Recallab › Question bank › Surgery › The Oesophagus › #50170
Zenker's diverticulum
A 72-year-old man has six months of difficulty initiating swallowing, gurgling in the neck, regurgitation of undigested food hours after meals, and halitosis. He has had two episodes of aspiration pneumonia. Through which anatomical weak point does the responsible lesion protrude?
- A. The oesophageal hiatus of the diaphragm
- B. The Killian-Jamieson area, below cricopharyngeus
- correctC. Killian's dehiscence, between thyropharyngeus and cricopharyngeus
- D. Laimer's triangle, below cricopharyngeus posteriorly
Explanation
Key fact
A pharyngeal pouch herniates through Killian's dehiscence - the gap between the oblique thyropharyngeus and the horizontal cricopharyngeus.
Killian's dehiscence. It is the weakest point of the posterior pharyngeal wall and lies immediately above the cricopharyngeal sphincter.
Why
Inferior constrictor has two parts with fibres running in different directions.
Thyropharyngeus runs obliquely; cricopharyngeus runs transversely.
Between them is a posterior area of relative muscular weakness.
Failure of cricopharyngeus to relax raises the pressure just above it.
The mucosa herniates through that gap - a pulsion, and therefore false, diverticulum.
Killian dehiscence lies between two muscle bellies
Why not the others
- A. The oesophageal hiatus of the diaphragm — is where a hiatus hernia occurs, at the other end of the oesophagus entirely.
- B. The Killian-Jamieson area, below cricopharyngeus — gives a rarer lateral diverticulum, not the classic posterior midline pouch.
- D. Laimer's triangle, below cricopharyngeus posteriorly — is a real area of weakness but is not the site of a Zenker's diverticulum.
Remember
Gurgling, halitosis, and food from hours ago. The pouch fills, then empties when the patient lies down - which is why aspiration pneumonia recurs.
Go deeper
Diagnosis is by barium swallow. Endoscopy is relatively hazardous - the scope can enter the pouch and perforate it - so it is done with care and after imaging.
Treatment divides the cricopharyngeal bar: endoscopic stapling (Dohlman's procedure) or open diverticulectomy with cricopharyngeal myotomy.
Long-standing pouches carry a small risk of squamous carcinoma developing within them.
Bailey & Love's Short Practice of Surgery, 28th ed. (CRC Press, 2023); Dhingra PL, Dhingra S. Diseases of Ear, Nose and Throat, 9th ed. (Elsevier, 2025).