Zenker Diverticulum Imaging

No Results

No Results

processing….

A diverticulum is an outpouching that protrudes from the wall of a viscus. As with the entire gastrointestinal (GI) tract, diverticula of the hypopharynx may be true or false, depending on the number of layers of the viscus wall that are involved. (See the images below.) ^{[1, 2, 3, 4, 5, 6]}

True diverticula consist of all layers of the wall, whereas false diverticula generally lack the muscularis layer. A Zenker diverticulum is a false diverticulum consisting of mucosa and submucosa that arises from the posterior portion of the inferior pharyngeal constrictor muscle.

Fluoroscopic studies of the upper GI tract have shown that the prevalence of Zenker diverticulum is 0.01-0.1%. Zenker diverticulum is found in approximately 2% of patients with nonspecific dysphagia who are referred for fluoroscopy.

Preoperative assessment of dysphagia characteristics, using fiberoptic endoscopic evaluation of swallowing, in patients with Zenker diverticulum revealed that postswallow hypopharyngeal reflux (PSHR) is predictive of a diverticulum larger than 1 cm and may be useful in surgical planning. PSHR was less frequent in patients with small diverticula (17%) than in those with medium (91%) and large diverticula (87%). According to the authors of the study, PSHR is also helpful in identifying patients with recurrent or residual symptomatic Zenker diverticulum after surgical treatment. ^[7]

Fluoroscopic barium esophagography is the mainstay of diagnosis of Zenker diverticulum. Physical examination findings are rare, although some extremely large diverticula are occasionally palpable on examination. These are usually to the left of midline.

Zenker diverticulum may be found on endoscopy; however, fluoroscopy remains the diagnostic study of choice. Care must be taken in performing endoscopy in patients with known Zenker diverticulum, as passage of the endoscope into the diverticulum carries some risk of perforation. Endoscopy may be indicated if the radiographic findings suggest carcinoma. The main limitation of barium esophagography is patient cooperation.

The fluoroscopic barium esophagram is the primary tool for the diagnosis of Zenker diverticulum. (See the image below.) The diverticulum appears as an outpouching arising from the midline of the posterior wall of the distal pharynx near the pharyngoesophageal junction. This is best identified during swallowing and is best seen on the lateral view, on which the diverticulum is typically noted at the C5-6 level.

Frequently, a posterior bar representing a prominent cricopharyngeus muscle is noted as the contrast bolus passes. As the contrast bolus normally travels quickly through the pharynx and upper esophagus, careful observation during fluoroscopy is necessary, and videofluoroscopy is helpful for documentation purposes.

When the diverticulum is large enough to protrude laterally, it protrudes to the left in 90% of cases. After the contrast agent bolus passes the upper esophagus, the diverticulum is typically seen extending posterior to the cricopharyngeus muscle, and contrast material that was trapped within the diverticulum may be regurgitated back into the hypopharynx.

A Valsalva maneuver may be helpful in visualizing the diverticulum after swallowing. Occasionally, a patient may aspirate contrast material from the diverticulum. Pay attention to the lumen of the diverticulum because irregularities or filling defects within the diverticulum may indicate the rare complication of squamous cell carcinoma.

When Zenker diverticulum is demonstrated on fluoroscopy, clearing of any residual contrast material within the diverticulum should be confirmed, as aspiration can occur.

A fluoroscopic diagnosis is made with a high degree of confidence.

Barium may become trapped above a cricopharyngeal muscle that has closed before the pharyngeal contraction has passed, and this may mimic the appearance of a Zenker diverticulum. This pseudo-Zenker diverticulum can be distinguished from a true Zenker diverticulum by means of fluoroscopic observation. The pseudo-Zenker diverticulum does not protrude beyond the expected location of the posterior pharyngeal wall, and it generally does not persist after the contrast agent bolus has passed.

When incidentally imaged on computed tomography (CT) scans, a Zenker diverticulum appears as a structure arising posteriorly from the hypopharynx and is filled with gas, fluid, oral contrast material, or a mixture of these. (See the image below.)

This examination is not routinely used to either confirm or exclude Zenker diverticulum.

When incidentally imaged on a magnetic resonance imaging (MRI) scan, a Zenker diverticulum appears as a structure arising posteriorly from the hypopharynx. It is filled with gas, fluid, or a mixture of these.

This examination is not routinely used to either confirm or exclude Zenker diverticulum.

Although barium esophagram is usually used to confirm the diagnosis, there has been a study of the use of swallow contrast-enhanced ultrasound to detect Zenker diverticulum. In 10 patients, Zenker diverticulum appeared as a pouch-shaped structure at the posterior pharyngoesophageal junction that retained ultrasound contrast agent for longer than 3 minutes. All 10 patients underwent a barium esophagram as the gold standard. The authors explained that contrast-enhanced ultrasound provides advantages of bedside availability and no radiation exposure. ^[8]

Achkar E. Esophageal diverticula. In: Castell DO, Richter JE, eds. The Esophagus. Lippincott Williams & Wilkins. 1999: 301-6.

Ekberg O. Benign structural disease of the pharynx. In: Freeny PC, et al, eds. Margulis and Burhenne’s Alimentary Tract Radiology. 5th ed. 1994: 114-26.

Lichtenstein GR. Esophageal rings, webs, and diverticula. In: Haubrich WS, Schaffner F, Berk JE, eds. Bockus Gastroenterology. 5th ed. 1995: 518-33.

Rubesin SE. Structural abnormalities of the pharynx. In: Gore RM, Levine MS, eds. Textbook of Gastrointestinal Radiology. 2nd ed. 2000: 227-55.

Ferreira LE, Simmons DT, Baron TH. Zenker’s diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus. 2008. 21(1):1-8. [Medline].

Visosky AM, Parke RB, Donovan DT. Endoscopic management of Zenker’s diverticulum: factors predictive of success or failure. Ann Otol Rhinol Laryngol. 2008 Jul. 117(7):531-7. [Medline].

Bergeron JL, Long JL, Chhetri DK. Dysphagia characteristics in Zenker’s diverticulum. Otolaryngol Head Neck Surg. 2013 Feb. 148(2):223-8. [Medline]. [Full Text].

Cui XW, Ignee A, Baum U, Dietrich CF. Feasibility and usefulness of using swallow contrast-enhanced ultrasound to diagnose Zenker’s diverticulum: preliminary results. Ultrasound Med Biol. Apr 2015;41(4):975-81. [Medline].

Spencer Sincleair, MD 

Spencer Sincleair, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Brenda L Holbert, MD, FACR Radiologist, Department of Radiology, Wake Forest University School of Medicine

Brenda L Holbert, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Abraham H Dachman, MD, FACR Professor, Department of Radiology, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine; Director of CT, Department of Radiology, The University of Chicago Hospitals

Abraham H Dachman, MD, FACR is a member of the following medical societies: Radiological Society of North America

Disclosure: Nothing to disclose.

Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Nothing to disclose.

Eric P Weinberg, MD Associate Professor, Department of Radiology, University of Rochester Medical Center, Strong Memorial Hospital

Eric P Weinberg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Zenker Diverticulum Imaging

Research & References of Zenker Diverticulum Imaging|A&C Accounting And Tax Services
Source

Share on Facebook

Tweet

Follow us