What Is the Best Technique for Diagnosing Esophageal Diverticulum?

The condition can also lead to aspiration pneumonia. Symptoms can be present for several years before patients seek treatment.

The Gold Standard

Although endoscopic treatment of esophageal diverticula is now becoming standard of care (see sidebar), endoscopic-based diagnosis is not the usual strategy. The gold standard remains the barium swallow, asserted Dr. Postma.

Alexander T. Hillel, MD, a resident in the Department of Otolaryngology-Head and Neck Surgery at Johns Hopkins School of Medicine in Baltimore, who recently co-authored a historical review of endoscopic surgical management of ZD with Department Chair Paul W. Flint, MD, concurred with this approach: At our institution, when we are referred patients who are demonstrating symptoms of dysphagia and in whom a suspicion for esophageal diverticulum is high, we typically order a barium swallow.

But in the offices of Dinesh K. Chhetri, MD, Assistant Professor of Head and Neck Surgery and Director of the Swallowing Disorders Center at the David Geffen School of Medicine at the University of California, Los Angeles, patients with symptoms such as Mr. Landis’s might just as likely undergo fiberoptic endoscopic evaluation of swallowing (FEES) followed by transnasal esophagoscopy (TNE) to diagnose their problem.

During the January 2009 meeting of the Triological Society’s Western Section, Dr. Chhetri and his research assistant Jennifer Long, MD, PhD, presented results of a retrospective cohort review, in which they reported that the finding of esophagopharyngeal reflux (EPR) when performing FEES has a high sensitivity and specificity for the presence of an esophageal diverticulum. TNE is then used to visualize and confirm the diagnosis of diverticulum during the same office visit, and the patient can be scheduled for surgery. I don’t find that the barium swallow is necessary anymore if I can diagnose the Zenker’s diverticulum in my office, Dr. Chhetri said recently from his Los Angeles office. With the knowledge that the pouch is there, I can then go ahead and schedule the patient for surgery.

Dr. Postma, who has published widely on the applications of FEES and TNE, said, When I do FEES and find an abnormality, very often it leads us to another diagnostic test. So, for example, if regurgitation occurs, that person is going to get a barium swallow. Many other conditions can account for the presence of EPR, he noted-including proximal esophageal strictures, severe esophageal dismotility, and tumors. Some small ZDs do not demonstrate EPR, and therefore would be missed if a barium swallow was not obtained. In addition, added Dr. Postma, obtaining a barium swallow allows me to look at the vertebral bodies for the presence of osteophytes. Large osteophytes sometimes make endoscopic exposure of a ZD more difficult.