Extraösophagealer Reflux und Zenker-Divertikel

Exteriorized Giant Zenker’s Diverticulum: Case Report

Zenker’s diverticulum (ZD) also known as cricopharyngeal (CP), pharyngoesophageal or hypopharyngeal diverticulum is an outpouching of mucosal and submucosal layers originated from the pharyngoesophageal junction. Radiological evaluation of deglutition, modified barium swallow radiography may reveal the retentive character of the diverticular sac and confirm the diagnosis. Many different types of surgical approaches have been developed over the decades with modifications focusing on the need to reduce intra-operative or post-operative complications and overall morbidity. The authors present the case of a 76-years-old woman with spontaneous apparition of an exteriorised tumor in the oral cavity after an excessive cough effort. Surgical treatment is elective, preventing the occurence of complications that may endanger the patients life and improve the quality of life. Surgical therapy was open neck resection of the Zenker’s diverticulum with esophageal myotomy and pharynx reconstruction.

Delayed diagnosis of a case of Zenker's diverticulum. What may happen when a family physician does not visit his family physician

INTRODUCTION

Zenker's diverticulum is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle. It occurs commonly in elderly patients (over 70 years) and the typical symptoms include dysphagia, regurgitation, chronic cough, aspiration and weight loss.

CASE

We are reporting dysphagia in a 49-years old man who was treated as having Helicobacter Pylori gastritis for three years. Being a family physician himself, the patient applied to specialists in gastroenterology, bypassing primary care. During a casual interview on his symptoms, a family physician referred him to undergo a repeated endoscopy with suspected Zenker's diverticulum. After being diagnosed with Zenker's diverticulum, the patient underwent surgical intervention at the department of thoracic surgery and made a full recovery. He regained five kilograms at the end of five weeks after the operation.

CONCLUSION

This case demonstrates once more the importance of history taking and follow-up in medical care. Attentive listening by a family physician could have probably prevented the delay of service in this case.

Gastroesophageal Reflux Disease Might Induce Certain-Supposedly Adaptive-Changes in the Esophagus: A Hypothesis

BACKGROUND

The increasing prevalence of GERD has become a major concern due to its major health and economic impacts. Beyond the typical unpleasant symptoms, reflux can also be the source of severe, potentially life-threatening complications, such as aspiration.

AIM

Our aim was to support our hypothesis that the human body may in some cases develop various protective mechanisms to prevent these conditions.

METHODS

Based on our experiences and review of the literature, we investigated the potential adaptive nature of seven reflux complications (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter, Zenker's diverticulum, Schatzki's ring, esophageal web, and Barrett's esophagus).

RESULTS

Patients with progressive GERD may develop diverse structural and functional esophageal changes that narrow the lumen of the esophagus and therefore reduce the risk of regurgitation and protect the upper aerodigestive tract from aspiration. The functional changes (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter) seem to be adaptive reactions aimed at easing the unpleasant symptoms and reducing acid regurgitation. The structural changes (Schatzki's ring, esophageal web) result in very similar outcomes, but we consider these are rather secondary consequences and not real adaptive mechanisms. Barrett's esophagus is a special form of adaptive protection. In these cases, patients report significant relief of their previous heartburn as Barrett's esophagus develops because of the replacement of the normal squamous epithelium of the esophagus by acid-resistant metaplastic epithelium.

CONCLUSION

We believe that GERD may induce different self-protective reactions in the esophagus that result in reduced acid regurgitation or decreased reflux symptoms.

Comorbid Dysphagia and Dyspnea in Muscle Tension Dysphonia: A Global Laryngeal Musculoskeletal Problem

Objective

To characterize the associated symptoms of dysphagia and dyspnea among patients presenting with muscle tension dysphonia (MTD).

Study Design

Retrospective chart review performed over a 14-month period from October 2014 to December 2015.

Setting

Voice and swallowing center of a tertiary academic medical center.

Subjects and Methods

Thirty-eight patients with MTD were included for analysis. Clinical data were collected and analyzed, including perceptual voice evaluation and patient-reported outcomes measures.

Results

Among patients with a diagnosis of MTD, the incidence of reported dysphagia during clinical history and examination was 44.7%. Among patients with MTD, 60.5% had an EAT-10 (10-item Eating Assessment Tool) score ≥3 (ie, abnormal). Patients who reported dysphagia and/or had abnormal EAT-10 score (≥3) had significantly greater voice impairment than that of patients without dysphagia (P = .02). Patients who reported dysphagia also had significantly higher Clinical COPD Questionnaire scores than those of patients who reported only dysphonia (P = .002).

Conclusions

Patients presenting for dysphonia who are diagnosed with MTD have a high rate of comorbid dysphagia. Patients who reported dysphagia had significantly higher self-reported voice impairment and greater severity of breathing dysfunction as measured by the Clinical COPD Questionnaire. The coincidence of these symptoms in this patient cohort may suggest an underlying pathophysiology that has yet to be elucidated. Further prospective studies are needed to clarify the underlying cause of dysphagia and breathing dysfunction in the setting of MTD and to investigate diagnostic and therapeutic paradigms.

Achalasia following reflux disease: coincidence, consequence, or accommodation? An experience-based literature review

Achalasia is a motility disorder of the esophagus characterized by the defective peristaltic activity of the esophageal body and impaired relaxation of the lower esophageal sphincter due to the degeneration of the inhibitory neurons in the myenteric plexus of the esophageal wall. The histopathological and pathophysiological changes in achalasia have been well described. However, the exact etiological factors leading to the disease still remain unclear. Currently, achalasia is believed to be a multifactorial disease, involving both extrinsic and intrinsic factors. Based on our experience and the review of literature, we believe that gastroesophageal reflux disease (GERD) might be one of the triggering factors leading to the development of achalasia. However, it is also stated that the two diseases can simultaneously appear independently from each other. Considering the large number and routine treatment of patients with GERD and achalasia, the rare combination of the two may even remain unnoticed; thus, the analysis of larger patient groups with this entity is not feasible. In this context, we report four cases where long-standing reflux symptoms preceded the development of achalasia. A literature review of the available data is also given. We hypothesize that achalasia following the chronic acid exposure of the esophagus is not accidental but either a consequence of a chronic inflammation or a protective reaction of the organism in order to prevent aspiration and lessen reflux-related symptoms. This hypothesis awaits further clinical confirmation.

Suture of the mucosa after the endoscopic LASER mucomyotomy of Zenker's diverticulum

The treatment of choice of Zenker's diverticulum is the rigid endoscopic mucomyotomy. At our ENT department, we usually perform an endoscopic mucosal suture after the myotomy. We diagnosed 49 patients and treated 39 patients between 2003 and 2013 due to a Zenker's diverticulum. We used the classification of Brombart to determine the size of the diverticulum. Surgery was performed as an endoscopic LASER mucomyotomy with mucosal sutures or as an open approach with diverticulectomy and myotomy. Patients were phoned to ask for their complaints postoperatively. The symptoms were classified using a visual scale from 0 (no complaint) until 10 (same or more complaints than before the surgery). The distribution of the diverticulum's size was: 6 patients Brombart I, 11 patients Brombart II, 14 patients Brombart III and 18 patients Brombart IV. 10 patients did not undergo surgery. With 33 patients, we performed an endoscopic operation and 6 patients underwent an open approach. The scale of postoperative complaints was the following: 20 patients (0/10), 12 patients (1/10 or 2/10), 3 patients (3/10), 1 patient (6/10) and 1 patient (10/10). None of the patients suffered from severe complications such as mediastinitis. In 85% of the cases, an endoscopic approach could be performed. Postoperatively, 94% of the patients did not have any or just mild complaints. The risk of severe complications or recurrence of the diverticulum is low. The mucosal suture might reduce the risk of infections.

Upper esophageal sphincter dysfunction: diverticula-globus pharyngeus

The following discussion of upper esophageal sphincter dysfunction includes commentaries on the role of the cricopharyngeus muscle in reflux disease; the etiology and treatment of Zenker diverticulum; the use of videofluoroscopy in patients with dysphagia, suspicion of aspiration, or globus; the role of pH-impedance monitoring in globus evaluation; and treatment for reflux-associated globus.

Does the hypopharyngeal cavernous body protect the development of Zenker's diverticulum?

OBJECTIVE

The aim of this study was to examine the morphology of the cavernous body at the pharyngoesophageal segment.

METHODS

In 47 cadavers the submucosal vascular plexus of the pharyngoesophageal segment and the cricopharyngeal muscle were examined.

RESULTS

A vascular plexus which was macroscopically non visible or slightly identified was observed in the majority of the specimens (28 or 59.6%). Fourteen of the cadavers (29.8%) exhibited macroscopically lightly observable blood vessels which were covering a discontinuous area of the hypopharyngeal wall. In the other five specimens (10.6%) the vascular plexus was covering a large part of the dorsal wall of the pharyngoesophageal segment as a compact mass. The grade of dilation of the vascular plexus corresponded to the degree of protrusion of the cricopharyngeal muscle.

CONCLUSIONS

In the case of a persistent constricted cricopharyngeal muscle, the dilation of the hypopharyngeal cavernous body may protect from developing a Zenker's diverticulum by reinforcing the Killian's dehiscence.

Pharyngeal adaptation in Zenker's diverticulum: the "faux pharyngoesophageal segment"

BACKGROUND

We have noticed a protrusion on the pharyngeal wall in patients with Zenker's diverticulum (ZD). The protrusion gives the appearance of a neo-pharyngoesophageal segment (faux-PES) and may represent an adaptation to protect the airway.

STUDY DESIGN

A case-control study.

METHODOLOGY

The fluoroscopic swallow studies of patients with ZD were compared with matched controls. Information regarding the presence and location of a faux-PES, true PES opening, pharyngeal constriction, and laryngohyoid elevation was compared.

RESULTS

The fluoroscopic swallow studies of 31 patients with ZD were compared with 31 controls. A faux-PES was found in 100 percent of ZD patients and in 0 percent of controls. The mean maximum opening of the faux-PES was 1.5 (+/-0.27) cm. The faux-PES was located 1 cm above the true PES below the entrance to the supraglottic airway. This is the optimal location for airway defense.

CONCLUSIONS

The faux-PES was identified in 100 percent of patients with ZD. The faux-PES may represent a physiologic adaptation to protect the airway from regurgitation out of a ZD.