Zenker’s Diverticulum

Zenker’s Diverticulum (ZD) is an outpouching or, in effect, a hernia of the swallowing passage just above a non-relaxing cricopharyngeus muscle.

In essence, the forces of swallowing are delivered against a somewhat unyielding muscle, and this causes the wall of the swallowing passage just above the cricopharyngeus muscle (i.e., the upper esophageal sphincter) to balloon outward. Hence, unknown to many, the Zenker’s diverticulum is only the reflection of the main problem, which is cricopharyngeal dysfunction.

Treatment for ZD

Myotomy of the cricopharyngeus muscle tends to resolve symptoms, even though the Zenker’s diverticulum is left in place and not removed.

Photo Essays of Zenkers Diverticulum

Saliva from Zenker's sac — Saliva from Zenker’s sac (2 of 4)

A few seconds later, saliva begins to return upwards into the post-arytenoid area (at arrow) from the Zenker’s sac.

More saliva (3 of 4)

Less than a second later, more saliva comes upward from the Zenker’s sac.

Forced to re-swallow (4 of 4)

A few seconds later, sufficient saliva has welled up from the sac that the patient is forced to re-swallow, taking her back to the appearance of the first photo in this series, only to begin the same cycle depicted in these four photos again and again.

Example 2

Postcricoid area (2 of 3)

Same view, a second later, as blue-stained applesauce emerges from the Zenker’s diverticulum upward (toward the camera) into the postcricoid area.

Post-swallow Return of Saliva into the Hypopharynx

This man began to experience solid food lodgment a few years earlier, along with gurgling noises every time he swallows. Even on an initial examination, Zenker’s diverticulum can be strongly suspected based on the findings of the videoendoscopic swallow study (VESS). Upon review of a videofluoroscopic swallow study (VFSS), a Zenker’s diverticulum is indeed the explanation for the findings below, which went away completely (return of saliva, gurgling noises, and food lodgment) after myotomy.

Pooling of saliva is seen in the post-arytenoid area. — Pooling of saliva (1 of 4)

Upon first visualization of the hypopharynx and larynx, organized pooling of saliva is seen in the post-arytenoid area.

Saliva disappears after swallow (2 of 2)

Right after swallowing, all of the saliva disappears. The following 2 photos can be harvested within one second of completion of the swallow.

Saliva begins to return (3 of 3)

Here, the saliva begins to return from a presumed Zenker’s diverticulum.

Saliva is ejected upwards swallow — Saliva is ejected upwards from Zenker’s sac (4 of 4)

Either spontaneously, or by gentle pressure on the low neck, much more saliva is ejected upwards from the presumed Zenker’s sac. This is seen commonly when there is a Zenker’s diverticulum, which, again, was subsequently diagnosed here. All of his symptoms and these findings vanished after myotomy.

Reflux Into Hypopharynx, Characteristic of Cricopharyngeal Dysfunction

Videoendoscopic View of Zenker’s Sac Opening and Cricopharyngeus Bar

Orientation (1 of 4)

The ‘X’ is for orientation with next photo; ‘A’ is for right arytenoid eminence (left of photo). The arrow points to the area of focus of the next photo.

View into post-arytenoid and post-cricoid area (2 of 4)

View into post-arytenoid and post-cricoid area. The ‘X’ orients to the same place in photo 1. The esophageal entrance is just beginning to appear at the arrow.

Esophageal and Zenker sac openings (3 of 4)

Descending further, we see two potential openings. ‘E’ designates actual esophageal opening and ‘Z’ the opening to the Zenker’s sac. Between the dotted lines is the cricopharyngeus muscle bar.

Cricopharyngeus muscle bar (4 of 4)

At very close range. Esophageal entrance is indicated at ‘E’ and the Zenker’s sac opening at ‘Z’ with the cricopharyngeus muscle bar (CPM) separating the two.

Cricopharyngeus Non-Relaxation and Zenker’s Sac Seen During VESS