Synopsis
Recognise a Zenker pharyngeal pouch, protect against aspiration and malnutrition, use contrast imaging safely, and refer symptomatic disease for specialist endoscopic or open division.
- Zenker diverticulum is a pulsion pouch through posterior hypopharyngeal weakness above a poorly relaxing cricopharyngeus.
- Typical clues are cervical dysphagia, regurgitation of undigested food, halitosis, gurgling, chronic cough and recurrent aspiration.
- A contrast swallow usually defines the pouch, neck and oesophageal passage; endoscopy is cautious because the instrument can enter and perforate the sac.
Key red flags
Regurgitation, nocturnal cough, recurrent pneumonia or wet voice indicates aspiration from retained pouch contents.
Progressive dysphagia with weight loss, bleeding or pain still requires malignancy assessment even if a pouch is demonstrated.
Nocturnal cough, voice change and recurrent lower respiratory infection suggest overflow into the larynx.
Investigation priorities
Outline the pouch, its neck, size and relationship to oesophageal entry.
Management branches
A symptomatic pouch causes weight loss, regurgitation and recurrent aspiration.
- Stabilise nutrition and any aspiration-related respiratory infection, then define pouch size, neck and dynamic emptying with video contrast swallow.
- Discuss treatment in an experienced service. Flexible endoscopic septotomy is a guideline-supported first-line option for symptomatic disease; rigid stapling depends on exposure and neck extension, while open repair remains appropriate for selected large, complex or recurrent pouches.