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Zenker's diverticulum

Chris J J Mulder, MD
Foke van Delft, MD
Section Editor
Nicholas J Talley, MD, PhD
Deputy Editor
Shilpa Grover, MD, MPH


Zenker's diverticulum is a sac-like outpouching of the mucosa and submucosa through Killian's triangle, an area of muscular weakness between the transverse fibers of the cricopharyngeus and the oblique fibers of the lower inferior constrictor. The annual incidence of symptomatic Zenker's diverticulum in the United Kingdom has been estimated at 2 per 100,000 per year [1]. Symptomatic Zenker's diverticula are male predominant (ratio 1.5) and typically seen in middle-aged adults and older adults in their seventh or eighth decade of life. The occurrence of Zenker's diverticula shows geographical variation and has been described more frequently in Northern Europe, North America, and Australia than in Southern Europe, Japan, or Indonesia [2]. The pharyngoesophageal diverticulum was first described by Ludlow in 1767 [3]. Zenker and von Ziemssen subsequently reviewed the world literature in 1877. Since then, this kind of diverticulum has been called Zenker's diverticulum [4].

Zenker's diverticulum is defined as a posterior "false" diverticulum that has a neck proximal to the cricopharyngeal muscle (image 1). Most authors consider it among the other types of esophageal diverticula, all of which are outpouchings of one or more layers of the esophageal wall. "True" diverticula contain all layers of the intestinal wall. In contrast, "false" diverticula contain only mucosa and submucosa, while "intramural" diverticula are confined to the submucosa.

The classification of esophageal diverticula depends upon their location. They predominantly occur in three areas:

Immediately above the upper esophageal sphincter (Zenker's diverticulum)

Near the midpoint of the esophagus (traction diverticulum)


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Literature review current through: Sep 2016. | This topic last updated: Nov 17, 2014.
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  1. Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (Zenker's diverticulum). Postgrad Med J 2001; 77:506.
  2. Verhaegen VJ, Feuth T, van den Hoogen FJ, et al. Endoscopic carbon dioxide laser diverticulostomy versus endoscopic staple-assisted diverticulostomy to treat Zenker's diverticulum. Head Neck 2011; 33:154.
  3. Ludlow A. A case of obstructed deglutition from a preternatural dilatation of a bagformed in pharynx. Med Observations Inquiries 1767; 3:85.
  4. Zenker FA, von Ziemssen H. Krankheiten des Oesophagus. In: Handbuch der specielen Pathologie und Therapie, Von Ziemssen H (Ed), FC Vogel, Leipzig 1877. p.1.
  5. D'Ugo D, Cardillo G, Granone P, et al. Esophageal diverticula. Physiopathological basis for surgical management. Eur J Cardiothorac Surg 1992; 6:330.
  6. Fékéte F, Vonns C. Surgical management of esophageal thoracic diverticula. Hepatogastroenterology 1992; 39:97.
  7. Anagiotos A, Preuss SF, Koebke J. Morphometric and anthropometric analysis of Killian's triangle. Laryngoscope 2010; 120:1082.
  8. Sen P, Bhattacharyya AK. Endoscopic stapling of pharyngeal pouch. J Laryngol Otol 2004; 118:601.
  9. Cook IJ, Gabb M, Panagopoulos V, et al. Pharyngeal (Zenker's) diverticulum is a disorder of upper esophageal sphincter opening. Gastroenterology 1992; 103:1229.
  10. Cook IJ, Blumbergs P, Cash K, et al. Structural abnormalities of the cricopharyngeus muscle in patients with pharyngeal (Zenker's) diverticulum. J Gastroenterol Hepatol 1992; 7:556.
  11. Venturi M, Bonavina L, Colombo L, et al. Biochemical markers of upper esophageal sphincter compliance in patients with Zenker's diverticulum. J Surg Res 1997; 70:46.
  12. Fulp SR, Castell DO. Manometric aspects of Zenker's diverticulum. Hepatogastroenterology 1992; 39:123.
  13. Resouly A, Braat J, Jackson A, Evans H. Pharyngeal pouch: link with reflux and oesophageal dysmotility. Clin Otolaryngol Allied Sci 1994; 19:241.
  14. Mulder CJ, Costamagna G, Sakai P. Zenker's diverticulum: treatment using a flexible endoscope. Endoscopy 2001; 33:991.
  15. Hunt PS, Connell AM, Smiley TB. The cricopharyngeal sphincter in gastric reflux. Gut 1970; 11:303.
  16. Sasaki CT, Ross DA, Hundal J. Association between Zenker diverticulum and gastroesophageal reflux disease: development of a working hypothesis. Am J Med 2003; 115 Suppl 3A:169S.
  17. Lixin J, Bing H, Zhigang W, Binghui Z. Sonographic diagnosis features of Zenker diverticulum. Eur J Radiol 2011; 80:e13.
  18. Shanker BA, Davidov T, Young J, et al. Zenker's diverticulum presenting as a thyroid nodule. Thyroid 2010; 20:439.
  19. Puricelli MD, Zitsch RP 3rd. Is it really a thyroid nodule? Another cause of a lower midline neck mass. Otolaryngol Head Neck Surg 2012; 147:397.
  20. Payne WS. The treatment of pharyngoesophageal diverticulum: the simple and complex. Hepatogastroenterology 1992; 39:109.
  21. Huang BS, Unni KK, Payne WS. Long-term survival following diverticulectomy for cancer in pharyngoesophageal (Zenker's) diverticulum. Ann Thorac Surg 1984; 38:207.
  22. Bowdler DA, Stell PM. Carcinoma arising in posterior pharyngeal pulsion diverticulum (Zenker's diverticulum). Br J Surg 1987; 74:561.
  23. Bradley PJ, Kochaar A, Quraishi MS. Pharyngeal pouch carcinoma: real or imaginary risks? Ann Otol Rhinol Laryngol 1999; 108:1027.
  24. Kensing KP, White JG, Korompai F, Dyck WP. Massive bleeding from a Zenker's diverticulum: case report and review of the literature. South Med J 1994; 87:1003.
  25. Sharma R, DeCross AJ. Zenker's diverticulitis secondary to alendronate ingestion: a rare cause of recurrent dysphagia. Gastrointest Endosc 2011; 73:368.
  26. Dickey W, Porter KG. Duodenoscope intubation of the oesophagus in the presence of pharyngeal pouch made possible by an overtube. Endoscopy 1995; 27:212.
  27. Ford RM, Affronti J, Cohen R, et al. Zenker's diverticulum: a contraindication for wireless capsule endoscopy? J Clin Gastroenterol 2005; 39:257.
  28. Knapp AB, Ladetsky L. Endoscopic retrieval of a small bowel enteroscopy capsule lodged in a Zenker's diverticulum. Clin Gastroenterol Hepatol 2005; 3:xxxiv.
  29. Witterick IJ, Gullane PJ, Yeung E. Outcome analysis of Zenker's diverticulectomy and cricopharyngeal myotomy. Head Neck 1995; 17:382.
  30. Lerut T, van Raemdonck D, Guelinckx P, et al. Zenker's diverticulum: is a myotomy of the cricopharyngeus useful? How long should it be? Hepatogastroenterology 1992; 39:127.
  31. Konowitz PM, Biller HF. Diverticulopexy and cricopharyngeal myotomy: treatment for the high-risk patient with a pharyngoesophageal (Zenker's) diverticulum. Otolaryngol Head Neck Surg 1989; 100:146.
  32. Barthlen W, Feussner H, Hannig C, et al. Surgical therapy of Zenker's diverticulum: low risk and high efficiency. Dysphagia 1990; 5:13.
  33. Feussner H. Reducing treatment of Zenker's diverticulum to the essentials: the flexible endoscopic approach. Endoscopy 1995; 27:445.
  34. Grund KE. Argon plasma coagulation (APC): ballyhoo or breakthrough? Endoscopy 1997; 29:196.
  35. Bremner CG, DeMeester TR. Endoscopic treatment of Zenker's diverticulum. Gastrointest Endosc 1999; 49:126.
  36. Altman JI, Genden EM, Moche J. Fiberoptic endoscopic-assisted diverticulotomy: a novel technique for the management of Zenker's diverticulum. Ann Otol Rhinol Laryngol 2005; 114:347.
  37. Gagic NM. Cricopharyngeal myotomy. Can J Surg 1983; 26:47.
  38. Duranceau A, Rheault MJ, Jamieson GG. Physiologic response to cricopharyngeal myotomy and diverticulum suspension. Surgery 1983; 94:655.
  39. Bonavina L, Khan NA, DeMeester TR. Pharyngoesophageal dysfunctions. The role of cricopharyngeal myotomy. Arch Surg 1985; 120:541.
  40. Lerut T, Van Raemdonck D, Guelinckx P, et al. Pharyngo-oesophageal diverticulum (Zenker's). Clinical, therapeutic and morphological aspects. Acta Gastroenterol Belg 1990; 53:330.
  41. Lindgren S, Ekberg O. Cricopharyngeal myotomy in the treatment of dysphagia. Clin Otolaryngol Allied Sci 1990; 15:221.
  42. Shaw DW, Cook IJ, Jamieson GG, et al. Influence of surgery on deglutitive upper oesophageal sphincter mechanics in Zenker's diverticulum. Gut 1996; 38:806.
  43. Aggerholm K, Illum P. Surgical treatment of Zenker's diverticulum. J Laryngol Otol 1990; 104:312.
  44. Gutschow CA, Hamoir M, Rombaux P, et al. Management of pharyngoesophageal (Zenker's) diverticulum: which technique? Ann Thorac Surg 2002; 74:1677.
  45. Law R, Katzka DA, Baron TH. Zenker's Diverticulum. Clin Gastroenterol Hepatol 2014; 12:1773.
  46. Yuan Y, Zhao YF, Hu Y, Chen LQ. Surgical treatment of Zenker's diverticulum. Dig Surg 2013; 30:207.
  47. DOHLMAN G, MATTSSON O. The endoscopic operation for hypopharyngeal diverticula: a roentgencinematographic study. AMA Arch Otolaryngol 1960; 71:744.
  48. van Overbeek JJ, Hoeksema PE, Edens ET. Microendoscopic surgery of the hypopharyngeal diverticulum using electrocoagulation or carbon dioxide laser. Ann Otol Rhinol Laryngol 1984; 93:34.
  49. van Overbeek JJ. Meditation on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 1994; 103:178.
  50. Collard JM, Otte JB, Kestens PJ. Endoscopic stapling technique of esophagodiverticulostomy for Zenker's diverticulum. Ann Thorac Surg 1993; 56:573.
  51. Narne S, Cutrone C, Bonavina L, et al. Endoscopic diverticulotomy for the treatment of Zenker's diverticulum: results in 102 patients with staple-assisted endoscopy. Ann Otol Rhinol Laryngol 1999; 108:810.
  52. Scher RL, Richtsmeier WJ. Long-term experience with endoscopic staple-assisted esophagodiverticulostomy for Zenker's diverticulum. Laryngoscope 1998; 108:200.
  53. Peracchia A, Bonavina L, Narne S, et al. Minimally invasive surgery for Zenker diverticulum: analysis of results in 95 consecutive patients. Arch Surg 1998; 133:695.
  54. van Overbeek JJ. Pathogenesis and methods of treatment of Zenker's diverticulum. Ann Otol Rhinol Laryngol 2003; 112:583.
  55. Mortensen M, Schaberg MR, Genden EM, Woo P. Transoral resection of short segment Zenker's diverticulum and cricopharyngeal myotomy: an alternative minimally invasive approach. Laryngoscope 2010; 120:17.
  56. Schipper J, Weerda N, Aschendorff A, et al. [Endoscopic assisted endoluminal stapler-diverticulotomy of Zenker diverticulum]. Laryngorhinootologie 2005; 84:577.
  57. Smith SR, Genden EM, Urken ML. Endoscopic stapling technique for the treatment of Zenker diverticulum vs standard open-neck technique: a direct comparison and charge analysis. Arch Otolaryngol Head Neck Surg 2002; 128:141.
  58. Chang CY, Payyapilli RJ, Scher RL. Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases. Laryngoscope 2003; 113:957.
  59. Hondo FY, Maluf-Filho F, Giordano-Nappi JH, et al. Endoscopic treatment of Zenker's diverticulum by harmonic scalpel. Gastrointest Endosc 2011; 74:666.
  60. Bizzotto A, Iacopini F, Landi R, Costamagna G. Zenker's diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital 2013; 33:219.
  61. Mirza S, Dutt SN, Irving RM. Iatrogenic perforation in endoscopic stapling diverticulotomy for pharyngeal pouches. J Laryngol Otol 2003; 117:93.
  62. Bloom JD, Bleier BS, Mirza N, et al. Factors predicting endoscopic exposure of Zenker's diverticulum. Ann Otol Rhinol Laryngol 2010; 119:736.
  63. Mantsopoulos K, Psychogios G, Künzel J, et al. Evaluation of the different transcervical approaches for Zenker diverticulum. Otolaryngol Head Neck Surg 2012; 146:725.
  64. Ishioka S, Sakai P, Maluf Filho F, Melo JM. Endoscopic incision of Zenker's diverticula. Endoscopy 1995; 27:433.
  65. Mulder CJ, den Hartog G, Robijn RJ, Thies JE. Flexible endoscopic treatment of Zenker's diverticulum: a new approach. Endoscopy 1995; 27:438.
  66. Hashiba K, de Paula AL, da Silva JG, et al. Endoscopic treatment of Zenker's diverticulum. Gastrointest Endosc 1999; 49:93.
  67. Wahab PJ, Mulder CJ, den Hartog G, Thies JE. Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences. Endoscopy 1997; 29:176.
  68. Evrard S, Le Moine O, Hassid S, Devière J. Zenker's diverticulum: a new endoscopic treatment with a soft diverticuloscope. Gastrointest Endosc 2003; 58:116.
  69. Sakai P, Ishioka S, Maluf-Filho F, et al. Endoscopic treatment of Zenker's diverticulum with an oblique-end hood attached to the endoscope. Gastrointest Endosc 2001; 54:760.
  70. Costamagna G, Iacopini F, Tringali A, et al. Flexible endoscopic Zenker's diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique. Endoscopy 2007; 39:146.
  71. Repici A, Pagano N, Romeo F, et al. Endoscopic flexible treatment of Zenker's diverticulum: a modification of the needle-knife technique. Endoscopy 2010; 42:532.
  72. Rieder E, Martinec DV, Dunst CM, Swanström LL. Flexible endoscopic Zenkers diverticulotomy with a novel bipolar forceps: a pilot study and comparison with needleknife dissection. Surg Endosc 2011; 25:3273.
  73. Tang SJ, Jazrawi SF, Chen E, et al. Flexible endoscopic clip-assisted Zenker's diverticulotomy: the first case series (with videos). Laryngoscope 2008; 118:1199.
  74. Vogelsang A, Preiss C, Neuhaus H, Schumacher B. Endotherapy of Zenker's diverticulum using the needle-knife technique: long-term follow-up. Endoscopy 2007; 39:131.
  75. Rabenstein T, May A, Michel J, et al. Argon plasma coagulation for flexible endoscopic Zenker's diverticulotomy. Endoscopy 2007; 39:141.
  76. Christiaens P, De Roock W, Van Olmen A, et al. Treatment of Zenker's diverticulum through a flexible endoscope with a transparent oblique-end hood attached to the tip and a monopolar forceps. Endoscopy 2007; 39:137.
  77. Repici A, Pagano N, Fumagalli U, et al. Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling. A retrospective comparison of outcomes. Dis Esophagus 2011; 24:235.
  78. Hookey LC, Le Moine O, Deviére J. Successful endoscopic management of a cervical pharyngeal perforation and mediastinal abscess. Gastrointest Endosc 2005; 61:158.
  79. Seaman DL, de la Mora Levy J, Gostout CJ, et al. An animal training model for endoscopic treatment of Zenker's diverticulum. Gastrointest Endosc 2007; 65:1050.