A 42-year-old man presents to clinic complaining of frequent regurgitation of undigested food, coughing whenever he tries to swallow, and halitosis. His wife has started to complain about his bad breath, and he wants to know what is wrong. He reports brushing his teeth three to four times daily, with no improvement in the smell of his breath.
Which of the following is the best step to take next in the evaluation of this patient?
A. Barium swallow B. Esophagogastroduodenoscopy (EGD) C. CT scan of the neck D. Modified barium swallow
Barium swallow-key concept/objective: to understand the diagnosis of zenker diverticulum an esophageal diverticulum is a sac that protrudes from the esophageal wall. as in the rest of the gastrointestinal tract, a true diverticulum is one that contains all layers of the wall. a false diverticulum contains mucosa and submucosa that have herniated through the muscular wall. esophageal diverticula are classified into four categories on the basis of anatomy: zenker diverticula; midesophageal diverticula; epiphrenic diverticula; and intramural pseudodiverticulosis. zenker diverticulum is often referred to as an esophageal diverticulum. however, its location is proximal to the esophagus, above the upper esophageal sphincter (ues), and should be considered a hypopharyngeal diverticulum. zenker diverticula are believed to form as a result of an area of weakness‚??the killian triangle‚??that exists between the cricopharyngeal sphincter and the inferior pharyngeal constrictor muscle. the primary abnormality that leads to the development of the diverticula is incomplete relaxation of the ues. an association between zenker diverticula and reflux has been suggested but not confirmed. typical symptoms include oropharyngeal dysphagia, regurgitation of undigested food, halitosis, cough, and aspiration pneumonia. barium swallow is an excellent test for the diagnosis of zenker diverticulum. many small diverticula are asymptomatic, but symptomatic patients with large diverticula should be offered treatment. the classic treatment is an open surgical resection of the diverticulum with division of the cricopharyngeus muscles. another option for extremely large diverticula is diverticulopexy, or suspension of the diverticulum in a cranial direction.