In this episode of BackTable ENT, Dr. Ashley Agan interviews Dr. Rebecca Howell, division chief of laryngology at University of Cincinnati, about her diagnosis and management of Zenker’s diverticulum.

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SHOW NOTES

First, Dr. Howell explains that Zenker’s diverticulum (ZD) is a swallowing disorder caused by abnormal outpouching in the esophagus. ZD is only a herniation of the mucosal layers instead of all three tissue layers, so it is classified as a false diverticulum. To have a diagnosis of ZD, patients must have evidence of cricopharyngeus muscle dysfunction and congenital dehiscence. Oftentimes, these patients are in their seventh decade of life and will have problems with regurgitation. Dr. Howell also explains how to distinguish ZD from other differential diagnoses such as pure cricopharyngeus muscle dysfunction and nutcracker esophagus. She notes that a typical ZD patient will have a “rising tide”, or the ability to elicit frothy secretions as they talk.

Next, the doctors discuss different surveys used to diagnose and assess ZD severity. Dr. Howell also speaks about her current prospective study to determine risk factors and prognosticators of ZD. She explains that in general, men and women are affected evenly by this condition and that endoscopy has allowed the earlier diagnosis of ZD patients. Some important factors she always asks while history taking are: previous surgeries, the patient’s motivation for pursuing surgery, and the presence of neurologic diseases. Next, the doctors discuss different imaging modalities like flexible endoscopy, barium swallow studies, EGD, and manometry. Dr. Howell sees lots of potential in the field to develop and standardize workup for ZD diagnosis. While analyzing imaging studies, she also looks for concurrent diagnoses, such as paraesophageal hernia and hiatal hernia.

Then, Dr. Howell discusses how she counsels patients about treatment options for ZD. She frames ZD as a quality of life issue instead of a necessary surgery for everyone. If her patient does not choose to pursue surgery, she makes sure that they are aware of future red flags, such as pneumonia hospitalization and unintentional weight loss. The doctors also weigh the pros and cons of using an endoscopic versus open surgical approach. Based on Dr. Howell’s studies, there is no difference between both approaches, so surgeons should choose the method they prefer more. She summarizes her endoscopic technique, including her list of equipment and how she collaborates with anesthesia providers. Finally, she summarizes her postoperative care regimen and explains how she deals with leaks, an uncommon but serious complication of ZD surgery.