A 76-year-old man with multi-infarct dementia comes to the emergency department due to cough and low-grade fever. He was treated for pneumonia twice in the last year. For the past 6 months, he has had difficulty swallowing and has occasionally regurgitated undigested food. The patient has a lengthy history of hypertension and chronic atrial fibrillation. BMI is 22 kg/m². Temperature is 38.5 C (101.3 F), blood pressure is 150/95 mm Hg, pulse is 102/min, and respirations are 16/min. Physical examination is notable for foul-smelling breath and a fluctuant mass in the left neck. Auscultation shows crackles in the right lung base. Chest x-ray shows an infiltrate without cavitation in the right lower lung field. The patient is admitted to the hospital, sputum and blood cultures are sent to the laboratory, and antibiotics are started. A few days later, the patient's condition is markedly improved. Which of the following is the most appropriate next step in management of this patient?

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11ec25c8_d90f_7adc_bc81_c5a1ebfbdbf1_MD0003_00 Recurrent pneumonia in an elderly patient with dysphagia and regurgitation of undigested food raises strong suspicion for a Zenker diverticulum (ZD), a pouch posterior to the esophagus that forms due to herniation of the esophageal mucosa through an area of muscle weakness. ZD presents with an insidious onset of progressive dysphagia. Trapping of food in the pouch can lead to halitosis. Patients often regurgitate the undigested food or medications several hours after eating, which can lead to aspiration and recurrent aspiration pneumonia. The pouch occasionally becomes so large that it is palpable, as in this patient. Zenker diverticulum A swallow study with contrast esophagography confirms the diagnosis. In this study, serial x-rays are taken of the esophagus after the patient has ingested a radiopaque contrast solution. In ZD, contrast is retained in the pouch. Despite the risk of pneumonitis due to aspiration of contrast, it remains the test of choice for diagnosing ZD because it is the only study that provides information regarding both the anatomy of the pouch (eg, size) and the functional impact of the diverticulum (eg, aspiration, esophageal obstruction). Treatment is surgical (cricopharyngeal myotomy ± diverticulectomy). (Choice A) Bronchoscopy is generally indicated if there is concern for an obstructing mass that could cause recurrent pneumonia in the same anatomic location. Even then, CT scan of the chest is the preferred initial study. (Choice C) Placement of a gastric feeding tube would be premature in this patient because surgical treatment of ZD will likely improve the aspiration. (Choice D) A neck mass in an adult is often suspicious for head and neck cancer. However, such masses are typically firm, whereas in the context of regurgitation of undigested food, a fluctuant mass is likely a very large ZD. Biopsy could therefore lead to esophageal perforation. (Choice E) Upper gastrointestinal endoscopy is not as sensitive as esophagography for detecting ZD because the openings of small diverticula may not be visible. Esophagography also yields more information about the functional impact of the diverticulum. Furthermore, endoscopy can be confusing or even risky if the cannula inadvertently enters the diverticulum during the procedure. Educational objective: Recurrent pneumonia in an elderly patient with dysphagia and regurgitation of undigested food raises concern for a Zenker diverticulum, which may occasionally present with a palpable mass. A swallow study with contrast esophagography can be used to confirm the diagnosis. References: Pharyngeal pouch (Zenker's diverticulum). (http://www.ncbi.nlm.nih.gov/pubmed/11470929) Zenker's diverticulum: aetiopathogenesis, symptoms and diagnosis. Comparison of operative methods. (http://www.ncbi.nlm.nih.gov/pubmed/24868270)

A 76-Year-Old Man with Multi-Infarct Dementia Comes to the Emergency