Zenker's Diverticulum
Zenker's Diverticulum
The radiologic features of ZD are well known. Esophagography is necessary to confirm the diagnosis of ZD (Figure 2A and B); however, dynamic continuous fluoroscopy is preferred (Supplementary Video 1 http://www.cghjournal.org/cms/attachment/2019475005/2039575870/mmc1.mp4%20/cms/attachment/2019475005/2039575877/mmc1.flv) because static images may be insufficient in patients with small diverticulum. Additionally, evidence of overflow and aspiration can be seen. Differentiation from the less common, and smaller, Killian-Jamieson diverticulum that arises from the proximal anterolateral cervical esophagus and lies inferior to the CP muscle is important. Although Killian-Jamieson diverticula may be treated endoscopically, it is unclear if the efficacy and safety are the same as with ZD, as the recurrent laryngeal nerve runs close to the base of the diverticulum.
(Enlarge Image)
Figure 2.
Radiographic images of ZD. (A) Frontal view; (B) lateral view.
Various radiologic correlations to ZD progression and predictors to therapy have been described. The little-known Brombart classification scheme seen on esophagography defines 4 types of ZD with the original concept of progression from one stage to another. In this schema, type 1 diverticula are only visible during the contraction phase of the UES, whereas type IV lesions are large and lead to compression on the esophagus. Although this has not been established, the scheme has been used to assess the response to therapy. In one study, Brombart III–IV diverticula were managed significantly more commonly with rigid endoscopic procedures than open procedures. Postprocedural residual diverticulum and filling with contrast were strongly associated with prolonged dysphagia in the early postoperative period but failed to correlate significantly with symptomatic recurrence.
In another study, pouch neck length, soft tissue plane between the pouch and the esophagus, diameter of the pouch opening, and the maximum diameter of the pouch were measured. A favorable outcome was predicted by a higher ratio of pouch neck diameter to soft tissue plane and predicts the need for a shorter myotomy. A closer apposition of the diverticulum to the proximal esophageal wall is expected to improve the technical ease of dividing the common septum containing the CP muscle.
ZD may also be diagnosed by transcutaneous ultrasonography. During ingestion of water, an increase in the lesion's size, a reduction in the definition of the margins, and heterogeneous echogenicity of the lesion's contents are seen. The importance of ultrasound findings is the differentiation of a ZD from a thyroid mass. Ultrasonography as a diagnostic modality for ZD may also be useful in elderly patients who cannot tolerate barium esophagography and in those with a neck mass on physical examination. In the future, neck ultrasonography may be used for assessing the UES. A recent study identified the normal diameters of the closed UES, the mean duration of opening, and the mean duration of displacement in the anterior and lateral directions. As this idea is further developed, it may allow us to detect abnormalities at the level of the UES that correlate with ZD.
Radiography as the Primary Means of Diagnosis of ZD
The radiologic features of ZD are well known. Esophagography is necessary to confirm the diagnosis of ZD (Figure 2A and B); however, dynamic continuous fluoroscopy is preferred (Supplementary Video 1 http://www.cghjournal.org/cms/attachment/2019475005/2039575870/mmc1.mp4%20/cms/attachment/2019475005/2039575877/mmc1.flv) because static images may be insufficient in patients with small diverticulum. Additionally, evidence of overflow and aspiration can be seen. Differentiation from the less common, and smaller, Killian-Jamieson diverticulum that arises from the proximal anterolateral cervical esophagus and lies inferior to the CP muscle is important. Although Killian-Jamieson diverticula may be treated endoscopically, it is unclear if the efficacy and safety are the same as with ZD, as the recurrent laryngeal nerve runs close to the base of the diverticulum.
(Enlarge Image)
Figure 2.
Radiographic images of ZD. (A) Frontal view; (B) lateral view.
Various radiologic correlations to ZD progression and predictors to therapy have been described. The little-known Brombart classification scheme seen on esophagography defines 4 types of ZD with the original concept of progression from one stage to another. In this schema, type 1 diverticula are only visible during the contraction phase of the UES, whereas type IV lesions are large and lead to compression on the esophagus. Although this has not been established, the scheme has been used to assess the response to therapy. In one study, Brombart III–IV diverticula were managed significantly more commonly with rigid endoscopic procedures than open procedures. Postprocedural residual diverticulum and filling with contrast were strongly associated with prolonged dysphagia in the early postoperative period but failed to correlate significantly with symptomatic recurrence.
In another study, pouch neck length, soft tissue plane between the pouch and the esophagus, diameter of the pouch opening, and the maximum diameter of the pouch were measured. A favorable outcome was predicted by a higher ratio of pouch neck diameter to soft tissue plane and predicts the need for a shorter myotomy. A closer apposition of the diverticulum to the proximal esophageal wall is expected to improve the technical ease of dividing the common septum containing the CP muscle.
ZD may also be diagnosed by transcutaneous ultrasonography. During ingestion of water, an increase in the lesion's size, a reduction in the definition of the margins, and heterogeneous echogenicity of the lesion's contents are seen. The importance of ultrasound findings is the differentiation of a ZD from a thyroid mass. Ultrasonography as a diagnostic modality for ZD may also be useful in elderly patients who cannot tolerate barium esophagography and in those with a neck mass on physical examination. In the future, neck ultrasonography may be used for assessing the UES. A recent study identified the normal diameters of the closed UES, the mean duration of opening, and the mean duration of displacement in the anterior and lateral directions. As this idea is further developed, it may allow us to detect abnormalities at the level of the UES that correlate with ZD.
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