BackTable / ENT / Podcast / Transcript #99

Podcast Transcript: Management of Zenker’s Diverticula

with Dr. Rebecca Howell

In this episode of BackTable ENT, Dr. Ashley Agan interviews Dr. Rebecca Howell, division chief of laryngology at University of Cincinnati, about her diagnosis and management of Zenker’s diverticulum. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) What is Zenker’s Diverticulum?

(2) Pathophysiology of Zenker’s Diverticulum

(3) The “Rising Tide” & Other Findings on Clinical Examination

(4) History Taking for Zenker’s Diverticulum

(5) Visualizing Diverticula with the Help of Swallow Studies

(6) Observation as a Management Option

(7) Improving Patient-Reported Outcomes with Surgical Management

(8) Surgical Techniques for Zenker’s Diverticulum

(9) Navigating Difficult Surgical Exposures

(10) Complications of Surgical Repair

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[Dr. Ashley Agan]
This week on The BackTable Podcast.

[Dr. Rebecca Howell]
Again, I think to get better buy-in, it's better to be honest with patients. I tell them, I'm like, "Listen, this is not cancer. You don't have to have this done." The other way that I explain my practice to patients is I tell them that I'm not a quantity-of-life doctor, I'm a quality-of-life doctor.

This is not going to extend your life, but it's going to make you enjoy eating, and enjoy going out to dinner, and enjoy being around company rather than becoming fearful that you're going to choke. I think when you phrase it in that way, I think patients are a little bit more open to even when they come in thinking like, "I'm just going to hear it, but I'm not interested." I think if you phrase it in a way that is more palatable, then it's an easier conversation.

[Dr. Ashley Agan]
Hi, everybody, welcome to The BackTable ENT Podcast. We're a podcast that focuses on all thing's otolaryngology, and we've got a really great show for you today. Thanks for stopping by. Now, a quick word from our sponsor. Cook Medical's Otolaryngology/Head and Neck Surgery clinical specialty strives to provide otolaryngologists with minimally invasive solutions to address unmet needs.

Areas of focus include head and neck, otology, and laryngology. With products ranging from a full suite of interventional thalendoscopy products, and the Doppler Blood Flow monitoring system, to the Biodesign Otologic Repair Graft, and the Hercules 100 Transnasal Esophageal Balloon. For more information, visit cookmedical.com/otolaryngology. Now, back to the show.

Our guest today is Dr. Rebecca J. Howell. She's an Associate Professor of Otolaryngology and Division Chief of Laryngology at University of Cincinnati. She is a clinician-researcher with a particular interest in the intersection of voice and swallowing disorders. She's here today to talk to us about the management of Zenker's diverticula. Welcome to the show, Rebecca. How are you?

[Dr. Rebecca Howell]
Thank you, Ashley. I'm great. Thanks for having me.

[Dr. Ashley Agan]
Before we get into it, tell us a little bit about yourself, and your practice, and how you got to this point in your career.

[Dr. Rebecca Howell]
Oh, I appreciate that. Like so many different people, I think I dabbled in a little bit of everything and then fell in love with the airway. The intersection, again, of voice and swallowing. At the glottic level, I think is the very interesting part of swallowing disorders in particular for me. I came to Cincinnati because my late partners in COSA did not do in-office procedures. He also didn't do a whole lot in the swallowing or dysphagia world, and so I was brought here specifically to grow that program.

Since then, we have added a couple more partners. I now have Aaron Friedman and Greg Dion who have joined me at University of Cincinnati, and we have a very robust voice swallowing and airway program. It's been a lot of fun to build and to grow. I have 10 phenomenal speech-language pathologists that also have like really helped me to evolve in my understanding of swallowing disorders, especially, but also for voice and airway. They are just phenomenal people and I couldn't thank them more.

[Dr. Ashley Agan]
That's awesome. You started a fellowship too.

[Dr. Rebecca Howell]
Right. We have our first fellow starting this summer. We have an international fellow starting in July, and we are currently interviewing for our fellowship for 2024 already. Everything in education and medicine takes forever. These have been like years in the work, so it's finally coming into fruition. It's really exciting. It's going to be a lot of fun to actually have somebody that we get to put our imprint on.

[Dr. Ashley Agan]
Yes. Congrats. That's awesome. That's really exciting.

[Dr. Rebecca Howell]
Thank you.

(1) What is Zenker’s Diverticulum?

[Dr. Ashley Agan]
We're going to cover Zenker's diverticulum. Maybe before we get into patient presentation and how you take care of these patients. Maybe just some definitions like for our listeners who maybe are a little rusty or don't know what a Zenker's diverticulum is. Can you talk about that?

[Dr. Rebecca Howell]
Sure. Zenker's diverticulum is a specific diagnosis of a swallowing disorder. In the upper esophagus, it's an abnormal outpouching of the esophagus that causes specific symptoms. They arise typically in patients that are in their seventh decade. They're not usually seen in younger patients, it's a red flag if they are. It causes problems with both swallowing, but more specifically with regurgitation of food. Regurgitation of food or pills, I think is even more specific to this particular thing.

[Dr. Ashley Agan]
I feel like when I think of Zenker's, it's always that classic regurgitation of undigested food, or regurgitation of pills, and you're like, "Oh, wait a minute, could this be a Zenker's diverticulum?"

[Dr. Rebecca Howell]
Exactly.

[Dr. Ashley Agan]
Being a Zenker's diverticulum as opposed to other types of diverticula or outpouchings, that's related to its location, is that right?

[Dr. Rebecca Howell]
That's right. That's right. Actually, it's a really important point. One of the first papers that our pouch collaborative designed was actually looking at the different types and flavors of upper esophageal diverticula. Zenker's is by far the most common, by far. You can also get Killian-Jamieson, you can get Laimer, you can also get iatrogenic. I think one of the things that I always talk to my residents about especially is if there are any neck incisions, just double check your imaging before believing that it's truly a Zenker's diverticulum.

Because a lot of times, especially if they're in C spine, you can actually get what's called a traction diverticulum. Traction diverticulum means that outpouching is caused because there's some scar tissue which actually pulls on the esophagus and then pulls out all three layers. Whereas a Zenker's diverticulum is really just the herniation of the mucosa. This actually goes through what's called the Killian-Jamieson triangle. It's the upper esophageal segment but between the fibers of the cricopharyngeus muscle and the inferior constrictors.

It's a triangle that actually is a congenital dehiscence. How we like to think about these things, especially in Zenker's is that you have to have a CP or cricopharyngeus muscle dysfunction and a congenital dehiscence of this area. If you just have one, then you have an obstructive CPMD, which in fact causes in some cases in our early study actually caused more symptoms. Their EAT-10 scores-- so an EAT-10 is a patient-reported outcome measure that's a validated instrument that we use and they actually do worse.

In some ways, if you are lucky enough to have one of these dehiscence, your symptoms are probably prolonged. You've had them-- and that's pretty common. Patients will present when you actually ask them if they've had swallowing problems or if you ask their family members, it's usually between one and three years. The symptoms come on slowly and gradually, but there's probably some points that then the regurgitation symptoms and the actual food and the pills that come up. I think that's really what sends them into the office.

(2) Pathophysiology of Zenker’s Diverticulum

[Dr. Ashley Agan]
That makes sense. Because in my mind, correct me if I'm wrong, the upper esophageal sphincter is not relaxing. When you're pushing that food bolus back, there's that area of weakness. That's just getting the pressure there pushes into that. Then over time basically a pouch develops there. Is that how to think of it?

[Dr. Rebecca Howell]
You're absolutely right. I explain to patients that the esophagus, it's all plumbing. I draw these very funny pictures for them of like lips, a straight tube, and then some wiggly lines that is the rest of the intestines. It's all plumbing. If you have a backup somewhere, then you're going to have symptoms above. Sometimes, and again, what I think will really be interesting in the long-term as we learn more and more about these patients, I think that the lower esophagus is probably affecting the upper esophagus.

One of the things that, again, I think in thinking of these Zenker’s patients, sometimes they come with what people will look at as a CP bar. A CP bar, a cricopharyngeal bar is a radiologic finding, which shows 50%-- this is from Ekberg and Olsson. They found that if you have a 50% reduction in the diameter, then it's called a CP bar, which is simply a radiologic finding. It's not a diagnosis. You have to actually have dysphagia symptoms then to say that you have a cricopharyngeal muscle dysfunction.

That's important because if you look at the lower esophagus, sometimes that muscle becomes tighter or that valve becomes tighter because you have really bad acid reflux, or you have really bad dysmotility, or you have a megaesophagus or nutcracker esophagus, something. You have some other dysmotility that's lower down that's actually causing your body to tighten up that valve so that you're not refluxing all the time. The CP muscle, I think, in the upper esophageal sphincter, it's a tricky muscle because it's not always just as it seems.

(3) The “Rising Tide” & Other Findings on Clinical Examination

[Dr. Ashley Agan]
That can make it really tricky to figure out what's going on. You talked a little bit about the demographics of these patients, so they tend to be older, maybe in their seventies. What's a typical patient that's coming to see you in your office? Maybe somebody who hasn't had the workup yet. Because I'm sure as the subspecialist, you probably get patients who are like already worked up. Let's say that you don't know what's going on and they're just coming in with dysphagia, what other things are key to be asking?

[Dr. Rebecca Howell]
That's a great question, Ashley. Any patient that comes in with a swallowing problem, I certainly think that a flexible laryngoscopy is very helpful. Sometimes a stroboscopy if you're looking for closure because again these patients are usually a little bit older. Sometimes that can be beneficial just for, again, the glottic closure. I think it's important, so even when you just look with a scope, one of the things that you'll notice or that I teach my residents to look at is just saliva or mucus, like pooling of secretions.

If you see a clean throat with absolutely nothing else compared to somebody who is full of spit, you know already that they've got a problem. They've got a swallowing problem. The thing that is unique to Zenker’s, and I believe it was Moradi that actually wrote this up several years ago, he called it the rising tide. One of the things that you will oftentimes see is these frothy secretions coming up out of the UES, especially as they voice.

As patients continue, I have them talk for a while. Sometimes we have them do some high-pitched E's or some glides. Because as they keep going, oftentimes you'll get this like rising frothy secretions that come out of the UES, then see in the pyriform sinus more often on the left than the right, which is also consistent with. Oftentimes when we see Zenker’s they're posteriorly oriented, but oftentimes they look or appear that they're on the left side and that's just due to the anatomy of the trachea, this occipital groove.

[Dr. Ashley Agan]
That rising tide finding, that's specific for Zenker’s or that could be in other forms of dysphagia, other pathologies that cause dysphagia as well?

[Dr. Rebecca Howell]
It's a good question. It hasn't been studied enough to be able to say whether it is, but I would say it definitely is a sign that the upper esophageal sphincter is not working properly. Most often I would say it's in diverticula patients, but it's a sign that the UES is not properly opening and allowing just normal secretions and saliva to go down. I think that that one's a very useful one. The other ones again are the patient-reported outcome measures. We use the eating assessment tool 10, we use the reflux symptom index, we use the voice handicapped index 10, and the glottal function index as sort of just basic metrics to be able to take upon when patients come in.

As far as gender predilection, there's a slight increase in men compared to women, but really it's pretty even. It's not statistically significant. We talked about age. Some of the other factors that we looked at, but really we haven't found anything clinically significant. As part of the pouch collaborative, we looked at MS, we've looked at ALS, neurologic conditions, stroke conditions as other sort of predictors of this. The other thing that we really looked at was weight loss. We looked at aspiration pneumonia and none of it was clinically significant.

The pouch collaborative is a dysphagia interest group of physicians, researchers, and surgeons started in 2017. It's a big REDCap database. It's a prospectively collected database of patients with CPMD, early Zenker’s, but they can be with or without a pouch. Also, it can be with or without surgery. I think that's a really important piece as we move forward to be able to tell patients this is actually, as I said, one to three years is usually where they present. It's not something that they have to hurry up and get done. On the other hand, if they're already older, they're probably not getting any healthier in a couple of years. It's really a balance in how bad their symptoms are and their surgical risks.

[Dr. Ashley Agan]
You're saying that Zenker’s patients are not more likely to have weight loss or aspiration pneumonia, those other things that you looked at?

[Dr. Rebecca Howell]
No. Those are things that I think we tell people, and this is really why I designed this REDCap database was to actually look at it. The things that we tell patients and then what's actually true-- it's not to say that they're zero, but it's a small minority that come in and actually present with like a feeding tube, or weight loss, or aspiration pneumonia. It's like that is sort of how I think of end stage of dysphagia. Most of them present well before that. Not to say that they maybe couldn't get to that point at some point, but that's not usually when they show up in the office.

[Dr. Ashley Agan]
Is it maybe one of these things where when it was first described patients presented so late that they did have all of those findings, but now we catch it earlier, maybe?

[Dr. Rebecca Howell]
It's probably true. these were originally written by von Zenker, by Ludlow. It was in the 18th century. When we first like really like wrote these things up and actually thought about it, yes, they probably were doing terrible by then. We didn't know. Now we have access to medicine and I think it's a lot simpler. Then we haven't gotten into like the differences between open and endoscopic, but really as like endoscopic took off like in the '80s. That's really when I think this even became more of a known diagnosis, I guess. We started looking for it a little bit more, I think.

(4) History Taking for Zenker’s Diverticulum

[Dr. Ashley Agan]
Right. When you're talking to these patients, is there anything that's important to ask during that history taking? You mentioned asking about maybe surgery, so like an ACDF, have you had any surgery on your cervical spine? Because that might make us more concerned that there's some sort of traction diverticula. Are there other specific questions outside of your normal questioning that you always want to make sure you ask these patients in particular?

[Dr. Rebecca Howell]
I think it helps more for your relationship with the patient and sort of having them understand that this disease is the timeframe. What brought them in this time? As I said, most of them have had problems from one to three years. In reality, there's something that started or changed in their presentation that made them finally come in. I think that's usually what I think. I think that that's important because that gets to the motivation of the patient, whether they want to do something or not. If they say, "My husband made me come in here," they're not ready for surgery. If they say, "Oh, I had this choking episode," or, "I really hate it when like pills come up the next day," those patients are usually much more open to, "Okay, well, what if, or what could you do?" I think it's important just for, again, patient physician relationship more than red flags. I think, again, knowing your anatomy, looking at your imaging is really, really important. Then again, neck scars, asking at least about neurologic diseases. I think while they're not common enough or not as common in most patients that have a Zenker's, it's still good to know. Because, again, we'll see like down the road if they actually do worse, don't do as well, et cetera.

[Dr. Ashley Agan]
That makes sense. You talked a little bit about the exam earlier with the scope exam and being able to see the pooling of secretions. There's no real way to see the pouch on a clinic exam, correct? It's beyond what we can see with a scope.

[Dr. Rebecca Howell]
Correct. With a normal flexible laryngoscopy, yes. One could argue you could use a transnasal esophagoscopy in the office. Honestly, in reality, I think most gastroenterologists will actually not see these and probably us as ENTs, we might not too. Because the upper esophagus, in that postcricoid space, it's so sensitive. You really have to like go quickly past there because that's that gag reflex.

I think they're usually missed on endoscopy, especially if they're small. Now, if they're giant, then yes, of course, you're going to see them. By giant, I mean probably greater than three are categories. They weren't ideal, but we did categories of less than one to two, three to four, five to six, or more. Again, once you're getting into the three to four category, then you probably would see it on most endoscopies.

[Dr. Ashley Agan]
That's interesting. That means if a patient comes to you and they're like, "Oh, yes, I had an EGD, had an upper endoscopy, it was fine," they may still have a Zenker’s that just wasn't seen.

[Dr. Rebecca Howell]
Absolutely. Again, admittedly, because I'm a specialist and this is the group of patients that I love to see. I do get that history a lot. It's fairly common. Again, it just is. It's not a bad thing. It's not a misdiagnosis. It just is. To be honest, for most patients, I do a fair amount of transnasal esophagoscopy in the office, but I usually order a swallow study first just because again you could miss muscular issues. You can miss certainly dysmotilities. HRM manometry is the better test for that. Again, it's more in the research field right now from a Zenker’s perspective. I think there'll be more to come and I think it'll give us a better understanding of why people develop these in the first place, why they get the CPMD.

[Dr. Ashley Agan]
Because the pouch, I guess if it's not full of food, it's collapsed anyway. It could be really easy to not see that space if it's-- it's a potential space if it's not full of anything.

[Dr. Rebecca Howell]
Yes, exactly. It's like a collapsible balloon and that's how I describe it to patients in the office. Particularly when they come in and they're like, "Well, I had an EGD and it didn't show anything." You can't always see it if you don't put enough insufflation. Insufflation of air, or in this case barium, then you can actually see these things. Otherwise, it's quite easy to miss.

(5) Visualizing Diverticula with the Help of Swallow Studies

[Dr. Ashley Agan]
Moving on to the imaging, you mentioned barium swallow studies. Do you like to get a modified barium swallow study or I guess video fluoroscopy, whichever term you prefer? There's probably other names of it as well, but I feel like I usually get that one because it also tells me more about other swallowing types. If it's not a Zenker’s, maybe it tells me more about the patient swallow in general. Whereas an X-ray esophagram really is just a picture of the outline of the esophagus with barium. How do you think of it?

[Dr. Rebecca Howell]
I think you've hit it on the head. Swallowing imaging in general, we have a lot of work to do there. I think that there's a lot of opportunities there to be able to really understand it and to do it better. As part of the database, we use an esophagram. The reason for that is because, again, looking for lower esophageal issues and because it's widely accessible. It's widely accessible. It's fairly standardized across the nation. That's why we chose the barium esophagram, but it's not because I think it's the best tool from an outcomes perspective.

I think it's a good thing just to be able to rule and rule out, get a better sense of what, again, the lower esophageal function is. I think you're right. I think the modified barium swallower video fluoroscopy gives you much better detail of the UES and the pharyngeal components. Again, the challenge there is it's still not truly standardized. if you do the MBSImP protocol, it is. Our university is finally standardized, finally, but my community partners, they're still not.

It's not uncommon to, and I'm sure you've seen this too, Ashley, you'll get a report back that says no aspiration or penetration and that's all you get. I've had conversations with my radiology colleagues and I've told them like, "I already know if they're aspirating. I don't need you to tell me that. I need you to tell me how to stop it." That's where I think modified barium swallows really, or video fluoroscopy, changes how we think about patients. Again, from my speech pathology colleagues, we've worked very closely, but it gives you a better sense of what's actually happening in the rest of the pharynx.

[Dr. Ashley Agan]
Is the limitation just the availability of a speech-language pathologist to do it? I know at our institution that the speech therapists are the ones who do the modified barium swallows. Does not everybody have the personnel to be able to do it or the expertise?

[Dr. Rebecca Howell]
I think it's a good question. I would assume that most hospitals would have a speech pathologist that's at least on board. There are state-to-state laws on who has to read these and who has to be in the room. We just found this out because I just got my credentials for video fluoroscopy at UC. In the state of Ohio, a physician has to be in the room. Can't be an APP. Can't be anybody else. For the actual start and stop of the machine, it has to be a physician. It has to be a licensed provider, a licensed physician.

Yes, a speech pathologist has to be there, but you also have to have-- again, this is state to state. State to state it is a different algorithm. Again, it's still not a standardized test. sometimes you'll get one swallow. Sometimes you'll get one thin and one cookie. It just really depends. It's not a true standardized practice. I think we are evolving in that direction and hopefully, we'll get there, sooner than later. I think that there's still a huge amount of discrepancy in the videofluoroscopy. To your point, I think it's probably a much better outcome metric.

The Davis Group had written about the PCR, the pharyngeal constriction ratio. I think that that probably is a better metric of how open or closed, if you will, the UES becomes particularly after surgical treatment. Manometry might be a really interesting one too, because I think like you're saying, I think that the pharynx also has a component too. Really having a better understanding of the different pressure differentials from the pharynx to the UES to the esophagus, I think will really in the future, I think, guide us a little bit more towards which patients need what types of surgery.

[Dr. Ashley Agan]
There's still a lot of potential in that area, it sounds like. Once you get your imaging and you are able to see that it does appear that there's a Zenker’s diverticulum there, can you describe a little bit about what you're seeing, what that looks like? I feel like it's always really ripe for tests because it's the classic picture. You'll see that outline of the pouch. Any other things that you're looking for when that, or is it pretty much just like, "Aha, there it is." Let's talk about what we need to do now.

[Dr. Rebecca Howell]
Again, I look for hardware, any sort of hardware that's on the spine. Then the other thing, I think you always need an AP and a lateral view. Whichever test you're looking at, I think you need both. It depends on how big they are. Sometimes you can actually miss them on a lateral. If it's really big, then it just obscures the whole thing. Then all of a sudden you switch them to an AP and you realize, "Ah, this is coming off the side." The other thing is you can also tell a Killian-Jamieson. Killian-Jamieson usually are more narrow-necked and they're below the cricopharyngeus muscle, which is different from a Zenker’s.

A Zenker’s is going to always be above the CP muscle. Those are the things that I look for. An AP, a lateral, and then if there's any, again, hardware. Again, I always look at secondary esophageal. Do they have a giant hiatal hernia? Do they have a paraesophageal? I've had a couple people now that have had giant paraesophageal hernias that as expected you operate on their Zenker’s, some of their symptoms get better. The regurgitation does, but they still have swallowing problems. Then you go and get their hiatal hernia and they feel like a million bucks.

[Dr. Ashley Agan]
Have you looked at the incidence of reflux? Do most of these patients have heartburn reflux problems too?

[Dr. Rebecca Howell]
We did. I think one of the challenges and you guys did a great podcast on LPR. There's a lot of challenges in what reflux is. The majority of patients do say that they have had a history of reflux. I'll be honest, Ashley, I have a history of reflux too. I'm not sure that it's super specific to anyone. I also tell patients, I say, "If I overate and had a margarita and a burrito, I'll get reflux." It's not super specific. I do think most of them they do say that they have had a history of some sort of reflux. I think that's the challenge is for us as clinicians too is like sometimes I think the pendulum has swung far in the other direction.

Then the other thing is even again to our colleagues in gastroenterology, sometimes I'll send patients for an evaluation for reflux and they send them back with an EGD that says they don't see reflux. That's not the test for reflux. That's like me telling people looking at a laryngoscopy and saying, "You have reflux. You have signs of reflux, but you don't have a diagnosis of reflux. I'm suspicious you have it. You have signs of acid reflux." You can use the RFS. I know that everybody has problems with that one, but still, nonetheless, it's the same idea. If you look at the esophagus, you can say, "Yes, you have an abnormal Z line," but you can't say anything more than that.

(6) Observation as a Management Option

[Dr. Ashley Agan]
Yes, it's tricky. You've seen your patient, you've gotten the imaging, and now you're having that discussion about treatment, about the patient who's ready to maybe do something, or maybe even the patient that's not ready to do something. I think a lot of us we know as far as surgical treatments and open and endoscopic. I guess before we get into those, is there anything to do from a non-surgical standpoint? When a patient's not ready for surgery, is there anything that helps it not progress, is there anything else to do, or is it just like, well, at some point we might be talking about surgery again?

[Dr. Rebecca Howell]
It's a good question. I tend to take the observation approach. I've sent some of them to my speech pathologist too for some swallowing therapy, and they said that's not really useful. We've dabbled in it. We've tried it. I don't think it really does much. What I'll usually do is just tell people like, "Hey, why don't we just have you come back in six months? Let's see how you're doing. We'll have the conversation again. In a year, we'll repeat your imaging and see if there's any difference." I think it'll be a really interesting cohort of patients to be able to look at like the ones that opted not to have surgery and sort of how they change over time.

Our database has been open since 2017, so we've got a good five years of data, but again, it just takes time just to first accumulate them and then watch them long-term. I think it will depend. I think observation is always an option. That's what I tell them. Again, I think to get better buy-in, it's better to be honest with patients. I tell them, I'm like, "Listen, this is not cancer. You don't have to have this done." The other way that I explain my practice to patients is I tell them that I'm not a quantity of life doctor, I'm a quality-of-life doctor.

"This is not going to extend your life, but it's going to make you enjoy eating and enjoy going out to dinner and enjoy being around company rather than becoming fearful that you're going to choke." I think when you phrase it in that way, I think patients are a little bit more open too. Even when they come in thinking like, "I'm just going to hear it, but I'm not interested." I think if you phrase it in a way that is more palatable, then it's an easier conversation. I think just the surgery or not surgery, that's sort of how I think about it and how I counsel them.

[Dr. Ashley Agan]
Some patients need to hear it more than once and think about it a little bit longer and takes time. Do they need to be observed if a patient's like, "You know what? I'm good. I'll let you know if I need you, but I'm going to go on my way." Is that okay too or do they need observation for any particular reason?

[Dr. Rebecca Howell]
I again, can't say for sure, but I think it's fine. I've told patients like, "Hey, I'm here if you need me." I've done that for a variety of different voice and swallowing disorders, not just this particular one. Yes, I don't think there's anything wrong with reaching out to their PCP and just saying like, "Hey, we had this conversation. They do have a Zenker’s. It's not bothering them right now, but I would be happy to see them if it does." I've had that happen. I've had a couple of patients that have said like, "Oh, I'm okay." They have physician, children or family members. Some of them do and some of them don't. I've had a couple that have just passed with their Zenker’s and that's okay too.

[Dr. Ashley Agan]
You basically let them know like, I guess, red flag types. If you start losing weight, if you start being hospitalized for pneumonia or things that are more serious, maybe it's time to talk about this again, that sort of thing.

[Dr. Rebecca Howell]
Exactly. I even have a dot phrase on my Epic that is the red flags of dysphagia and that is you've hit them all. It's unintentional weight loss, aspiration pneumonias. The third one that I really tell people is if you stop eating a certain type of food, or if you stop enjoying eating, then that's probably also a sign.

(7) Improving Patient-Reported Outcomes with Surgical Management

[Dr. Ashley Agan]
Transitioning then to our patients who are ready, I want to do something about this, help me enjoy eating again. What does that conversation look like, and how do you decide who is a candidate for an endoscopic approach versus an open approach?

[Dr. Rebecca Howell]
This is my favorite question. I just presented this data at trial and it is going out this weekend actually. We have an outcomes paper that actually looked at endoscopic versus open. What we've found is that when you look at raw data, so if we use those EAT-10 scores, which is what we've used as an outcome marker. In general, they all do well. When you actually look at percent change, so one of the things that we really notice is that it's not a homogenous group. They don't all show up with the same EAT-10 score.

In order to sort of normalize their pre-op EAT-10 score, we looked at percent change. When we look at raw data alone, then open actually does a little bit better, statistically significant between the two. When you change it to percent change, there's no difference. There's no difference whether you do it endoscopic or you do it open. When we look at the whole cohort, so 66% of people will do 100% better. 88% of patients will do more than 50% better on their EAT-10 scores. What I think is fascinating about that data is, number one, as surgeons, they're not all home runs. 66 is pretty good, but they're not all home runs.

There is definitely a tail on our histogram that there are patients that just they don't do well. Even 50% I think is probably still-- I would look for more, but that's two standard deviations. 50% improvement in scores is still reasonable. Again, to that there's more to this disease than just the pouch. The pouch isn't there because of dysphagia. I think they have dysphagia, then they get a pouch. Not everybody is going to get 100% improvement. Endoscopic and open, they both work. When we look at percent change, it doesn't matter. The other, I think, hot topic and this will be down the road, we'll certainly understand it a little bit more, but there's flexible techniques.

There is the Z-POEMs. That's another hot one now too. I think it will be great to now have a number to be able to actually compare them because I think before all you could do is say, "Oh, yes, they're better." That's really why I did this study was because-- I've challenged even my colleagues and said, "Well, most studies, they're retrospective," and they say, "Okay, well, if the patients didn't come back to the office, then it must've been a success." Patients don't come back to the office also if they're pissed off. There's two reasons. We can't discount the other one.

Again, what the data has shown though, is that they do do better. It's still a surgical disease. It does well. I think a lot of it is, it depends on what tools are good in your hands. I think this whole concept or notion of like, everyone gets an open, or everybody gets an endoscopic, it's null. I think both have value. Really what this shows is surgeon preferences. We looked between endoscopic and open, we looked at gender of patients, age of patients, size of diverticulum, starting EAT-10s, also we looked at whether they had already had a history of recurrence. The only factor that made any difference in a surgeon's decision to do an endoscopic or an open was recurrent disease.

Meaning that when patients come to the office and they say, "I've already had a Zenker surgery," the tendency is then to do more opens. That's actually counter to-- there was a retrospective study, a group of four different institutions that pooled all of their revision cases and they still did more endoscopic. Again, not perfect, but I think it's very interesting that it's not as distinct as I would have thought. I would have expected that younger, patients with bigger diverticula tended towards open, but it's not what we do. We do what's probably best in our hands.

[Dr. Ashley Agan]
You mentioned Z-POEMS. What is that? I haven't heard of that one.

[Dr. Rebecca Howell]
POEMs is a peroral submucosal resection endoscopic musclectomy. You're taking down the muscle. Mostly it's for achalasia. That's what it's really been done in. Then they've adapted the same surgical techniques to Zenker's, to the UES. It's a submucosal tunneling. You inject some saline with some dye. It opens up the space. This is all done endoscopically. Then within this submucosal tiny little incision, then you take down the muscle. It's interesting. I think flexible techniques too, or hybrid techniques. Lots of people do various different hybrid approaches.

Some staple, some laser, some flexible, some laser. There's lots and lots of different ways to skin this cat. Again, I think it'll be interesting down the road to actually be able to at least try to compare them a little bit better, especially when you can do it prospectively. Retrospectively, as I said, it's just really hard because your outcome measure to this point has been having another surgery, not coming back, or like a complication. Complications are important, but it's not an outcome measure. It's an important thing to consider.

(8) Surgical Techniques for Zenker’s Diverticulum

[Dr. Ashley Agan]
When you're talking to patients about what type of surgery you're going to do, is it shared decision-making about whether it's going to be open or endoscopic? Or do you say, "Hey, I think in my hands, this is going to be a really great slam dunk endoscopic case," or what does your conversation look like with them?

[Dr. Rebecca Howell]
Ashley, my surgeon bias is young patients. If patients are-- so definitely in their fifties or sixties is still a little bit young, not too young, but if you're in your fifties, for sure. If they have a really big diverticulum, I usually recommend an open approach. Again, the three to four is borderline for me, but if they're five to six, then I do, I recommend it.

[Dr. Ashley Agan]
Five to six centimeters?

[Dr. Rebecca Howell]
Those are my own biases. Those are the ones that I tend to tell them to do an open and recurrent ones as well.

[Dr. Ashley Agan]
The rationale for that is that you just have better exposure, better ability to feel like you're treating it comprehensively.

[Dr. Rebecca Howell]
I think in recurrence, it just means that they've got like a different disease, is sort of how I think about it. Now, one could argue, and certainly I've been there that maybe-- especially with stapler, so it has been shown even through meta-analyses, et cetera, that laser tends to be better than stapler, which I think makes sense just because you're going to do a longer myotomy. Sometimes those staplers, people will do all kinds of different things to figure out how to cut the end of the stapler, et cetera, et cetera.

Sometimes it doesn't get all the way down, so you leave a little bit of a lip of that CP. Who that's important in and who it's not, I'm not sure. It's tough to say, again, this is what we're looking at, which is how much better should you be. Again, in my mind, I think of the recurrent patients as having a different type of disease. Yes, it's still called a Zenker’s, but I think there's probably something else more underlying that caused them to have it again.

[Dr. Ashley Agan]
That makes sense. I want to be able to get into the nitty gritties of how you do your endoscopic approach. Take us through everything. Maybe we'll start with the equipment that you need to have to be able to do endoscopic approach. Are you a stapler or are you a laser?

[Dr. Rebecca Howell]
I tell patients I do it all, which is honestly the truth. I tell them, "The patient chooses the tool." I have a bunch of different ones. I'm very comfortable with using all of the different ones. It just depends on my exposure. I think the exposure is really the key if all other things equal. We have a Wierda. To be honest, I don't use it very often. I usually end up using the Benjamin or what we call the Slimline. It's just easier, it's gentler, it's more narrow.

I think we probably cause less pharyngeal lacerations definitely if trainees are involved for sure. I have both of those scopes that are available for every Zenker’s that I do, but I tend to just use the Slimline. I was using the Wierda more for the stapler. I've gotten away from using some of the staplers just because again, as they've made different modifications to them, because we're using laparoscopic instruments, which are giant. They're just huge. I think that stapler is probably safer, probably less complications when we get into the weeds of that data then we'll see.

So far even between endoscopic and open, the numbers are so small for complications that you can't even do any statistical significance of them. Yes, you do get more leaks with an open approach versus an endoscopic, but you do get crepitus. I've gotten them all. You do a lot of surgery and you get all the complications. Those are the two rigid scopes that I use. I also always have a flexible esophagus scope available to me. I don't necessarily always use it, but I always have it available. It doesn't have to be a TNE. It could be just a pediatric gastroscope or it doesn't matter.

Whatever you're good with, I think it's useful. Then I have used everything from a stapler to-- I do like the CO2 laser. I also have used the ligasure lately. I've done that a couple times as well. I think in patients that you have to hurry up and get them off the table. I always send everybody to a pre-op anesthesia visit. My anesthesia colleagues are great about that. We have very good conversations about how much, how long, how quick, what risks are worthwhile. If patients are like at a higher bleeding risk or something like that, then perhaps a stapler is fine.

Maybe if they have a giant pouch, then a stapler will do most of it. If you get them better, then maybe that's okay. It doesn't have to be 100%. I usually have all of those things together. Lately, I have been using some endoscopic suturing and some TUSIL. I don't know if it makes a difference, I'm not sure. When I do lasers, so smaller pouches, so less than like two centimeters, I think probably a laser is better because again, you can't really engage the tissue, whether it's with a ligature or a stapler. Smaller pouches, I tend to use the CO2.

The other thing that I've been doing a little bit more is I take like a piece of the muscle out. I make a linear incision, but then sort of take that laser underneath the mucosa. Again, same idea as this whole Z-POEMs thing, you'd basically do like a submucosal resection of some of the muscle. Then I put a couple of stitches in. The stitches, I put them in the inferior superior direction. I'm not sure if it makes a difference. One of my partners does it lateral, so who knows? Maybe we'll find a difference later, but I don't know.

[Dr. Ashley Agan]
What are your settings on your CO2 laser?

[Dr. Rebecca Howell]
That's a good question. I've gone back and forth between using the AccuBlade and using a DECA. Lately, I've been using a DECA. I tend to do a more shallow, so I'll do a line first. I'll start on a line. I usually use a pulsed setting. Then again, I tend to go a little bit slower, so I'll use like a 0.1 and we'll do like even a depth of one millimeter. I tend to go a little bit slower. The reason, if you go faster, you get more bleeding.

I think when you let that tissue just cool and you just go slower, ultimately it's like a tonsil. You'll ultimately do better if you just take a little bit of extra time rather than blowing through all the muscle, and then you have to go deal with all the bleeding. Yes, I have really liked using the DECA and then I'll use it on what's called a milling setting to actually do some of this musclectomy, take a big chunk of the muscle out. As soon as you start to see that buccopharyngeal fascia, you got to slow down.

[Dr. Ashley Agan]
That's my favorite part of these cases. I feel like it's so beautiful when you're just watching the fibers come apart as you're coming through with a laser. It's very elegant surgery, I feel like.

[Dr. Rebecca Howell]
It's beautiful.

(9) Navigating Difficult Surgical Exposures

[Dr. Ashley Agan]
Yes. We talked about the scope. Do you ever have patients' difficult exposures? Any tips for patients who might have mandibular tori, or small mandible, or poor neck extension? Maybe they've been radiated for something. How do those types of considerations come into your thoughts about how to do the case?

[Dr. Rebecca Howell]
I talk to patients in advance about what do you want me to do if I can't do it endoscopic. I've done some of the hybrid flexible approaches too. Again, same thing. I think it's still good and it's good in your hands. What the flexible has shown is that people tend to have to have a couple of surgeries to be able to really get all that muscle versus, again, getting a good rigid or open exposure than you do it in one shot. Is that good or bad? I'm not sure, but it is what we know so far. What was my question? Oh, the difficult exposures. Yuma is actually just looking at this. She's using the database with me and we're looking at predictors for this.

In the pre-op evaluation, I look for it and then we talk about what if. What I do because I use all kinds of different techniques is I tell them, "Okay, do you want me to wake you up and do nothing?" Sometimes I'll talk to them about, we could do Botox in a stretch, we could do Botox in a dilation, or we could do open. If I can't expose it and I tell them 90% of the time I can do the exposure. It's fine. It goes the way that we want it to. What is your preference? Again, I think it just depends on how you frame it and who they are. Some patients are just not great candidates and they say, "No, if you can't do it, you can't do it." I would say the majority, when you lay it out for them, they say, "Fine, just get it done."

[Dr. Ashley Agan]
I hadn't thought about Botox. That's a good thought. You do Botox into the CP muscle to just hopefully help that to relax so that food will go there instead of into the pouch, basically.

[Dr. Rebecca Howell]
Exactly. Again, for smaller pouches it's reasonable. It's a reasonable option. I think bigger pouches, again, you probably won't get quite as much bang for your buck. I think it's an easy enough one that if you can at least see your CP, but you just can't quite engage those scopes enough for a laser, a stapler or what have you. Then I think Botox and a dilation are reasonable options, and then you can always see how they do and it's a minimal risk.

[Dr. Ashley Agan]
Do you have any preference on the size of the tube as far as the tube that anesthesia uses? I assume if you're going to use a laser, you use a laser tube. Do you care what size it is or any preference on that?

[Dr. Rebecca Howell]
I don't think it matters too much. I tend to and my anesthesiologist just know that I tend to use smaller tubes. We don't ever use anything bigger than a six and a half. 5-0 is like my go-to. It probably doesn't really make a huge difference as far as exposures and things like that. I don't think it matters. Again, I tend to go smaller and that's just because honestly, actually I had—

I think it was probably my first year I was doing an esophageal, it was just a dilation on a head and neck patient and anesthesia was intubating. She got a hemorrhage and so then she got a bruise on her vocal cord, which was fine. It always comes back, it's all fine. The patient was so bummed that she went in for her swallowing, then came out hoarse. One of my anesthesiologists said, "Why don't you just do all your own intubations?" I said, "Okay, fine." That's what I do.

[Dr. Ashley Agan]
That was that.

[Dr. Rebecca Howell]
That was the end of that. I do all my own intubations. I pick my own tubes and tell them what I'm going to use.

[Dr. Ashley Agan]
I love it. That's great. Assume we're talking about the laser patient. You have the endoscopic suture that passes that needle back and forth through the tissue. How many stitches do you need to do? How many passes?

[Dr. Rebecca Howell]
One good one is usually enough. If you still see a hole or something, then I'll put two and then I use to seal. Again, I can't tell you that any of it necessarily is necessary, but it makes me sleep better at night.

[Dr. Ashley Agan]
Any tips on how do you tie that knot? Do you have like a knot pusher?

[Dr. Rebecca Howell]
I don't end up using a knot pusher. We just do hand ties and then it's a really good and humbling experience for my residents, especially. I tie that knot outside the scope and then usually I just use like an alligator trick is just lubing it up. Putting a lot of either ointment or lube on both your stitch and on your alligator and then you just push that knot down. It usually works a little bit easier because otherwise you have to thread the needle through those knot pushers and you just spend so much time doing it. I tend to skip it just because it takes forever.

[Dr. Ashley Agan]
How many knots do you throw?

[Dr. Rebecca Howell]
Three. As long as it's staying down again, then I think it's okay. I used to not do it at all, but when I started to get a little bit more aggressive with taking more muscle, that's really when I started to do the stitch with it.

[Dr. Ashley Agan]
The stitch comes across where that defect is to help that close a little bit better.

[Dr. Rebecca Howell]
Just keeps your mucosa together. This is all trends. We're going to present this data at COSM. It's how I do it, but I keep people overnight. Regardless whether they're endoscopic or open, I treat them the exact same. They get ice chips for post-op day zero. Then in the morning, if no crepitus, nothing else is going on, then they get liquids in the morning and then they get soft foods for lunch.

If they're still good, then they get to go home the same day. If they have an open approach, if they've met all those metrics, then we take the drain out right before discharge. I don't do a swallowing test just to check. I don't do it if they have a leak and I think that they have a leak. I'll just keep them NPO for an extra day or two first. If it's still concerning, then I'll get the swallow test.

[Dr. Ashley Agan]
Most patients, if everything goes according to plan, they're going home the next day. They're basically staying overnight, 23-hour obs. Once they go home, are they free to eat whatever they want, or do you keep them on a more restricted diet for a certain amount of time?

[Dr. Rebecca Howell]
I tell them to do a soft diet for two weeks. I tell them, "Whatever you were eating before is probably okay. Things that were getting stuck before, don't try them in the first two weeks." I'll often tell them, "Okay, cooked carrots are fine. Raw carrots, probably too much. Fried chicken, we're close to Kentucky. Don't do it. Shredded chicken, fine." Those are sort of my criteria. "Ground meat, okay. Don't go get a steak or at least not a cheap one."

[Dr. Ashley Agan]
What red flags are you telling them to look for? "If this or this happens, you need to call me." What's that conversation going?

[Dr. Rebecca Howell]
Ashley, I don't even have it. Once they get out of my 23-hour window because that's what I tell them, like my complications. I think I've had one guy come back that ended up having-- it was just a wound infection. He had an open approach and had a delayed wound infection. Knock on wood, if they get out of that first 24 hours, it's going to declare it right away. I don't even bother having that conversation with them.

[Dr. Ashley Agan]
Don't even put that out into the universe.

[Dr. Rebecca Howell]
I tell them like, "You make it through my criteria, you're good. By the next day, you can go and you're fine." So far so good. Knock on wood.

[Dr. Ashley Agan]
The patients that are going to have trouble have it in that first 24 hours is what you usually see?

[Dr. Rebecca Howell]
They do. In my experience, yes. As I said, actually we're looking at the data now to see what does everybody else do? What does it look like? What should we be doing rather than me just saying like, "This is how I do it." Let's be honest, it's a lot of like otolaryngology training to this point.

(10) Complications of Surgical Repair

[Dr. Ashley Agan]
As far as getting into the complications of the bad things that can happen, what do you counsel patients on as far as what can happen in that first 24 hours after surgery?

[Dr. Rebecca Howell]
I tell all of them, "I am intentionally cutting your esophagus." A hole in the esophagus, that's the biggest one. That's what I'm watching for. That is the complication that I'm looking for. I tell them, "Usually it presents with, you have some swelling of your neck." Sometimes air gets in. I said, "We're going to push on your neck for the next 24 hours." Just palpating for crepitus is really what I end up doing.

The drain for the open folks, I just make sure that it's serosanguineous. Again, that comes out right at the end because it's also there for a leak. It's not just there for a seroma or hematoma, but it's really there in case they have a leak. Because then you just have to wait, which is incredibly painful and nobody wants to do it. At least you already have your drain there, it's already done. You just have to give them some time.

[Dr. Ashley Agan]
For your patients who you do feel some crepitus, you tell them we're not going to eat anything for a little while. What do you do next?

[Dr. Rebecca Howell]
I usually give them an extra day. I give them one more day of NPO.

[Dr. Ashley Agan]
Completely NPO?

[Dr. Rebecca Howell]
Yes. Again, if they have crepitus in the morning, they don't get started on any of the diet. If they started a diet, we stop their diet. We make them NPO. I make them NPO for usually one to two days, and then see if the crepitus resolves and it goes away, then we restart. Then I do the liquids in the morning. We do the soft foods at night. I would say if it's more than two days that they're still having fluoride crepitus, then just wait. Plus or minus a swallow test, although you already know they have a leak. I think they probably do need an alternative source of nutrition.

If they're open, they have a drain. Even if it's endoscopic, it depends. If their neck doesn't look infected, they just have the leak. Because you can have a clean leak, a hole, but it's not causing an infection. In those cases, then they just need an NG tube. Sometimes that's a little tricky though, because again, whether you put it in-- I've done both. Sometimes our folks will do it, we could do it under fluoro, or we do it like in the IR and just go do it and put it in just to, again, make sure you're not going through the hole. You don't want your NG tube going into the mediastinum.

[Dr. Ashley Agan]
Does it just depend on how big the incision was, your decision to put it in under direct visualization versus letting somebody else do it?

[Dr. Rebecca Howell]
I think it just depends. I think it depends on your situation. How much do you trust your institution and your colleagues to be able to do it like under fluoro or under IR versus just doing it yourself? I think it really depends. It depends on the patient. if they look like they've got an infection, that's different. You're going to go wash them out anyways, so you're going to wash them out, so you might as well just put the NG tube in yourself. I think that the clinical dilemma is those patients that they don't have an infection yet. I do put them on antibiotics, though.

[Dr. Ashley Agan]
Does everybody get antibiotics or only if they have crepitus?

[Dr. Rebecca Howell]
My open patients, I'll give them three doses while they have a drain. As soon as the drain comes out, they're done. My endos and opens both get a pre-incision dose of antibiotics and that's it. I don't give them anything prophylactic. If I really think there's a leak or if we've proven that there's a leak, then they're on antibiotics.

[Dr. Ashley Agan]
Do you have an antibiotic of choice?

[Dr. Rebecca Howell]
I usually do Unasyn or clinda, one of the two of those. Then we just wait. Again, if they've got a fluoride leak, like you haven't been able to resolve it quickly within those first couple of days, because usually, that's just like a pinhole. That'll close up pretty well and easily on their own. If they've got a big defect, and I've had them, it happens, then you're better off just like giving them two weeks rest. Put a feeding tube in, let them sit, hold their hand through it, but like don't test them, don't do anything. Just give it two weeks and then test them and see. I usually just send them for a leak test. I'll send them for a leak test, see how they do, and then go from-- it's incredibly defeating.

[Dr. Ashley Agan]
This has been really fantastic, really comprehensive talk about Zenker's diverticulum. Any final pearls or parting words, anything to leave our listeners with, anything that I have failed to ask about that you feel like is important for people to know?

[Dr. Rebecca Howell]
No, Ashley, I think I've given you all my tips, tricks, pearls, and questions for the future. More to come. It's been a ton of fun. Thank you so much for having me.

[Dr. Ashley Agan]
Yes, awesome. If people want to find you or learn more about you, any websites or social media or anywhere to send them to?

[Dr. Rebecca Howell]
We are on Instagram. We've got an Instagram account that's UC Voice and Swallow. I am on LinkedIn as well. Otherwise, I will tell you, I'm not a great social media person.

[Dr. Ashley Agan]
I'm not so great at it either. All right, awesome. Thank you. Thanks again for taking the time. It was great. Appreciate it.

[Dr. Rebecca Howell]
Wonderful. Thanks, Ashley.

Podcast Contributors

Dr. Rebecca Howell

Dr. Rebecca Howell is the division chief of laryngology at University of Cincinnati in Ohio.

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, March 28). Ep. 99 – Management of Zenker’s Diverticula [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.