Dale Ekbom, M.D., Mayo Clinic Otolaryngology-Head and Neck Surgery: Hi. My name is Dr. Dale Ekbom. I am an Otolaryngologist. I specialize in laryngology, or voice, swallowing and airway. And today, we're going to be talking a little about Zenker's diverticulum.
Zenker's diverticulum is actually a pouch of mucosa that comes off the top of the esophagus. So at the very top of your esophagus, you have a cricopharyngeus (CP) muscle, and that is your upper sphincter. And just above that, you can get this outpouching of mucosa that can actually collect food up there. And so that's what a Zenker's is.
What causes a Zenker's diverticulum is a very good question. Some think that it's related to the discoordination or the tightness of the upper esophageal muscle at the top of esophagus. And then the pouch can start forming over the top of that muscle. But it's strange because we don't know why this happens to some people and doesn't happen to others. So, it's a little unclear, reflux might be a factor with this, but right now, it's still mainly chalked up to being this discoordination of the muscle, the top of the esophagus.
The symptoms of Zenker's diverticulum is typically the main thing is swallowing difficulties, specifically to solid foods, but also to liquids. The solid foods and pills and other thickened liquids, especially, can get caught in that pouch. And some of those foods can actually come back up or a patient can regurgitate that even a couple hours after they eat. So regurgitation of undigested food is one of the symptoms as well as the swallowing difficulties. Some people feel like they have a lump in the throat or something caught in the throat. They also notice more coughing. Other patients notice sounds or gurgling coming from the pouch. The other more dramatic symptoms that can occur with this would be an aspiration pneumonia, for instance, because the pouches contents or the food can come up and spill into the airway, and that can be aspirated. Now, most patients will have a strong cough, so they can avoid that aspiration pneumonia just by coughing that up and coughing it away. And the final symptom probably could be weight loss if this really affects the eating.
The Zenker's diverticulum is diagnosed mainly by what's called a swallow study. But we have to be clear here because there's a swallow study that
looks at just the upper part of the swallow, and there's another swallow study that looks at the esophagus. And so the upper part of the swallow is called a video fluoroscopic swallow study. It's an x-ray, like a moving x-ray. That's also called a modified barium swallow, depending on what part of the country or what physician you have. That's the most important part of the test because that will show any swallowing difficulties from the tongue all the way down and through that pouch or the upper part of the esophagus. The second part of the swell study is really important, though, and that's called the esophagram, where they look at the esophagus, and that's also called a barium swallow. So when you come to see us, we like to have both the video fluoroscopic swallow study or modified barium swallow, as well as a full esophagram to look at the esophagus. Sometimes people can have esophageal dysmotility or movement disorders of the esophagus or a hiatal hernia with more reflux. And that's very important for us to know if you have not just the Zenker's, but also other factors that can affect your swallowing.
In terms of treatment options for Zenker's diverticulum, there's the gold standard, which is open approach through the neck, and for a larger Zenker's pouch that is an excellent option. And patients can tolerate this and do very well with an open neck approach. I think some patients feel nervous. They, they want that endoscopic approach and I also prefer the endoscopic, if I can. But an open neck approach is fairly straightforward. Usually one night in the hospital and patients go home the next day typically. But endoscopic approaches are also great options for this and that's the majority of what I do is a rigid endoscopic approach where we have the patient completely asleep, and it's a rigid scope that goes into the mouth and down into the Zenker's pouch. It shows a part of the esophagus up front and the Zenker's pouch in the back, and then we use a laser, a CO2 laser to cut down on that partition between the esophagus and the Zenker's pouch, and then attempt to remove a portion of the pouch with the laser. Now, there are other endoscopic techniques. There's the endoscopic stapler technique and a flexible technique that we can use in ENT, but also is used with our GI colleagues. But those are and then the harmonic scalpel is one other option that was used more often in the past and less often now.
In thinking about the best surgical option, it depends on a few different things. It depends on the patient and do they have neck extension, or are they pretty rigid? You know, if there's not a lot of neck extension and they are a patient who has other medical problems or a lot of medical problems, then sometimes a flexible approach, where it could sometimes be done under sedation might be a better approach. But the majority of the time, I find that the best approach is a rigid endoscopic technique, where I can have the patient completely asleep under general anesthesia, and then the patient is very still. And then I will use a laser to cut down on that partition between the Zenker's pouch and the esophagus. And one of the newer innovative things that we're doing at Mayo here is working on removing that pouch through this endoscopic technique. We use a CO2 laser, and I cut through that partition and then up the back wall of the pouch, and I split the pouch in half, and then I take one side of the pouch and I use my laser and cut out that side of the pouch, and then I pull the other side and remove it there. And then I let your body just heal up and over time usually fairly quickly within the next week or so the mucosa regrows over that area. I typically use fibering glue to lay over the top that dissolves within a week. And so that allows for a better healing too. Now, for some patients, if that pouch is large, then an open approach is a better option. Or sometimes surgeons are just excellent at that open approach, too. And we do a lot of Zenker's surgery here and have a couple of surgeons that do the majority and myself included. And, you know, overall, endoscopic is preferred for a lot of my patients, but it also open approaches something that we have a lot of experience with, too, especially for those that are larger pouches.
In terms of complications from Zenker's surgery. Some of the more standard things that are discussed is bleeding. It's rare to have this be a factor, but that can occur. Infection is another complication, and we typically give antibiotics as well as a precautionary thing to avoid infection. The main complication that can happen after Zenker's surgery is what's called crepitus in the neck or air in the neck. And this can happen after a laser or another approach, where there's a tiny hole in the back wall of the esophagus or the back wall of the pouch. And if it goes through the fascia, that layer behind the esophagus or behind the pouch, then it goes into what's called the retropharyngeal space or it has fat in that location. And a little bit of air can travel out into the neck and that's why we watch all these patients overnight. We keep you overnight. And basically check your neck. And if we don't feel any air in the neck, then you're good to go the next day. But if there is air in the neck, that happens about 5% to even 8% of the time in our patients, then we have to keep an eye on you. If it's a tiny little bit of air in the neck, maybe we say no eating for a day and recheck it. If it's more air extending into the neck than we do a feeding tube, a temporary feeding tube for typically two weeks, sometimes three. And those are the main complications that can occur. I have some patients that this happens to, and it's never fun to have a feeding tube even temporarily in. It goes from the nose into the stomach. But in the end after two weeks, typically, once that feeding tube is removed, that whole has healed on its own, and the feeding tube is removed, then patients are eating and drinking better than they have in years, typically. So it is a very even if even if it is that worst complication that we've seen in the past, patients can still do well after. One other complication that can occur is increased reflux. If you think about this, we're cutting the upper sphincter muscle as a part of that partition between the Zenker's pouch and the esophagus. So occasionally, if this lower sphincter doesn't work as well, you can have a little more reflux that can come up and patients can notice that. There are medicines that we can give to treat reflux though.
The chance of recurrence after Zenker's surgery really depends on the approach and the procedure and the surgeon who's doing it. You know, I would say, you want to find someone that does a lot of these procedures. And we do a lot here at Mayo. But overall, the recurrence rate for certain procedures such as the flexible approach, the endoscopic stapler approach and the harmonic scalpel approach are higher. The latest research shows around 15% or more than the typical laser approach we use here with a rigid laser or the open neck approach. Those have lower recurrence rates. So overall, I feel that's another thing that points us more towards a rigid endoscopic approach as being a better approach for the majority of our patients.
In terms of being prepared for a meeting with us here at Mayo, I would love to see any records that you have. Outside records would be wonderful for me to review, and especially an outside swallow study. If you had that done closer to home, it doesn't have to be an up-to-date one because often we like to do that again when you visit here at Mayo. But it can be an older swallow study as well, and then I can get a sense of how large the Zenker's is and have a conversation with our scheduling team. The best option, especially for our patients that live far away, is to see me the day before a surgical day and tentatively be listed on that next day for surgery if you want that and if it works for your schedule. So the best thing would be to talk to my our schedulers or nursing team, and they can find a time that works for you, and I can review all your outside records and then actually have some good material to discuss when you come the day before a surgical day.
Some questions to ask when you come to discuss the Zenker's diverticulum is, what's the best surgery for me, and what are the chances that this can come back and what are the risks associated with it. Some of the things we discussed already, but we can definitely review that when you come. I think every patient is unique, and we just need to make sure we find the right procedure that would work best for you with the lowest risk.
If you're wondering about bringing a family member or a friend or somebody with you, I think it's very helpful to have that. I also sometimes we call a family member and have them on a speaker phone in the room, and they can listen in. So I'm happy to do that too. But just to share more about best options and how to make that right decision. You know, sometimes the Zenker's is really small, and if you have very little in the way of symptoms, you don't have to have the surgery either. So making those decisions, it's kind of nice to have someone else with you. Now, also, if you are planning on needing surgery next day or planning on surgery next day, then I would for sure have someone with you because you can't drive for 24 hours after you're going to be staying in the hospital typically one night after this procedure. But it's nice to have someone with if you can.
From an Internet standpoint, there's so much information that you can read. And there's up-to-date approaches, like you'll see a lot on the Internet about the flexible technique and that approach. And I think it is a good approach for the right patient. And for me, that patient is someone who again, has maybe many medical issues and we'll struggle with neck extension and struggle with the general anesthesia. Then flexible approach could be done, occasionally done under sedation. Most of the flexible approaches are done under general anesthesia, anyways. I do feel that with the recent literature and looking at recurrence rate, when we do our rigid endoscopic approach, we can get to the bottom of that pouch, and not just the bottom of the pouch, we get up the back wall of it and then attempt to remove the pouch. Now, sometimes we're more successful than others, and occasionally, there's a residual pouch left. But that is a way to avoid recurrence. So when you're looking online and see all about some of the newer techniques and newer flexible techniques, remember that some of these, you know, we would discuss this together when I'd meet you, but some of these more tried and true rigid endoscopic techniques or even open through the neck can give you an approach that results in a lesser recurrence rate and a lesser complication rate for many.