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These are a series of barium swallow pictures showing the upper and mid oesophagus. Both show a free flow of barium into a smooth-lined pouch at the crico-pharyngeal junction with its mouth facing upwards. There is some amount of barium entering into the oesophagus. The second film shows the pouch with filling defects suggestive of old food particles. These x-rays are typical of a pharyngeal pouch or diverticulum (Zenker's diverticulum).

It usually occurs in the elderly; men are affected more commonly than women (2:1). In the initial stages they present with a foreign body sensation in the throat. As it progresses, they present with repeated attacks of respiratory tract infection due to aspiration of food particles from the pouch. They may complain of regurgitation of food material, eaten in the previous meal, during an unexpected time of the day, and are awakened during sleep by a feeling of suffocation and violent coughing due to the aspiration from the pouch while changing posture in bed. In late stages as the pouch enlarges, they may have dysphagia, because it presses on the oesophagus. They may also come with a gurgling lump in the left side of the neck and rarely with a lung abscess. Typically four stages of the formation of a pharyngeal diverticulum are described.

On examination they are anaemic with evidence of weight loss because of relative starvation. In a third of the cases, examination of the neck may reveal a globular lump on left side which enlarges while swallowing and has a gurgling noise. Chest examination may reveal evidence of aspiration pneumonitis.

The treatment is to perform excision of the pouch with crico-pharyngeal myotomy after pre-operative stabilisation of the patient. Anaemia is corrected; physiotherapy and antibiotics are given to treat the chest infection.

Before starting the operation the pharyngeal pouch is completely emptied by the anaesthetist and packed with ribbon gauze soaked in acriflavine solution. A large bore oesophageal bougie is inserted and left in place so that when the pouch is excised, closure of the pharyngeal defect will not result in narrowing of the lumen.

The neck is opened by a left-sided collar incision at the level of the cricoid cartilage. The pouch is identified by acriflavine colour lying beneath the fascia and behind the pharynx. The middle thyroid vein is ligated and divided. The pouch is dissected from the surrounding area until the lateral pharyngeal wall. It is excised and the defect closed in two layers. If the sac is very small it can be invaginated into the pharyngeal lumen and the muscle is closed with interrupted sutures. Then a complete crico-pharyngeal myotomy is performed. The wound is closed after leaving a suction drain.

Nowadays the ideal procedure is Dohlmans endoscopic stapling diverticulotomy carried out by minimal access surgery usually by the ENT surgeon.

Complication of a pharyngeal diverticulum: Rarely squamous carcinoma can supervene in a long-standing diverticulum.