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DEAR DR. ROACH: What's a Zenker's diverticulum? My 74-year-old friend was diagnosed with it, along with "cricopharyngeal achalasia." I've never noticed any swallowing difficulties before.
-- S.W.
ANSWER: A Zenker's diverticulum is an outpouching of the esophagus that extends posteriorly toward the spine, at about the level of the thyroid. The muscles there are relatively weak, and a swallowing abnormality can lead the inside of the esophagus to go through the muscular layer around the esophagus, leading to a blind pouch.
The cricopharyngeus muscle is the primary muscle responsible for the upper esophageal sphincter, which regulates the initial part of swallowing. This muscle can become damaged by years of acid reflux (which your friend may have had without knowing, or they could've thought it was heartburn) and by getting older. Your friend is near the most common age for this condition.
When the cricopharyngeus muscle becomes stiff and is unable to open properly, pressure inside the esophagus is increased. This leads part of the esophagus to push through into the neck (which is the diverticulum).
Treatment should address both the diverticulum and the swallowing difficulty, which your friend must have had to get the evaluation that lead to this diagnosis. There are several surgical approaches to fix this problem, but the standard approach is to incise part of the muscle to decrease the pressure needed for swallowing.
Fortunately, the muscle heals itself in a way that allows it to retain normal function (opening and closing properly during swallowing, rather than just staying wide open). With some surgical approaches, the diverticulum is usually able to become part of the normal esophagus again. But in some people with very large diverticula, a different surgical approach is used to close, reposition or remove the pouch.
This is an oversimplification, and an expert surgeon and gastroenterologist need to work together to choose the optimal approach for your friend. There are both open and endoscopic approaches, and each has its own pros and cons that need to be considered individually.
Finally, if your friend does have acid reflux, this should be treated. Since the muscular part of the sphincter is weakened, acid reflux can get worse and even include the vocal cords and pharynx.
ToYourGoodHealth@med.cornell.edu