngeus muscle.


  • Chest imaging may reveal evidence of chronic aspiration pneumonitis.






FIG 2 • As intraluminal pressure increases due to spasticity of the cricopharyngeus muscle, the pulsion diverticulum forms.


SURGICAL MANAGEMENT

Jul 24, 2016 | Posted by in GENERAL | Comments Off on Cricopharyngeal Diverticulum: Open Repair

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