A 72-year-old man comes to the physician complaining of difficulty swallowing for the last 6 months. He reports that food gets stuck in the back of his throat. His wife notes that he often sounds "gurgly" and has bad breath throughout the day. He has lost 4.53 kg (10 lb) over the last 3 months since being discharged from the hospital with pneumonia. The patient's other medical problems include hypertension, gout, and gastroesophageal reflux disease. He is a lifetime nonsmoker and does not drink alcohol.
His blood pressure is 146/78 mm Hg, pulse is 84/min, and respirations are 14/min. Examination shows moist mucous membranes. There are no oral lesions or cervical lymphadenopathy. Scattered wheezes are heard at the right lung base. The abdomen is soft and nontender.
Laboratory results are as follows:

Which of the following is the most appropriate next step in management?

Question

A 72-year-old man comes to the physician complaining of difficulty swallowing for the last 6 months.  He reports that food gets stuck in the back of his throat.  His wife notes that he often sounds "gurgly" and has bad breath throughout the day.  He has lost 4.53 kg (10 lb) over the last 3 months since being discharged from the hospital with pneumonia.  The patient's other medical problems include hypertension, gout, and gastroesophageal reflux disease.  He is a lifetime nonsmoker and does not drink alcohol.
His blood pressure is 146/78 mm Hg, pulse is 84/min, and respirations are 14/min.  Examination shows moist mucous membranes.  There are no oral lesions or cervical lymphadenopathy.  Scattered wheezes are heard at the right lung base.  The abdomen is soft and nontender.
Laboratory results are as follows:

Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

This patient's presentation is likely due to Zenker's diverticulum (ZD). ZD possibly results from esophageal motility abnormalities and a defect in the musculature of the posterior hypopharynx. The pharyngeal pouch eventually enlarges enough to trap food, mucus, pills, and sputum. Zenker's diverticulum Patients usually present after age 60 with months to years of transient oropharyngeal dysphagia, halitosis, gurgling in the throat, food regurgitation, appearance of a neck mass, and weight loss. Patients may also develop recurrent aspiration pneumonia. Barium esophagram is preferred for diagnosing the diverticulum. Esophageal manometry is not needed for diagnosis but can also show the etiology (Choice C). Treatment of symptomatic ZD involves surgery, but endoscopy to close the diverticulum can be used in highly skilled centers. Barium esophagram (Choice B) CT of the neck and chest is not necessary for diagnosis but may be requested before surgery to further delineate the diverticulum if necessary. (Choice D) Esophagogastroduodenoscopy can diagnose the diverticulum but is risky as blind passage of the scope in the oropharynx can inadvertently perforate the diverticulum. (Choice E) Impedance testing is often used to assess the amount of acid refluxed into the esophagus. However, this patient does not have active symptoms of reflux. Educational objective: Zenker's diverticulum is a pouch formed by pharyngoesophageal wall herniation above the upper esophageal sphincter. Patients usually present with months to years of transient oropharyngeal dysphagia, halitosis, gurgling in the throat, food regurgitation, appearance of a neck mass, and weight loss. Barium swallow is preferred for diagnosis. Treatment usually involves surgery or endoscopy in highly skilled centers. __________ References: Oropharyngeal dysphagia. (http://www.ncbi.nlm.nih.gov/pubmed/19699405) Zenker's diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. (http://www.ncbi.nlm.nih.gov/pubmed/18197932)

A 72-Year-Old Man Comes to the Physician Complaining of Difficulty