Pharyngeal pouch (Zenker's diverticulum): swallowing problems and treatment

When you swallow, food passes from the throat (pharynx) into the gullet (oesophagus) through a muscular sphincter. NICE explains that a pharyngeal pouch occurs when part of the pharyngeal lining herniates through the muscles of the pharyngeal wall. The pouch forms a pocket where food, liquid and saliva can collect instead of passing into the oesophagus.

NHS Greater Glasgow and Clyde's ENT referral guidance describes it as a rare herniation of the pharynx where foodstuffs can accumulate. NICE's account of the procedure explains that the part of the sphincter muscle implicated in pouch development lies in the septum between the pouch and the oesophagus, which is why many treatments divide that septum.

NICE lists the presenting symptoms as dysphagia (difficulty swallowing), regurgitation of undigested food, halitosis (bad breath), hoarseness and chronic cough. The Glasgow guidance adds that regurgitation of food hours or days after eating, with or without dysphagia, can be a symptom of a pharyngeal pouch, that some people have a wet-sounding voice, and that halitosis may be present.

The NHS page on dysphagia lists general signs of swallowing problems: coughing or choking when eating or drinking, bringing food back up sometimes through the nose, a feeling that food is stuck in the throat or chest, and a gurgly wet-sounding voice when eating or drinking. Over time, it says, dysphagia can cause weight loss, dehydration and repeated chest infections.

NICE says that a pharyngeal pouch sometimes causes respiratory problems because of aspiration of the pouch contents into the lungs. As the pouch enlarges symptoms become more severe and may result in weight loss and malnutrition. In a small proportion of patients carcinoma may develop in the pouch.

The Glasgow referral guidance tells GPs to check for recurrent chest infections, which may indicate recurrent aspiration and require expedited referral and management. Most patients with a suspected pharyngeal pouch are referred to ENT on a routine basis, while those with suspected aspiration are referred on an urgent basis.

The NHS advises asking for an urgent GP appointment or getting help from NHS 111 if you or someone you care for has difficulty swallowing, coughs or chokes while eating or drinking, feels like something is stuck in the throat after eating, keeps bringing food back up, has a wet gurgly voice after eating or drinking, is short of breath after eating or drinking, or gets lots of chest infections.

A GP will usually examine you and may refer you to a specialist for further tests, and sometimes to a speech and language therapist or dietitian for advice, according to the NHS dysphagia page.

The Glasgow guidance illustrates a pharyngeal pouch with a lateral view on a barium swallow, an X-ray test using a contrast drink. NICE's description of treatment mentions a diagnostic endoscopy being done at the start of the procedure. A specialist needs to distinguish a pouch from other causes of swallowing difficulty, and the NHS lists several of those, including acid reflux, conditions affecting the nervous system and cancer.

NICE says the traditional treatment for a pharyngeal pouch involves open surgery to the neck. This may take the form of complete removal of the pouch, or division of the muscle responsible for pouch formation, sometimes combined with inversion of the pouch. Endoscopic techniques using rigid endoscopes are also used, in which the wall between the pouch and the oesophagus is divided using diathermy, lasers or a stapling technique.

NICE HealthTech guidance HTG367 covers flexible endoscopic treatment. It says the procedure aims to divide the septum between the pouch and the oesophagus without the neck hyperextension that may be necessary with a rigid endoscope, can be done without general anaesthesia (under sedation or general anaesthetic) and may be particularly useful for older patients with significant comorbidity or spinal stiffness. More than one treatment session may be needed to achieve adequate division and relief of symptoms. NICE says current evidence is adequate to support its use provided normal arrangements are in place for clinical governance, consent and audit, and that it should only be done by experienced interventional endoscopists with training in the procedure.

The aim of treatment is to restore a clear path for food to the oesophagus so that regurgitation, swallowing difficulty and aspiration improve. Because the NHS notes dysphagia can lead to weight loss and dehydration, nutritional input from a dietitian is sometimes part of care. Recovery details, such as how long you stay in hospital and when you can eat normally, depend on the type of procedure and the hospital, so ask the ENT team for their own written information.

If swallowing difficulty comes back after treatment, return to your GP or ENT team rather than waiting, particularly if you have repeated chest infections or weight loss.

Pharyngeal pouch is managed by ENT surgeons and sometimes gastroenterology or upper gastrointestinal teams. In the NHS, referral is through a GP, and the Glasgow guidance indicates routine referral unless aspiration is suspected. Private ENT clinics may be able to arrange tests and treatment more quickly. As NICE says, flexible endoscopic treatment should be done by experienced endoscopists, so it is reasonable to ask about the operator's experience whichever route you choose.