Zenker Diverticulum

History: 50 year old male presents with difficulty swallowing, halitosis, and hoarseness.

Zenker Diverticulum: Lateral oblique image of the esophagus with dual contrast (barium and air) reveals a posterior outpouching of the esophagus filling with barium.

The differential diagnosis of a barium filled sac in the cervical esophagus essentially includes two types of diverticula. The first, and the diagnosis in this case, is a Zenker diverticulum. A Zenker diverticulum is a mucosal herniation through weak areas in the cricopharyngeal muscle, and the barium sac will be above the level of the cricopharyngeal muscle at about the level of C5-6, posterior to the esophagus. Many patients with Zenker diverticula will also have esophageal hiatal hernias and gastroesophageal reflux disease.

The other type of cervical esophageal diverticulum is a Killian-Jamieson diverticulum. These diverticula protrude laterally and below the level of the cricopharyngeus muscle, are less common, and smaller than Zenker diverticula.

Credit to Paul Murphy, M.D., Ph.D. for this classic case!