Zenker's diverticulum

When Zenker 's diverticulum is a diverticulum of the hypopharynx ( throat) and not the esophagus, as is often incorrectly specified. The Zenker 's diverticulum is a pulsion and pseudodiverticula. It was first described in 1764 by Abraham Ludlow and is named after Friedrich Albert von Zenker. Most men are affected at an advanced age.

Cause and anatomy

The cause for the emergence of this diverticulum is the muscle weak triangle ( Killian triangle) between the pars obliqua and pars fundiformis ( Killian sling muscle, named after Gustav Killian ) the pars cricopharyngea (proportion of pharyngeal constrictor inferior). It is located dorsally above the cricoid cartilage narrowness of the esophagus. With the cause is usually a malfunction of the upper esophageal sphincter ( esophageal sphincter ) in the form of a lack of time, or non-coordinated opening. The diverticulum is often localized to the left side.

Classification and symptoms

Radiologists share the Zenker 's diverticulum after Brombart into four stages of increasing severity one:

• Stage 1 is a thorn -shaped, 2-3 mm long niche formation, which is not always visible.
• Diverticulum in stage 2 are 7-8 mm long and club-shaped.
• Diverticulum in stage 3 are about 10 mm in size, sack -shaped and bent down.
• In stage 4, the diverticulum compresses the esophagus and visibly disabled the contrast medium.

The symptoms vary depending on the stage of the diverticulum. Not all diverticula are symptomatic. In the early stages ( Brombart 1 and 2 ), there is not yet a retention of food in the diverticulum, as the diverticulum only temporarily everts during swallowing and completely passes back into the posterior pharyngeal wall in the interval. In the foreground is often dysphagia, usually in the form of a foreign body sensation ( globus sensation ). One speaks of pouches as opposed to the permanent demonstrable diverticula in the higher stages ( Brombart 3 and 4). Here at food waste in the diverticulum in addition a strong halitosis arise. It comes to the regurgitation of unleavened food ( diagnostically pioneering: the food was not in the stomach, as opposed to reflux ). Cough may be an indication that Divertikelinhalt (food residues) passes into the trachea, it can lead to aspiration pneumonia (lung inflammation). In addition, the swallowing often lead elderly people to weight loss.

Diagnostics

The test has been done with symptomatic with endoscopy and x-rays with contrast. Once a patient noted dysphagia, he should go to specialized care, for a variety of diseases of the esophagus can cause these symptoms. Then there should be a close inspection of the patient's mouth and throat and neck are enlarged lymph nodes sampled by or soft tissue changes. , Depending on the diagnosis, a reflection of the esophagus is performed, and simultaneously removed in the region of prominent mucosal areas a tissue sample. In addition, especially in diverticula, an X-ray examination of the esophagus is carried out with a liquid contrast agent, which may also show movement disorders of the esophagus wall. Is it the disease is a tumor, it may be necessary to perform an additional CT or MRI to see its extent and position of the chest. Under certain circumstances, a preliminary investigation by an ear, nose and throat specialist is required, the need to check the viability of a major nerve in the area of the larynx. Depending on pre-existing conditions and age of the patient and ultrasound examinations of the heart and lung function tests be performed. In a Zenker diverticulum, the indication for operation is given, regardless of how strong the patient's symptoms, because the complication rate is low.

Therapy

First, attempts should be made to treat an underlying dysfunction of the upper esophageal sphincter, as this can lead to relapses otherwise. In the early stages this is the only starting point.

In the more advanced stages currently three methods are used: Open surgical repair ( cervicotomy ) makes it possible to completely resect the diverticulum, however, is associated with the highest effort. A second method is the ENT medical division with a rigid endoscope under general anesthesia. The method with the least amount of effort using flexible endoscopy. In the esophagus, a stomach tube is inserted, then a gastroscope is inserted through an electric needle knife or argon beam probe and the muscle ridge ( Pars fundiformis ) between the diverticulum and the esophagus at least partially severed. Here only the necessary for gastroscopy sedation is required. The risk of relapse is offset by the ease of repeatability. During the operation of the skin cut is made laterally in the longitudinal direction and to the left of the larynx on a length of six centimeters. Then carefully dissected until the left thyroid lobe can be mobilized and lifted up and you have a very important nerve ( recurrent laryngeal nerve ) that runs here, clearly sees. Now the diverticulum is prepared, presented and removed and locked the esophagus at this point again. Finally, in the area of the upper esophageal sphincter, in which the pressure peaks during swallowing occur, carried out a specific muscle transection, so that the resistance in this region decreases in swallowing and can help prevent a recurrence of a diverticulum.

Sources and References

• Vogelsang, A. et al. Treatment of Zenker's diverticulum. In: Dtsch Arztebl. No. 105 (7 ), 2008, pp. 120-126 (Abstract).
• Brombart M.: Le diverticule pharyngo- oesophagien de Zenker. Considerations pathogenetiques. , J Radiol 76 Belg, 1953, 128
• Brombart M.: Radiology of the gastrointestinal tract, Stuttgart, Thieme Verlag 1980, ISBN 3-13-586301-8