Snapshot A 73-year-old female is being seen at the emergency department after having recurrent coughing spells and regurgitation following meal. Her husband reports that the symptoms have been occurring over a year and has recently gotten worse. She denies any fever, chest pain, dyspnea, or abdominal pain but endorses a 10-lb. weight loss over the past 3 months. A medical history is significant for hypertension that is controlled with lisinopril. A physical examination demonstrates a palpable, fluctuant neck mass on physical examination and halitosis. Introduction Clinical definition false diverticula (sac-like outpouching of only the mucosa and submucosa) of the esophagus true diverticula contain all layers of the intestinal wall Epidemiology Incidence estimated at 2 per 100,000 a year Demographics 1.5:1 male predominance typically seen in middle-aged adults and older adults in 7th or 8th decade of life Location occurs at the upper part of the esophagus at Killian triangle (an area of muscular weakness between the cricopharyngeus muscle and lower inferior constriction) ETIOLOGY Pathogenesis Killian triangle is a natural area of weakness within the muscular wall of the esophagus and is more common in men thought to result from chronic increased pressure on the weakened area due to either high intrabolus pressures during swallowing resistance to swallowing due to abnormalities of the upper esophageal sphincter Presentation Symptoms dysphagia regurgitation choking chronic cough bad breath (halitosis) Physical exam palpable, fluctuant neck mass may be appreciable Imaging Barium swallow gold standard of diagnosis will demonstrate dye collection posterior to the esophagus Transcutaneous ultrasound allows for differentiation from a thyroid/neck mass good alternative for people who have difficulties swallowing barium Esophageal manometry not required for diagnosis may help to delineate the pathogenesis of the diverticulum Studies Diagnostic testing diagnostic approach diagnosis is based on clinical history and physical exam and confirmed via barium esophagram Differential Achalasia distinguishing factor will demonstrate a bird’s beak on barium swallow Diffuse esophageal spasm distinguishing factor will have characteristic findings on esophageal manometry Complications Aspiration pneumonia Squamous cell carcinoma of the diverticulum prevalence ranges from 0.3-7.0 % Ulceration and bleeding Increased risk of iatrogenic perforation should avoid endoscopy if there is clinical suspicion of Zenker diverticulum