Nihon Jibiinkoka Gakkai Kaiho. Zenkers diverticulum is usually found in older patients who have dysphagia, regurgitation of undigested food, halitosis, choking, hoarseness, or a neck mass. Altered esophagealmotility is sometimes seen in patients with anorexia nervosa. Note the "bird-beak" appearance of the lower esophageal sphincter (LES), with a dilated, barium-filled esophagus proximal to it. The primary role is to clear the esophagus of retained food or any gastroesophageal refluxate. 1995 Jul;98(7):1154-63. doi: 10.3950/jibiinkoka.98.1154. High-resolution manometry in clinical practice: utilizing pressure topography to classify oesophageal motility abnormalities. These studies are especially valuable in areas of the pharynx that are difficult to evaluate by endoscopy (e.g., lower base of the tongue, valleculae, lower hypopharynx, pharyngoesophageal segment). Neurological disorders affecting oral, pharyngeal . The relationship between the mouth of the Zenkers diverticulum and prominent cricopharyngeus is demonstrated. Hoarseness occurs primarily in patients with laryngeal carcinoma, supraglottic carcinoma, or carcinoma of the medial piriform sinus infiltrating the arytenoid cartilage or cricoarytenoid joint. [QxMD MEDLINE Link]. The pouches are usually bilateral. Dysphagia. anthony coaxum football coach; overflow shelter wichita, ks; what does the green leaf mean on parkrun results PVA was injected under fluoroscopic monitoring until significant stasis of the artery was noted. Unauthorized use of these marks is strictly prohibited. Structural Abnormalities of the Pharynx | Radiology Key These tumors infiltrate deeply into the intrinsic and extrinsic muscles of the tongue. All signs seem to be pointing to a neurological basis for his dysphagia and Im just wondering if there are any last hail marys to try before we start to plan for home on NG, OP feeding therapy, etc. The third and fourth branchial pouches form the piriform sinuses. If it is not neurologic, could it be anatomic? Hoarseness. Webs in the distal esophagus have been associated with gastroesophageal reflux disease. 2009 Apr. This space is bounded superiorly by the inferior margin of the cricopharyngeal muscle, anteriorly by the inferior margin of the cricoid cartilage, and inferomedially by the suspensory ligament of the esophagus originating from the posterior wall of the cricoid cartilage, just before the tendon forms the longitudinal muscle of the esophagus. Pharyngeal swallowing phase and chronic cough Lymph node metastases are seen ipsilaterally or contralaterally in more than 70% of patients. Esophageal dysmotility develops as the smooth muscle of the esophagus is replaced by scar tissue, gradually leading to progressive loss of peristalsis and a weakening of LES. The mid esophagus contains a graded transition of striated and smooth muscle types. The pharynx is the site of common illnesses, including sore throat and tonsillitis. Rommel N, Omari TI, Selleslagh M, et al. Asymmetrical distensibility is seen as flattening of the pharyngeal contour caused by fixation of structures by infiltrating tumor or by an extrinsic mass impinging on the pharynx. A wide variety of benign tumors occur in the pharynx. Clipboard, Search History, and several other advanced features are temporarily unavailable. The dysmorphic features stand out as worrisome, and often craniofacial and cardiac variants like an ASD can co-occur. for: Medscape. Inability to swallow. Branchial ridges (arches) lie between the branchial clefts. In Laufer I, Levine MS [eds]: Double Contrast Gastrointestinal Radiology, 2nd ed. Any ideas are greatly appreciated! Clinical symptoms may include dysphagia, choking, cough, hoarseness, regurgitation of undigested food, or a painless neck mass. 2011 Nov. 21(4):465-75. )dC(SOL*W vRlYE1Zt[@m.)S*=V!/XZ;,3`{9WW(Kr[tfJ[XR[N{\Q*}iRf8w!fM}CS7x.03cO]Mux: T*xo~g|[IlyQV[G_W6W(=ihk- 16-14 ). %PDF-1.6 % In some patients, this regurgitation of barium results in overflow aspiration. van Hoeij FB, Tack JF, Pandolfino JE, et al. This area of weakness occurs in one third of patients. J39.2 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Sato Y, Fukudo S. Gastrointestinal symptoms and disorders in patients with eating disorders. Muscle wall thickening has been described in patients who are asymptomatic and, conversely, has been absent in some patients with typical symptoms and manometric findings. The symptoms of pharyngeal carcinoma are nonspecific and usually of short duration (<4 months). 233 0 obj <>/Filter/FlateDecode/ID[<9925DAB172E4C04EAA11C856BA143EA3>]/Index[223 23]/Info 222 0 R/Length 65/Prev 694135/Root 224 0 R/Size 246/Type/XRef/W[1 2 1]>>stream Patients with pharyngeal symptoms or a palpable neck mass may undergo pharyngoesophagography as the initial diagnostic examination. hb```f``r OT consult? With severe lymphoid hyperplasia of the base of the tongue, the nodules may extend into the valleculae, along the lingual surface of the epiglottis, or even into the upper hypopharynx. Scintigraphy also had good sensitivity in detecting penetration and/or aspiration in VFS. Catherine Shaker 2023 Seminars: Reinforce Your Intellectual Curiosity! [Full Text]. The .gov means its official. Barium, MRI, or CT studies may be extremely helpful in detecting clinically occult lesions with nodal metastases. The value of pharyngeal scintigraphy in predicting - PubMed A sensation of food getting stuck in the throat or chest or behind the breastbone (sternum) Drooling. 16-19 ). Webs are thin mucosal folds usually located along the anterior wall of the lower hypopharynx and proximal cervical esophagus. Laryngoceles are seen in patients with increased intralaryngeal pressure, such as glass blowers and wind instrument players. Most patients with cervical esophageal webs are asymptomatic. The radiologist may be the first physician to suggest a diagnosis of pharyngeal carcinoma ( Fig. Tonsillar tumors may spread to the soft palate, base of the tongue, and posterior pharyngeal wall. 22(2):226-30. The exception is the . [QxMD MEDLINE Link]. The cause and clinical significance of webs are controversial. Pharyngeal | definition of pharyngeal by Medical dictionary V4IQ){lP E Multiple co-morbidities at play it seems. [QxMD MEDLINE Link]. He also gets very constipated. The body of the esophagus is similarly composed of 2 muscle types. Catherine Shaker Seminars: Formula One Style in Austin! Radiologists should be as familiar with pharyngeal carcinoma as they are with esophageal carcinoma. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Radiographic findings in pharyngeal carcinoma. Rarely, branchial cleft cysts may communicate with the pharynx (branchial cleft fistulas), filling with barium during pharyngography. It carries air, food and fluid down from the nose and mouth. After swallowing, barium in the diverticulum is regurgitated into the hypopharynx. The most common benign lesions are retention cysts of the valleculae or aryepiglottic folds. The inferior constrictor muscle is composed of the thyropharyngeal and cricopharyngeal muscles. What is vallecular pooling? Explained by Sharing Culture Achalasia is associated with significant and progressive symptomatic discomfort. HHS Vulnerability Disclosure, Help Some diseases with diffuse mucous membrane ulceration affect the pharynx. Method This study used a prospective analysis of outcomes data from the University of Wisconsin-Madison Voice and Swallow Outcomes database in patients with complaints of bolus stasis who completed the combined videofluoroscopic swallowing study and esophagram to determine the accuracy of bolus stasis localization. With achalasia, the risk of squamous cell carcinoma of the esophagus is higher than that of the general population. Physiologic characteristics of achalasia are additionally useful in assisting with establishing the diagnosis through chemical challenge testing. What causes VPI? Head Neck. The lateral pharyngeal wall may protrude beyond the normal expected contour of the pharynx in areas unsupported by muscle layers. In Europe, the incidence of achalasia is similar to that of the United States. In the United States, no strong association of cervical esophageal webs, iron deficiency anemia, and pharyngoesophageal carcinoma has been found. There are no skeletal structures in the fourth pharyngeal arch. Esophageal stasis was the most common finding regardless of complaint location. If high-amplitude (>60 mm Hg) simultaneous contractions occur, the entity is categorized as vigorous achalasia, which may represent an early stage of classic achalasia. Many nasopharyngeal squamous cell cancers are undifferentiated tumors, and many have a reactive lymphoid stroma. PDF Swallowing Problems in Adults - American Speech-Language-Hearing 16-10 ). The upper anterolateral pharyngeal wall is poorly supported in the region of the posterior and superior portions of the thyrohyoid membrane. Most of these patients have recurrent aphthous stomatitis and oropharyngeal ulceration. 37(12):1210-9. Genetics consult? 16-17 ). However, tumor-like cysts of various histologic types are not uncommonly seen in the pharynx. 7(2):101-13. The site is secure. Anteriorly, there is the larynx, epiglottis, and posterior part of the tongue. This infant has pharyngeal stasis post swallow on the swallow study. A referred earache may occur, especially when nasopharyngeal tumors block the eustachian tube. Some diseases with diffuse mucous membrane ulceration affect the pharynx. Webs may extend laterally, and a few extend circumferentially. Webs appear radiographically as 1- to 2-mm wide, shelflike filling defects along the anterior wall of the hypopharynx or cervical esophagus ( Fig. The review of VFSSs was used to confirm whether swallowing with head rotation was effective for dysphagia caused by cervical osteophytes. He was eventually diagnosed with a posterior tongue tie and underwent a frenulectomy. 2015 Oct. 28(7):699-704. The radiographic findings of pharyngeal cancer include an intraluminal mass, mucosal irregularity, and impairment or loss of normal mobility or distensibility ( Fig. National Library of Medicine Zenkers diverticulum (posterior hypopharyngeal diverticulum) is an acquired mucosal herniation through an area of anatomic weakness in the region of the cricopharyngeal muscle (Killians dehiscence). Although esophagram shows a typical picture of achalasia, this patient had adenocarcinoma of the gastroesophageal junction. Peristalsis is a sequential, coordinated contraction wave that travels the entire length of the esophagus, propelling intraluminal contents distally to the stomach. This characteristic likely explains why the botulinum toxin (acetylcholine release inhibitor) may have therapeutic benefit in patients with achalasia. cess. Not an uncommon presentation that can go many directions as further data comes in. Dig Dis Sci. This work supports a comprehensive evaluation of both the pharynx and the esophagus for patients with complaints of bolus stasis in the throat. Esophageal dysmotility may be caused by: An ulcer, stricture, irritation, infection, inflammation, or cancer in the esophagus. Life expectancy is not affected, and weight loss is rare. Timing of events during deglutition after chemoradiation therapy for oropharyngeal carcinoma. Squamous cell carcinoma of the right palatine tonsil. 16-3 ). Squamous cell carcinoma of the palatine tonsil is the most common malignant tumor arising in the pharynx. Barium that is retained in pouches during swallowing spills into the ipsilateral piriform sinus after the bolus passes. hTmo6+bpNQ@av@A9G^I;Rr$;Y\#0"&Z2-t2& #WBq#@ @+$>EWuO72Ou-Zs*[P Jd|!6kSKWEsw]J]WfDvNj _i8n[&7gsct In contrast, saccular cysts of the aryepiglottic folds arise from the mucus-secreting glands of the appendix of the laryngeal ventricle and are filled with mucoid secretions. This work supports a comprehensive evaluation of both the pharynx and the esophagus for patients with complaints of bolus stasis in the throat. Patients with internal laryngoceles may complain of hoarseness, dysphagia, or choking. Motility is preserved at the proximal striated muscle portion of the esophagus. This association was termed Plummer-Vinson syndrome or Paterson-Kelly syndrome. what is pharyngeal stasis - brodebeau.com Cochrane Database Syst Rev. Achalasia is the best defined primary motility disorder and the only one with an established pathology. Patients with second branchial cleft cysts usually present between the ages of 10 and 40 years with a painless or fluctuant mass in the upper neck along the upper third of the anterior border of the sternocleidomastoid muscle. Unable to load your collection due to an error, Unable to load your delegates due to an error. Radiographically, a small (3-20mm in diameter), round to ovoid, smooth-surfaced outpouching is seen just below the level of the cricopharyngeal muscle ( Fig. Pharyngeal recess | definition of pharyngeal recess by Medical dictionary At the LES, the loss of inhibitory nerves is demonstrated by loss of nitric oxide synthase and vasoactive intestinal peptide (VIP) immunohistochemistry staining. Incomplete opening and early closure of the cricopharyngeal muscle, and early closure of the upper cervical esophagus, have been associated with gastroesophageal reflux disease. Long-term outcome following pneumatic dilatation as initial therapy for idiopathic achalasia: an 18-year single-centre experience. Pharyngeal Versus Esophageal Stasis: Accuracy of Symptom Localization Squamous cell carcinomas of the head and neck (e.g., tongue, pharynx, larynx) constitute 5% of all cancers in the United States, whereas esophageal carcinomas constitute only 1% of all cancers. Retention cysts and granular cell tumors are the most common benign tumors of the base of the tongue ( Fig. A videofluoroscopic swallow study (VFSS) allows for visualization of the oral, pharyngeal, and esophageal phases of the swallow. Dysphagia. J Am Coll Surg. 16-9 ). Oropharyngeal dysphagia is a medical condition that causes a disruption or delay in swallowing. Patients with small lesions are often asymptomatic but present with enlarged cervical nodes. 16-1 ). As a result, pending further data, they might consider a G-Tube with a Nissen (to optimize airway protection and more safely buy him time for response to therapy and evolution to guide the differential), instead of home NG, which would have its own attendant sequelae. Some radiographic and manometric studies have suggested that spasm with elevated pressure of the upper esophageal sphincter or incoordination and abnormal relaxation of the upper esophageal sphincter (achalasia) are contributing factors. I like to start with the whys to guide intervention options. Before entertaining a diagnosis of a motility disorder, first and foremost, the physician must evaluate for a mechanical obstructing lesion. Patients with complaints of bolus stasis in the throat (i.e., pharynx and cervical esophagus) were less accurate at localizing bolus stasis than patients with complaints in the thoracic esophagus ( p < .001). Patients with impaired base of tongue movement and impaired pressure generation resulting in pharyngeal residue in the setting of a normal neurologic workup could possibly present with a posterior tongue tie which should be examined and included in the differential diagnosis. Lateral Pharyngeal Pouches and Diverticula, Branchial Cleft Cysts, Branchial Cleft Fistulas, and Branchial Pouch Sinuses, Lateral Cervical Esophageal Pouches and Diverticula, Lymphoid Hyperplasia of the Lingual and Palatine Tonsils, Surgery for Tongue and Oropharyngeal Cancers, Surgery for Zenkers Diverticulum and Pharyngeal Pouches. 2014. Please confirm that you would like to log out of Medscape. Catherine Shaker Swallowing and Feeding Seminars, Research Corner: Infant and maternal factors associated with attainment of full oral feeding (FOF) in premature infants. Multiple primary lesions of the oral cavity, pharynx, esophagus, and lung are seen in more than 20% of patients. Retention cyst at the base of the tongue. If unilateral, the diverticula are usually found on the left side of the proximal cervical esophagus. These webs are thought to be normal variants in the valleculae and piriform sinuses. The spectrum of these disorders ranges from the well-defined primary esophageal motility disorders (PEMDs) to very nonspecific disorders that may play a more indirect role in reflux disease and otherwise be asymptomatic. Patients with benign tumors of the base of the tongue may be asymptomatic or may complain of throat irritation or dysphagia. With severe luminal narrowing, dysphagia may result, especially in patients with circumferential cervical esophageal webs. When large, the cysts may extend posteriorly to the sternocleidomastoid muscle, displacing the carotid sheath. What pharyngeal stage disorder is a result of reduced and / or mistimed laryngeal closure before, during, and after the swallow? This controversial finding causes difficulty in attributing symptoms or manometric abnormalities to muscle structure changes. Choking or coughing may be caused by laryngeal penetration during swallowing or aspiration of barium trapped in ulcerated tumors. [QxMD MEDLINE Link]. Cross-sectional imaging of noninfected cysts may reveal a smooth, thin-walled mass with a homogeneous water core. Advanced achalasia can lead to malnutrition, dehydration, and aspiration. Overall low energy and alertness for his age. Gatto AR, Cola PC, da Silva RG, Ribeiro PW, Spadotto AA, Henry MAAC. grade 1 pharyngeal anastomotic leak - National Library of Medicine Esophageal motility disorders discussed in this article include the following: Spastic esophageal motility disorders, including diffuse esophageal spasm (DES), nutcracker esophagus, and hypertensive LES, Nonspecific esophageal motility disorder (inefficient esophageal motility disorder), Secondary esophageal motility disorders related to scleroderma, diabetes mellitus, alcohol consumption, psychiatric disorders, and presbyesophagus. However, no studies to date have shown convincing evidence that surveillance is worthwhile. The fourth and sixth pharyngeal arches cartilages merge to give rise to the laryngeal cartilages. On lateral views, the anterior wall of the sac is anterior to the cervical esophagus, below the level of the cricopharyngeal muscle. Conclusion Patients are poor at localizing bolus stasis, and esophageal stasis is common in patients who complain of pharyngeal stasis. Leonard DS, Broe P. Oesophageal achalasia: an argument for primary surgical management. The webs protrude to various depths into the esophageal lumen. Influence of Thermal and Gustatory Stimulus in the Initiation of the Pharyngeal Swallow and Bolus Location Instroke. The esophagus functions solely to deliver food from the mouth to the stomach where the process of digestion can begin. surefire led conversion head; bayou club houston membership fees. what is pharyngeal stasislack of education leads to violence what is pharyngeal stasis. The pathogenesis is not well documented, but chronic mucosal irritation is incriminated. Nonepithelial tumors arising from the supporting tissues of the pharynx are rare. [QxMD MEDLINE Link]. They are also known as Killian-Jamieson pouches or Killian-Jamieson diverticula . Initial results of diagnostic endoscopy may be negative. Reasons for the swallow study were bedside symptoms of desaturations during oral feeding at ~37 weeks PMA and a steady decline in his oral intake & feeding cues. A lateral pharyngeal diverticulum is a protrusion of nonkeratinizing squamous mucosa originating in the pharynx. The 5-year survival rate varies from 76% for patients with localized tumors to 10% to 20% for patients with cervical lymph node metastases. Plain radiographic diagnosis of acute epiglottitis is important (even in adults) because manipulation of the tongue or pharynx may exacerbate edema and respiratory distress. connect4education register; don't be a felix cdcr video; westfield knox redevelopment 2020 0 Thorac Surg Clin. With the partial ganglion cell loss in patients with achalasia, edrophonium (acetylcholine esterase inhibitor) increases LES pressure while atropine (muscarinic antagonist) decreases LES pressure. A frontal view shows loss of the normal contour of the left piriform sinus. Tumors of various histologic types tend to occur at specific locations in the pharynx. [3] It is also seen in patientsfollowing eradication of esophageal varices by endoscopic sclerotherapy, in association with an increased number of endoscopic sessions but not with manometric parameters. The pharyngeal outpouchings are of endodermal origin and are termed branchial pouches. The risk factors, age of presentation, and histologic type are more varied than those of the typical squamous cell carcinoma of the oropharynx and hypopharynx. PDF Case Report Relato de Caso electrical stimulation on deglutition after Barium studies are used primarily to evaluate the symptoms of nasal regurgitation and voice changes caused by soft palate insufficiency and to rule out a synchronous esophageal tumor. Tumors of the epiglottis and aryepiglottic folds may also result in dysphagia, coughing, or choking because of laryngeal penetration. A dynamic examination reveals a higher percentage of webs than spot images alone. being unable to chew food properly. On lateral radiographs, the base of the tongue may seem to protrude posteriorly. When decreased base of tongue movement, impaired pharyngeal pressure generation, and presence of pharyngeal residue are noted during a VFSS, a neurologic etiology can be suspected. Possible complications, therapeutic options, expected outcomes, and dietary modifications should be explained. a sensation that food is stuck in your throat or chest. Salvador R, Dubecz A, Polomsky M, et al. Response to amyl nitrate, with disappearance of the spasm on esophagram. Variable amounts of inflammatory cells have been described within the myenteric plexus along with the disappearing nerves. Bookshelf In addition to alcohol and smoking abuse, poor ventilation, nasal balms, ingested carcinogens, and upper respiratory viruses such as the Epstein-Barr virus have been implicated as causative factors. 223 0 obj <> endobj None of the clinical or physiologic behaviors can be attributed strictly to being born preterm, though preterm birth would increase risk for co-morbidities. On barium studies, irregularity of the contour of Zenkers diverticulum should suggest an inflammatory or neoplastic complication. The pathogenesis of Zenkers diverticulum is as controversial as the muscular anatomy. Lateral radiographs may show the air-filled sac anterior to the epiglottic plate, in contrast to a lateral pharyngeal diverticulum, which lies posterior to the epiglottic plate. for stability and/or r/t tethered oral tissues, r/t mild mandibular hypoplasia). A person with cricopharyngeal dysfunction may experience: a feeling of having something stuck in their throat difficulty swallowing. Some cervical esophageal webs may also be associated with gastroesophageal reflux. Manometry may reveal elevated LES pressure greater than 40 mm Hg in more than 60% of patients; however, hypertensive LES is not universal or required for the manometric diagnosis. Esophageal motility disorders are less common than mechanical and inflammatory diseases affecting the esophagus, such as reflux esophagitis, peptic strictures, and mucosal rings. Inflammation-induced dysmotility may result in laryngeal penetration and stasis. Enter your email address to subscribe to this blog and receive notifications of new posts by email. Systemic complications are the major cause of mortality. In one autopsy series, 16% of patients had incidental cervical esophageal webs. what is pharyngeal stasis - lupaclass.com In lymphoid hyperplasia of the palatine tonsils, masslike enlargement of the palatine tonsils is seen in the frontal and lateral views ( Fig. Pharyngeal inflammation and ulceration may be seen in patients with Behets syndrome, Stevens-Johnson syndrome, Reiters syndrome, epidermolysis bullosa, or bullous pemphigoid. There are no criteria based on size for differentiating nodularity of the base of the tongue because of normal lingual tonsils from that resulting from reactive lymphoid hyperplasia. [QxMD MEDLINE Link]. Disclaimer. ), An 80-year-old patient with dementia underwent an upper GI examination for epigastric pain. [1] As with any other chronic illness, prevalence exceeds incidence significantly. The quiet cry may suggest retracted tongue (? 2015 Dec. 174(12):1629-37. Can dysphagia be cured by surgery? Among the anomalies seen in SCI patients weretype II achalasia (12%), type III achalasia (4%), esophagogastric junction outflow obstruction (20%), hypercontractile esophagus (4%), and peristaltic abnormalities (weak peristalsis with small or large defects or frequent failed peristalsis) (48%). bringing food back up, sometimes through the nose. Only rarely do these tumors extend through the laryngeal ventricles into the true vocal cords. Food or stomach acid backing up into the throat. Most patients with squamous cell carcinoma are 50 to 70 years of age. If you log out, you will be required to enter your username and password the next time you visit. [QxMD MEDLINE Link]. A zone of lymphoid tissue surrounds the epithelium. o Can protude into pharynx and cause pharyngeal stasis. Nutcracker esophagus is the most common motility disorder (>40% of all motility disorders diagnosed), but it is the most controversial in significance. Some background: He is an ex 33-weeker, now 39+5. Most patients are asymptomatic and in the fifth to sixth decade of life. [2]. In DES, muscular hypertrophy or hyperplasia has been described in the distal two thirds of the esophagus. The benign nature of these lesions should be confirmed by endoscopic examination. Hypertrophy of the lingual tonsil frequently occurs after puberty, as a compensatory response after tonsillectomy, or as a nonspecific response to allergies or repeated infection. Accessibility 16-4 ). Radiographically, the diverticula are persistent, barium-filled sacs of various sizes connected to a bulging lateral hypopharyngeal wall by a narrow neck ( Fig. "When the results of the oropharyngeal exam and the esophagram were combined, esophageal stasis in isolation was the most common finding at all complaint locations, with the exception of patients who complained of stasis in the cervical and thoracic esophagus where the most common finding was no stasis." "Pharyngeal stasis in isolation . 2021 Dec;36(6):1063-1071. doi: 10.1007/s00455-020-10239-3. What we know so far suggests a poor prognosis for being a full PO feeder at time of d/c from the NICU and the etiology(ies) is/are unlikely to resolve in the short term, given multiple complex co-morbidities, as yet not fully determined. 2010 Feb. 22(2):142-9, e46-7. endstream endobj startxref iowa golf coaches association; recent advances in mechanical engineering ppt; houses for rent in rancho cucamonga'' craigslist; are there seagulls in puerto rico Diagnostic Accuracy of an Esophageal Screening Protocol Interpreted by the Speech-Language Pathologist. 16-11 ). Scleroderma is a systemic disease with a progressive nature. During swallowing, Zenkers diverticulum appears as a posterior bulging of the lowermost hypopharyngeal wall above an anteriorly protruding pharyngoesophageal segment (cricopharyngeal muscle; Fig.