Head & neck imagingCase Type
Dr Juvaina P, Dr. Rinu Susan Thomas, Dr Lin Varghese, Dr Sandeep Govindan PrasadPatient
55 years, female
A 55-year-old female patient presented with a swelling on left side of neck for a duration of 5 months and pain during swallowing for the past 1 week.
X-ray neck lateral view showed widening of the prevertebral soft tissue (fig 1). Barium contrast study showed a posterior contrast filled outpouching arising from cervical oesophagus (Fig 2,3 ). CT images showed a right posterolateral outpouching from cervical oesophagus with air and fluid within (fig 4,5). Retropharyngeal soft tissue with peripherally enhancing fluid density was noted (fig 6).
Zenker’s diverticulum or pharyngoesophageal diverticulum is an acquired pulsion diverticulum through Killian’s dehiscence in the cricopharyngeal muscle. It is believed to be a consequence of mechanic incoordination of the muscle. Although it maybe posterior, lateral or posterolateral, posterior pulsion diverticulum is the most frequent (1). First described by Ludlow in 1769, it has also been described as a protrusion between thyropharyngeus and cricopharyngeus portion of inferior constrictor muscle. It is usually seen in seventh and eighth decade of life with a male predilection .
Clinical features include regurgitation, aspiration of undigested food, halitosis and hoarseness of voice. Cervical borborygmus is pathognomonic. Although rare, squamous cell carcinoma in the pouch is a reported complication. Other reported complications include recurrent laryngeal nerve paralysis, mediastinitis, retropharyngeal abscess and oesophagal stenosis.
Definitive diagnosis is made by barium study of pharynx.. Barium image shows a contrast filled sac posterior to cervical oesophagus, which may extend to mediastinum, the opening of which lies above the cricopharyngeus muscle (1). Zenker's diverticulum can be classified based on size into small (<2cm), intermediate (2-4cm) and large (4 – 6cm) (3). However, the more commonly used classification is Brombart’s classification which has 4 stages. The 1st stage consists of a thorn-like diverticulum with longitudinal axis of 2-3 mm visible only during contraction phase of upper oesophagal sphincter. The 2nd stage is a club like diverticulum with longitudinal axis of 7-8 mm. Stages 3 and 4 are advanced stages with compression of oesophagus in the latter. Filling defect or loss of smooth contour should raise a suspicion of carcinoma.
Zenker’s diverticulum can be treated by open surgical or endoscopic approach. Cricopharyngeal myotomy is combined with a definitive procedure. Recently lasers have also been used for resection(5). However, in our case, the patient was conservatively managed.
Zenker’s diverticulum is an uncommon entity with an incidence between 0.01 to 0.11% (5). Even though post-surgical abscess formation caused by anastomotic leak has known to occur in up to 20 % of operated cases, non-iatrogenic abscess formation is a theoretically described complication, which has been rarely reported in literature (6, 7). It is postulated to be due to lodgement of food particles within the diverticulum and subsequent micro-perforation. Clinically they present with neck pain and progressively increasing neck swelling and need to be managed by drainage of the abscess with lateral pharyngotomy . Persistence of a fistulous track with adjacent scarring and fibrosis worsening preexisting dysphagia needs to be looked for in subsequent imaging following drainage . This case report serves to report this rare but significant complication of Zenker’s diverticulum.
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