Esophargeal DysphagiaEsophargeal Dysphagia

Jean Paul Font, MDJean Paul Font, MDMichael Underbrink, MD, MBAMichael Underbrink, MD, MBA

University of Texas Medical BranchUniversity of Texas Medical BranchDepartment of OtolaryngologyDepartment of OtolaryngologyGrand Rounds PresentationGrand Rounds Presentation

February 6, 2008February 6, 2008

Esophageal AnatomyEsophageal AnatomyMuscular tube connecting the pharynx Muscular tube connecting the pharynx to the stomachto the stomach

Esophagus begins where the inferior Esophagus begins where the inferior pharyngeal constrictor merges with the pharyngeal constrictor merges with the cricopharyngeus cricopharyngeus

– Upper esophageal sphincter (UES)Upper esophageal sphincter (UES)

18 to 26 cm in length18 to 26 cm in length

Lower esophageal sphincter (LES) Lower esophageal sphincter (LES) – Thickened circular smooth muscleThickened circular smooth muscle– 40cm from incisors40cm from incisors

Extrinsic indentationsExtrinsic indentations– Anterior body of C7 (worsen by Anterior body of C7 (worsen by

osteophytes)osteophytes)– Arch of the aorta, the left mainstem Arch of the aorta, the left mainstem

bronchusbronchus– Diaphragmatic hiatus Diaphragmatic hiatus

Four layers: Four layers:

– MucosaMucosa

– SubmucosaSubmucosa

– Muscularis propriaMuscularis propria

– Adventitia; no serosa. Adventitia; no serosa.

Esophageal MucosaEsophageal Mucosa– Nonkeratinized, stratified Nonkeratinized, stratified

squamous epitheliumsquamous epithelium

Gastric lining Gastric lining – Columnar epithelium Columnar epithelium

(rugae)(rugae)

Z-lineZ-line– Junction of the squamous Junction of the squamous

epithelium and columnar epithelium and columnar epitheliumepithelium

Cephalad movement Cephalad movement – Barrett’s esophagus. Barrett’s esophagus.

Muscularis propriaMuscularis propria

Skeletal and smooth muscleSkeletal and smooth muscle

– Skeletal muscle Skeletal muscle (Proximal 1/3)(Proximal 1/3)

– Mixed Mixed (Middle 1/3)(Middle 1/3)

– Smooth muscle Smooth muscle (Distal 1/3)(Distal 1/3)

Inner circularInner circular

Outer longitudinal layers. Outer longitudinal layers.

Innervation mainly by Vagus n.Innervation mainly by Vagus n.

Auerbach’s (myenteric) plexusAuerbach’s (myenteric) plexus

– Between the two muscle layersBetween the two muscle layers– Controls esophageal peristalsisControls esophageal peristalsis– Acetylcholine mediates Acetylcholine mediates

contractioncontraction– Nitric oxide relaxationNitric oxide relaxation

Meissner's plexusMeissner's plexus

– Submucosal layerSubmucosal layer– Sensory input Sensory input – Pain sensation overlap with the Pain sensation overlap with the

heart and respiratory systemheart and respiratory system

At rest At rest – UES & LES UES & LES

tonically contractedtonically contracted

Immediately after a Immediately after a swallow swallow – UES pressure falls UES pressure falls

transientlytransiently

Shortly thereafterShortly thereafter– LES pressure falls LES pressure falls

and remains low and remains low until the peristaltic until the peristaltic contraction closes contraction closes the LES the LES

Esophageal PeristalsisEsophageal Peristalsis

DysphagiaDysphagia

Greek Greek dysdys (difficulty, disordered) and (difficulty, disordered) and phagiaphagia (to eat) (to eat)Sensation that food is hindered in its passage from the Sensation that food is hindered in its passage from the mouth to the stomachmouth to the stomachMost patients complain that foodMost patients complain that food– ““sticks,” “hangs up,” “stops,” or “just won't go down right” sticks,” “hangs up,” “stops,” or “just won't go down right”

Anatomically classified into two separate clinical Anatomically classified into two separate clinical categories: categories: – Oropharyngeal and esophageal. Oropharyngeal and esophageal.

Psychiatric disorders can amplify this symptom. Psychiatric disorders can amplify this symptom. Dysphagia is a common symptomDysphagia is a common symptom– Present in 12% of patients admitted to an acute care hospital Present in 12% of patients admitted to an acute care hospital

and in more than 50% of those in a chronic care facility. and in more than 50% of those in a chronic care facility.

HistoryHistory

Three questions are crucial: Three questions are crucial:

(1) What type of food or liquid causes symptoms? (1) What type of food or liquid causes symptoms? – Mechanical vs neuromuscular defect Mechanical vs neuromuscular defect – Primarily solids Primarily solids

Structural lesion- peptic stricture, ring, or malignancyStructural lesion- peptic stricture, ring, or malignancy– Both solid and liquid Both solid and liquid

a motility disorder like achalasia or sclerodermaa motility disorder like achalasia or scleroderma

(2) Is the dysphagia intermittent or progressive?(2) Is the dysphagia intermittent or progressive?– Esophageal rings tend to cause intermittent solid food dysphagia Esophageal rings tend to cause intermittent solid food dysphagia – Strictures and cancer cause progressive dysphagiaStrictures and cancer cause progressive dysphagia

(3) Does the patient have heartburn?(3) Does the patient have heartburn?– Complication of GERD- Esophagitis, stricture & Barrett’sComplication of GERD- Esophagitis, stricture & Barrett’s

HistoryHistory

Location of dysphagiaLocation of dysphagia– Limited value (Referred from any site)Limited value (Referred from any site)

Weight loss Weight loss – Significance and duration of the diseaseSignificance and duration of the disease

Dietary changes Dietary changes – Nature and severity of disease. Nature and severity of disease.

Dysphagia must be distinguished from Dysphagia must be distinguished from odynophagiaodynophagia– Associated with an inflammatory condition Associated with an inflammatory condition

(esophagitis)(esophagitis)

Diagnostic ToolsDiagnostic Tools

EsophagogramEsophagogram

EndoscopyEndoscopy

Esophageal ManometryEsophageal Manometry

pH probepH probe

Esophageal UltrasoundEsophageal Ultrasound

CT, MRICT, MRI

EsophagogramEsophagogram

Double-contrast barium esophagogramDouble-contrast barium esophagogram

Usually the first specific diagnostic test in Usually the first specific diagnostic test in the evaluation of esophageal dysphagiathe evaluation of esophageal dysphagia

Detect subtle narrowing or esophageal Detect subtle narrowing or esophageal webs that may not be appreciated on webs that may not be appreciated on endoscopy endoscopy

EndoscopyEndoscopy

Procedure of choice to evaluate the mucosa of Procedure of choice to evaluate the mucosa of the esophagus the esophagus Detection of structural abnormalities Detection of structural abnormalities

Flexible esophagoscopy Flexible esophagoscopy – Used by GI serviceUsed by GI service– TransorallyTransorally– Diameters approaching 1cmDiameters approaching 1cm– Allows the insufflation of air to distend the esophagus Allows the insufflation of air to distend the esophagus

and more easily see all of the mucosaand more easily see all of the mucosa– Magnified view, suction, irrigation, and biopsy ports. Magnified view, suction, irrigation, and biopsy ports. – Requires intravenous sedation settingRequires intravenous sedation setting

Rigid esophagoscopyRigid esophagoscopy

– Used by otolaryngologistsUsed by otolaryngologists– Requires general anesthesiaRequires general anesthesia– Examine the full extent of the esophagusExamine the full extent of the esophagus– View is not magnifiedView is not magnified– Esophagus is not distendedEsophagus is not distended– Allows use of instrumentationAllows use of instrumentation– The risks of general anesthesia and the rigid The risks of general anesthesia and the rigid

esophagoscopyesophagoscopy

Transnasal EsophagoscopyTransnasal Esophagoscopy

Flexible esophagoscopyFlexible esophagoscopy– Smaller size (5mm) allows their passage through the Smaller size (5mm) allows their passage through the

nasal cavity nasal cavity

Topical anesthesiaTopical anesthesia““Easily” performed clinic procedure Easily” performed clinic procedure Patient can returned to work after the Patient can returned to work after the appointmentappointmentAllows the insufflation of air to distend the Allows the insufflation of air to distend the esophagus and more easily see all of the esophagus and more easily see all of the mucosa. mucosa.

Transnasal EsophagoscopyTransnasal Esophagoscopy

Patient is asked to Patient is asked to swallow as scope is swallow as scope is gently advanced through gently advanced through the UESthe UESAir is insufflated into Air is insufflated into esophagusesophagusIf mucosal lesions or If mucosal lesions or irregularities are found irregularities are found multiple biopsies are multiple biopsies are taken with biopsy forceps taken with biopsy forceps passed through the passed through the biopsy portbiopsy port

Postma et al in 2005 Postma et al in 2005 – Review of 711 consecutive patients examined Review of 711 consecutive patients examined

with transnasal esophagoscopywith transnasal esophagoscopy– They used a spray combination of 0.05% They used a spray combination of 0.05%

oxymetazoline and 4% lidocaine in the nasal oxymetazoline and 4% lidocaine in the nasal cavity cavity

– If biopsy or a longer procedure is required, If biopsy or a longer procedure is required, one Tessalon Perle is usedone Tessalon Perle is used

– Seventeen of 711 procedures (3%) were Seventeen of 711 procedures (3%) were terminated due to a tight nasal vault and 2 terminated due to a tight nasal vault and 2 due to a self-limited vasovagal responsedue to a self-limited vasovagal response

– 50% incidence of significant findings50% incidence of significant findings

Esophageal ManometryEsophageal Manometry

Measures intraluminal pressuresMeasures intraluminal pressures– LES, esophageal body & UESLES, esophageal body & UES

With each swallowWith each swallow– StrengthStrength– TimingTiming– Sequencing of pressure eventsSequencing of pressure events

Indicated for patients who need recurrent intraluminal Indicated for patients who need recurrent intraluminal pressure assessmentpressure assessment– AchalasiaAchalasia– Diffuse esophageal spasm Diffuse esophageal spasm

AchalasiaAchalasia

Primary esophageal motility disorderPrimary esophageal motility disorder– Insufficient LES relaxationInsufficient LES relaxation– Loss of esophageal peristalsisLoss of esophageal peristalsis

PathologicPathologic– Loss of ganglion cell in the myenteric plexusLoss of ganglion cell in the myenteric plexus– Infiltrate of T lymphocytes, eosinophils, and mast cellsInfiltrate of T lymphocytes, eosinophils, and mast cells– Selective loss of postganglionic inhibitory neurons, which contain Selective loss of postganglionic inhibitory neurons, which contain

both nitric oxide and vasoactive intestinal polypeptideboth nitric oxide and vasoactive intestinal polypeptide

SymptomsSymptoms– Dysphagia to solids and liquidDysphagia to solids and liquid– RegurgitationRegurgitation– Chest painChest pain

Achalasia DiagnosisAchalasia Diagnosis

Best initial diagnostic Best initial diagnostic studystudy

– Barium esophagram Barium esophagram with fluoroscopywith fluoroscopy

Esophageal dilationEsophageal dilation

Closed LESClosed LES

Loss peristalsisLoss peristalsis

Bird's beakBird's beak

Esophageal manometryEsophageal manometry

– Establish the diagnosis Establish the diagnosis

Absent or incomplete LES Absent or incomplete LES relaxationrelaxation

Loss peristalsisLoss peristalsis

EndoscopyEndoscopy– Exclusion of Exclusion of

pseudoachalasia pseudoachalasia by carcinoma at by carcinoma at the GE junctionthe GE junction

TreatmentTreatment

Pneumatic dilation Pneumatic dilation – Should be a surgical candidates Should be a surgical candidates

2% to 5% risk of perforation2% to 5% risk of perforation– After dilation need a gastrograffin study followed by After dilation need a gastrograffin study followed by

barium swallow to exclude esophageal perforationbarium swallow to exclude esophageal perforation– Good to excellent relief of symptoms in 50% to 93% Good to excellent relief of symptoms in 50% to 93%

of patients of patients

Surgical myotomy Surgical myotomy – Myotomy across the LESMyotomy across the LES– Laparoscopy with a response rate of 80% to 94%Laparoscopy with a response rate of 80% to 94%– Complication- GERD in 10% to 20% Complication- GERD in 10% to 20%

High risk for pneumatic dilation or surgeryHigh risk for pneumatic dilation or surgery– BotoxBotox

Effective in about 85% of patientsEffective in about 85% of patients

Symptoms recur in more than 50% of patients after Symptoms recur in more than 50% of patients after 6 months6 months

– Pharmacologic treatment with nitrates or Pharmacologic treatment with nitrates or calcium-channel blockers calcium-channel blockers

Non-achalasia Motility DisordersNon-achalasia Motility Disorders

Diffuse esophageal spasm (DES) Diffuse esophageal spasm (DES) – Simultaneous and repetitive contractions in Simultaneous and repetitive contractions in

the esophageal bodythe esophageal body– Normal LES relaxationNormal LES relaxation– Dysphagia if the contraction amplitudes are Dysphagia if the contraction amplitudes are

lowlow– Chest pain if the contraction amplitudes are Chest pain if the contraction amplitudes are

highhigh

Diffuse esophageal spasmDiffuse esophageal spasm

DiagnosisDiagnosis– EsophagogramEsophagogram

"corkscrew" esophagus"corkscrew" esophagus

– ManometryManometrySimultaneous and Simultaneous and repetitive contractions repetitive contractions in the esophageal body in the esophageal body

TreatmentTreatment– Medications that relax Medications that relax

the esophagusthe esophagusNitrates and calcium-Nitrates and calcium-channel blockerschannel blockers

SclerodermaScleroderma

Connective tissue diseaseConnective tissue disease

Peristalsis is absent in the Peristalsis is absent in the distal two-thirdsdistal two-thirds

Mild dilation of the distal Mild dilation of the distal esophagusesophagus

LES becomes incompetentLES becomes incompetent

Associated Associated – Aspiration pneumoniaAspiration pneumonia– Reflux esophagitis with Barrett's Reflux esophagitis with Barrett's

esophagusesophagus

Esophageal StricturesEsophageal Strictures

Loss of lumen area Loss of lumen area – Normal 20 mm in diameterNormal 20 mm in diameter

Dysphagia main symptomDysphagia main symptom– Less than 15 mmLess than 15 mm

Worse with large food Worse with large food pieces such as meat and pieces such as meat and breadbread

Acid/peptic stricture Acid/peptic stricture accounting for the accounting for the majority of cases (60%–majority of cases (60%–70%). 70%).

ETIOLOGY OF ESOPHAGEAL ETIOLOGY OF ESOPHAGEAL STRICTURESSTRICTURES

Intrinsic strictures

Acid peptic

Pill-induced

Chemical/lye

Post-nasogastric tube

Infectious esophagitis

Sclerotherapy

Radiation-induced

Esophageal/gastric malignancies

Surgical anastomotic

Congenital

Systemic inflammatory disease

Epidermolysis bullosa

Extrinsic strictures

Pulmonary/mediastinal malignancies

Anomalous vessels and aneurysms

Metastatic submucosal infiltration (breast cancer, mesothelioma, adenocarcinoma of gastric cardia)

DiagnosisDiagnosis

EsophagogramEsophagogram– Initial diagnostic studyInitial diagnostic study– Delineate the strictureDelineate the stricture

EndoscopyEndoscopy– Evaluate the mucosa Evaluate the mucosa

Distal stricture Caustic ingestion

normal mucosa Barrett's metaplasia

TreatmentTreatment

Esophageal dilationEsophageal dilation– Depends on the length and diameterDepends on the length and diameter– Tight or complex strictures Tight or complex strictures

Less than 10 mm in diameterLess than 10 mm in diameterGreater than 2 cm in lengthGreater than 2 cm in lengthBest managed with wire-guided bougies under fluoroscopic and Best managed with wire-guided bougies under fluoroscopic and endoscopic controlendoscopic control

– Simple strictures can be dilated with Maloney dilatorsSimple strictures can be dilated with Maloney dilators– Progressively over weeks to months with a gradual increase in Progressively over weeks to months with a gradual increase in

the diameters of the dilatorsthe diameters of the dilators– Most patients have relief of dysphagia after dilation to a diameter Most patients have relief of dysphagia after dilation to a diameter

of 40 to 54 French with no requirement for maintenance dilationsof 40 to 54 French with no requirement for maintenance dilations– Radiation-induced or malignant strictures are at higher risk of Radiation-induced or malignant strictures are at higher risk of

perforation perforation

TreatmentTreatment

To minimize the risk of perforation, the "rule of To minimize the risk of perforation, the "rule of threes" appliesthrees" applies– No more than three sequential dilators should be No more than three sequential dilators should be

performed per sessionperformed per session– Refractory strictures can be treated endoscopically Refractory strictures can be treated endoscopically

with injection of triamcinolone into the stricture in all with injection of triamcinolone into the stricture in all four quadrants prior to dilationfour quadrants prior to dilation

– More recently, endoscopically placed temporary More recently, endoscopically placed temporary nonmetallic expandable stents (Polyflex)nonmetallic expandable stents (Polyflex)

Effective in refractory benign stricturesEffective in refractory benign strictures

Esophageal Rings & WebsEsophageal Rings & Webs

SymptomsSymptoms– Intermittent solid food Intermittent solid food dysphagiadysphagia, ,

aspiration, and regurgitationaspiration, and regurgitation

RingsRings– CircumferentialCircumferential– Mucosa or muscleMucosa or muscle– Most commonly occur in the distal Most commonly occur in the distal

esophagusesophagus– Schatzki's ring occurs at the GEJ Schatzki's ring occurs at the GEJ

Webs Webs – Only part of the esophageal lumenOnly part of the esophageal lumen– Always mucosalAlways mucosal– Located in the proximal esophagusLocated in the proximal esophagus– Association with iron deficiency Association with iron deficiency

(Plummer and Vinson)(Plummer and Vinson)

DiagnosisDiagnosis

Barium EsophagogramBarium Esophagogram– Most sensitive testMost sensitive test

Endoscopic visualizationEndoscopic visualization– Normal-appearing mucosalNormal-appearing mucosal– Cervical webs are associated Cervical webs are associated

with carcinomawith carcinomaTreatmentTreatment– Endoscopic dilationEndoscopic dilation– Large bougie or balloon (15 to Large bougie or balloon (15 to

20 mm) so as to fracture the 20 mm) so as to fracture the ringring

– Refractory ringsRefractory ringsPneumatic dilation (large Pneumatic dilation (large balloon)balloon)Electrosurgical incisionElectrosurgical incisionSurgical resectionSurgical resectionTreat GERDTreat GERD

Dysphagia lusoriaDysphagia lusoriaAberrant right subclavian arteryAberrant right subclavian artery– Arises from the left side of the aortic arch Arises from the left side of the aortic arch – Compress the posterior esophagus Compress the posterior esophagus – 20% of cases anterior 20% of cases anterior

Barium esophagogramBarium esophagogram– Indentation at the level of the third and fourth thoracic vertebraeIndentation at the level of the third and fourth thoracic vertebrae

ConfirmationConfirmation– CT, MRI, arteriography, or EUSCT, MRI, arteriography, or EUS

EndoscopyEndoscopy– Right radial pulse may diminish with compression of the right subclavian arteryRight radial pulse may diminish with compression of the right subclavian artery

Esophageal manometryEsophageal manometry– High-pressure zone at the location of the aberrant arteryHigh-pressure zone at the location of the aberrant artery

Symptoms usually respond to changes in diet to soft consistency and small Symptoms usually respond to changes in diet to soft consistency and small sizesizeWhen necessary, surgery relieves the obstruction by reanastomosing the When necessary, surgery relieves the obstruction by reanastomosing the aberrant artery to the ascending aortaaberrant artery to the ascending aorta

Gastroesophageal Reflux Gastroesophageal Reflux DiseaseDisease

GERD is recognized in about 10-15% of the populationGERD is recognized in about 10-15% of the populationReflux esophagitisReflux esophagitis – Changes in the esophageal mucosaChanges in the esophageal mucosa– Present in 30% to 40%Present in 30% to 40%

Barrett's esophagusBarrett's esophagus– 10% to 20%10% to 20%

Defects in the esophagogastric barrier such as Defects in the esophagogastric barrier such as – LES incompetenceLES incompetence– Transient relaxation of LESTransient relaxation of LES– Hiatal herniaHiatal hernia

GERD DiagnosisGERD Diagnosis

Classic symptom is heartburnClassic symptom is heartburn– Retrosternal burning discomfort and acid Retrosternal burning discomfort and acid

regurgitationregurgitation– Other symptoms are dysphagia, odynophagia, Other symptoms are dysphagia, odynophagia,

and belchingand belching

Laryngopharyngeal reflux (LPR)Laryngopharyngeal reflux (LPR)– Hoarseness, throat clearing, dysphagia, Hoarseness, throat clearing, dysphagia,

increased phlegm and globus sensation increased phlegm and globus sensation

ManagementManagement

Treatment Treatment – Initial empiric trial in the absence of alarm Initial empiric trial in the absence of alarm

signssigns– Diagnostic testing Diagnostic testing

if there is a failure to respond to an empiric course if there is a failure to respond to an empiric course of antisecretory therapy of antisecretory therapy

if alarm signs such as dysphagia, odynophagia, if alarm signs such as dysphagia, odynophagia, weight loss, chest pain, or choking are present. weight loss, chest pain, or choking are present.

pH probepH probe

Ambulatory 24-hour Ambulatory 24-hour esophageal pH monitoringesophageal pH monitoring– Gold standard for the diagnosis Gold standard for the diagnosis

of GERDof GERD– Detect and quantify Detect and quantify

gastroesophageal refluxgastroesophageal reflux– Correlate symptoms temporally Correlate symptoms temporally

with refluxwith reflux

BravoBravo pH probe pH probe

Size of a capsuleSize of a capsulePlaced endoscopically Placed endoscopically – 6 cm above the GEJ 6 cm above the GEJ

Transmits to a recording Transmits to a recording devicedevice48 hours of pH data48 hours of pH dataFalls off after 4 to 10 days Falls off after 4 to 10 days Patients prefer this device over Patients prefer this device over the catheter-based system due the catheter-based system due to reduced discomfortto reduced discomfort

EndoscopyEndoscopy– Reflux esophagitis Reflux esophagitis

Erosions or ulcerations Erosions or ulcerations

– pH probe results are pH probe results are normal in 25% of normal in 25% of patients with erosive patients with erosive esophagitisesophagitis

Barrett's esophagusBarrett's esophagus

Potentially serious complication of long-Potentially serious complication of long-standing GERDstanding GERDStratified squamous epithelium of the Stratified squamous epithelium of the distal esophagus is replaced by intestinal distal esophagus is replaced by intestinal columnar metaplasiacolumnar metaplasiaIt is the most significant outcome of It is the most significant outcome of chronic GERD and predisposes patients to chronic GERD and predisposes patients to the development of esophageal the development of esophageal adenocarcinoma. adenocarcinoma.

MALIGNANT STRICTURES MALIGNANT STRICTURES

12,000 new cases each year in the United States12,000 new cases each year in the United StatesSquamous cell carcinoma (SCC) Squamous cell carcinoma (SCC) – Black malesBlack males– Alcohol and tobacco abuseAlcohol and tobacco abuse– History of caustic esophageal injuryHistory of caustic esophageal injury– Other conditions including achalasia, Plummer-Vinson Other conditions including achalasia, Plummer-Vinson

syndrome, and a history of head and neck SCCsyndrome, and a history of head and neck SCC– Have also been associated with human papillomavirus. Have also been associated with human papillomavirus.

Adenocarcinoma Adenocarcinoma – white maleswhite males– well-documented association with GERDwell-documented association with GERD– Barrett's esophagusBarrett's esophagus

MALIGNANT STRICTURESMALIGNANT STRICTURES

Malignant obstructionMalignant obstruction– Late presentation and carries a poor prognosisLate presentation and carries a poor prognosis– Dysphagia is rapidly progressiveDysphagia is rapidly progressive– DiagnosisDiagnosis

Endoscopy with mucosal biopsyEndoscopy with mucosal biopsyEvaluation includes staging Evaluation includes staging

– CT and Endoscopic USCT and Endoscopic US

– Staging is based on the TNM classification Staging is based on the TNM classification – T1 or T2 without nodal or metastatic disease, can be T1 or T2 without nodal or metastatic disease, can be

treated with surgery alonetreated with surgery alone– Patients with more advanced disease Patients with more advanced disease

Neoadjuvant chemotherapy/radiation before surgical Neoadjuvant chemotherapy/radiation before surgical resectionresection

Cricopharyngeal Dysfunction Cricopharyngeal Dysfunction

The cricopharyngeus The cricopharyngeus remains contracted remains contracted between swallowsbetween swallowsCricopharyngealCricopharyngeal achalasiaachalasia – Muscle fails to Muscle fails to

completely relaxcompletely relax– smooth posterior smooth posterior

impression on the impression on the hypopharynxhypopharynx

Zenker’s DiverticulumZenker’s Diverticulum

Esophageal diverticula are classified based on: Esophageal diverticula are classified based on: – Anatomic locationAnatomic location– Mechanism of origin (pulsion or traction). Mechanism of origin (pulsion or traction).

Zenker's diverticulum (ZD)Zenker's diverticulum (ZD)– Pulsion type diverticulumPulsion type diverticulum

Herniation of esophageal mucosa and submucosa through Herniation of esophageal mucosa and submucosa through an area of weakened esophageal musculaturean area of weakened esophageal musculature

– Annual incidence of 2 per 100,000 people per yearAnnual incidence of 2 per 100,000 people per year– Males predominance (2 to 3 times)Males predominance (2 to 3 times)

Zenker’s DiverticulumZenker’s Diverticulum

Killian's dehiscence or Killian's dehiscence or triangletriangle– Between the Between the

cricopharyngeal muscle cricopharyngeal muscle and inferior constrictor and inferior constrictor musclemuscle

Killian-Jamieson's areaKillian-Jamieson's area– between the oblique and between the oblique and

transverse fibers of the transverse fibers of the cricopharyngeal musclecricopharyngeal muscle

Laimer's triangleLaimer's triangle– Between the Between the

cricopharyngeal muscle cricopharyngeal muscle and the most superior and the most superior esophageal wall circular esophageal wall circular muscles muscles

DiagnosisDiagnosis

HistoryHistory– Progressive dysphagia Progressive dysphagia

90% of patients 90% of patients presenting with ZDpresenting with ZD

– Regurgitation of foodRegurgitation of food– Unprovoked aspirationUnprovoked aspiration– Noisy deglutitionNoisy deglutition

Barium Barium EsophagogramEsophagogram

TreatmentTreatment

SurgerySurgery– Cricopharyngeal Cricopharyngeal

myotomy myotomy

External External – cricopharyngeal cricopharyngeal

myotomy myotomy – Diverticulum is excised Diverticulum is excised

and the defect closed and the defect closed

EndoscopicEndoscopic

ReferencesReferencesBechi P:  Long-term ambulatory enterogastric reflux monitoring: validation of a new Bechi P:  Long-term ambulatory enterogastric reflux monitoring: validation of a new fiberoptic technique.   fiberoptic technique.   Dig Dis SciDig Dis Sci  1993; 38:1297-1306.  1993; 38:1297-1306.Devault KR, Castell DO:  Updated guideline for the diagnosis and treatment of Devault KR, Castell DO:  Updated guideline for the diagnosis and treatment of gastroesophageal reflux disease.   gastroesophageal reflux disease.   Am J GastroenterolAm J Gastroenterol  1999; 94:1434-1442.  1999; 94:1434-1442.Elluru RG, Willging JP. Endoscopy of the Pharynx and Esophagus. Cummings Elluru RG, Willging JP. Endoscopy of the Pharynx and Esophagus. Cummings CW, ed. Otolaryngology Head & Neck Surgery. Philadelphia: Elsevier Mosby; 2005, CW, ed. Otolaryngology Head & Neck Surgery. Philadelphia: Elsevier Mosby; 2005, 1825-1834.1825-1834.Mittal RK:  Transient lower esophageal sphincter relaxation. Mittal RK:  Transient lower esophageal sphincter relaxation. GastroenterologyGastroenterology  1995; 109:601-610  1995; 109:601-610Postma GN, Cohen JT, Belafsky PC, et al. Transnasal Esophagoscopy: Revisited Postma GN, Cohen JT, Belafsky PC, et al. Transnasal Esophagoscopy: Revisited (over 700 Consecutive Cases). (over 700 Consecutive Cases). Laryngoscope Laryngoscope 2005;115:321-323.2005;115:321-323.Postma GN, Bach KK, et al. The Role of Transnasal Esophagoscopy in Head and Postma GN, Bach KK, et al. The Role of Transnasal Esophagoscopy in Head and Neck Oncology. Neck Oncology. LaryngoscopeLaryngoscope 2002;112:2242-2243. 2002;112:2242-2243.Tobin RW:  Esophageal rings, webs, and diverticula.   Tobin RW:  Esophageal rings, webs, and diverticula.   J Clin J Clin GastroenterolGastroenterol  1998; 27:285.  1998; 27:285.Vaezi MF, Richter JE:  Diagnosis and management of achalasia.   Vaezi MF, Richter JE:  Diagnosis and management of achalasia.   Am J Am J GastroenterolGastroenterol  1999; 12:3406-3413.  1999; 12:3406-3413.Vollweiller JF, Vaezi MF. The Esophagus: Anatomy, Physiology, and Diseases. Vollweiller JF, Vaezi MF. The Esophagus: Anatomy, Physiology, and Diseases. Cummings CW, ed. Otolaryngology Head & Neck Surgery. Phaladelphia: Elsevier Cummings CW, ed. Otolaryngology Head & Neck Surgery. Phaladelphia: Elsevier Mosby, 2005, 1835-1998.Mosby, 2005, 1835-1998.