Zenker's diverticulum
| Classification according to ICD-10 | |
|---|---|
| K22.5 | Zenker's diverticulum |
| ICD-10 online (WHO version 2019) | |
When Zenker's diverticulum is a diverticulum of the hypopharynx ( gullet ) and not the esophagus as is often misrepresented. The Zenker's diverticulum is a pulsation diverticulum and pseudodiverticulum . It was first described by Abraham Ludlow in 1764 and is named after Friedrich Albert von Zenker . Men of advanced age are most commonly affected.
Cause and anatomy
The cause of the development of this diverticulum is the muscular triangle (Killian triangle) between the pars obliqua and the pars fundiformis (Killian whiplash muscle , named after Gustav Killian ) of the pars cricopharyngea (part of the M. constrictor pharyngis inferior ). It is located dorsally above the narrow cricoid cartilage of the esophagus . The cause is usually a dysfunction of the upper esophageal sphincter (esophageal mouth) in the form of an inadequate or temporally non-coordinated opening. The diverticulum is often localized to the left.
Classification and symptoms
Radiologists classify Zenker's diverticula according to Brombart's four stages of increasing severity:
- Stage 1 is a thorn-shaped, 2–3 mm long niche that is not always visible.
- Stage 2 diverticula are 7–8 mm in size and club-shaped.
- Stage 3 diverticula are over 10 mm in size, sack-shaped and bent downwards.
- In stage 4, the diverticulum compresses the esophagus and visibly obstructs its contrast medium passage.
The symptoms vary depending on the stage of the diverticulum. Not all diverticula are symptomatic. In the early stages (bromobart 1 and 2), there is no retention of food in the diverticulum, as the diverticulum only temporarily protrudes during the act of swallowing and disappears completely into the posterior wall of the pharynx in the interval. Dysphagia is often in the foreground , usually in the form of a foreign body sensation (globus sensation). One speaks of pouches in contrast to the permanently detectable diverticula in the higher stages (Brombart 3 and 4). In this case, if there is leftover food in the diverticulum, a strong bad breath can develop. It comes to the regurgitation (diagnostic pioneering: the food was not in the stomach, unlike the unleavened food reflux ). Coughing can be an indication that diverticulum content (leftover food) is leaking into the windpipe, it can lead to aspiration pneumonia (pneumonia). In addition, swallowing difficulties often lead to weight loss in older people.
Diagnosis
If there are symptoms, the diagnosis is made with endoscopy and X-rays with contrast media . As soon as a patient notices swallowing disorders, he should seek medical care, because various diseases of the esophagus can cause these complaints. This should be followed by a close inspection of the patient's mouth and throat and the neck should be scanned for enlarged lymph nodes or changes in the soft tissue. Depending on the suspected diagnosis, the esophagus is mirrored and a tissue sample is taken at the same time in the area of abnormal mucous membrane areas. In addition, especially in the case of diverticula, an X-ray examination of the esophagus with a liquid contrast medium is carried out, which can also show movement disorders of the esophageal wall. If the disease is a tumor , it may be necessary to do an additional CT or MRI examination to see its extent and location in the chest. A preliminary examination by an ear, nose and throat doctor may also be necessary, who will have to check the functionality of an important nerve in the area of the larynx. Depending on the patient's previous illnesses and age, ultrasound examinations of the heart and a lung function test are also carried out. In the case of a Zenker diverticulum, the indication for surgery is given, regardless of how severe the patient's symptoms are, because the complication rate is low.
therapy
Attempts should first be made to treat an underlying dysfunction of the upper esophageal sphincter, as otherwise recurrences may occur. In the early stages, this is the only starting point.
In the more advanced stages, three procedures are currently used: Open surgery (cervicotomy) allows the diverticulum to be completely resected, but is associated with the greatest effort. A second method is the ENT-medical splitting with a rigid endoscope under anesthesia. The method with the least effort uses flexible endoscopy. A gastric tube is inserted into the esophagus, an electric needle knife or an argon beamer probe is then inserted through a gastroscope and the muscle bridge (pars fundiformis) between the diverticulum and the esophagus is at least partially severed. Here only the sedation necessary for gastroscopy is required. The risk of relapse is offset by easy repeatability. During the operation, the skin incision is made lengthways to the side and left of the larynx over a length of six centimeters. Then carefully dissect the left thyroid lobe until it can be mobilized and folded up and a very important nerve (the recurrent laryngeal nerve ) that runs here can be clearly seen. Now the diverticulum is prepared, visualized and removed and the esophagus is closed again at this point. Finally, a special muscle transection is carried out in the area of the upper sphincter of the esophagus, in which the pressure peaks arise during the act of swallowing, so that the resistance in this area decreases during swallowing and a recurrence of a diverticulum can be prevented.
Sources and individual references
- ^ A. Ludlow: A case of obstructed deglutition from a preternatural dilatation of and bag formed in the pharynx. In: Medical Observations and Inquiries by a Society of Physicians in London. 2nd Edition. 1769; 3, pp. 85-101.
- ↑ Ludlow's preternatural bag. In: British medical journal. Volume 2, Number 6204, December 1979, pp. 1531-1532, PMID 119566 , PMC 1597444 (free full text).
- ↑ Diverticula of the pharynx and esophagus. In: Jürgen Freyschmidt (Ed.): Handbook diagnostic radiology / gastrointestinal system. Springer, 2006, ISBN 3-540-68472-7 , pp. 97ff.
- Vogelsang, A. et al .: Treatment of Zenker's Diverticulum . In: Dtsch Arztebl . No. 105 (7) , 2008, pp. 120-126 ( abstract ).
- M. Brombart: Le diverticule pharyngo-oesophagien de Zenker. Considerations pathogenetiques. In: J Belg Radiol. 76, 1953, p. 128.
- M. Brombart: Radiology of the digestive tract. Thieme Verlag, Stuttgart 1980, ISBN 3-13-586301-8 .
