Why Would a Zenker's Diverticulum Recur After Surgical Treatment?

Zenker's diverticulum is an extremely rare disorder whereby a pouch develops in the throat leading to food and liquids getting caught causing symptoms of swallowing difficulties and food regurgitation. One of the best ways to address this rare condition is a procedure called endoscopic staple diverticulostomy (ESD).

Unfortunately, with any Zenker's treatment including ESD, there is a small percentage (~10%) that the Zenker's diverticulum recurs typically within one year of treatment (average 8.5 months).

Why might that be?

There are some known (and unknown) issues that may lead to recurrence including:

• Incomplete division of the cricopharyngeus muscle: If the pouch is small, the cricopharyngeus muscle may not be completely divided using the ESD method. It is a shortcoming inherent to the method itself and not a lapse on the surgeon's part. The only way to completely address the muscle when the pouch is small (less than 1 .5cm) is via external approach or use of a laser with its associated increased risk of complications.
• Unaddressed or persistent laryngopharyngeal reflux: Proton pump inhibitor medications are ALWAYS prescribed before and after surgery... even if heartburn symptoms are absent. However, even with such medications, there may be a certain sub-population that suffer from persistent throat-level reflux that may trigger the Zenker's diverticulum to reform. This factor is probably the single most important reason why recurrence may occur within months.
• Loose staples: After surgery is performed, all loose staples are removed to minimize recurrence from this factor.
• Idiopathic scarring of the common wall: Some unindentified inflammatory process leads to restenosis of the common wall.
• Unknown: Whatever factor lead to the Zenker's formation in the first place may cause it to happen again. Indeed, we actually don't precisely know what causes the Zenker's pouch to occur in the first place.

As such, if recurrence occurs years after treatment, it usually will suggest an incomplete cricopharyngeus muscle division. Repeat ESD can be performed with good results.

If recurrence occurs within one year of treatment, I typically will consider the possibility of persistent throat-level reflux (laryngopharyngeal reflux) that was not or incompletely addressed with reflux medications. Before performing ESD again after a recurrence, I will obtain a few studies to determine how significant throat-level reflux may be present.

That typically entails getting a 24 hour multi-channel pH and impedance testing with manometry. The most important result from this study is the frequency of proximal esophageal reflux events and as such, any other type of reflux study that does not include proximal esophageal or hypopharyngeal sensors would be considered inadequate. Ideally, it should be as close to zero as possible. If proximal esophageal reflux events are present, this needs to be thoroughly eliminated prior to revision Zenker's surgery... otherwise, the Zenker's pouch may yet again recur.

Manometry is performed to ensure the cricopharyngeus muscle (if present) is adequately "loose".

Of course, the barium swallow needs to be repeated as well.

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Video of Epiglottitis

The normal epiglottis is a very thin flap of tissue that closes over the windpipe when swallowing preventing food/liquids from going down the wrong way. Shown by the blue arrow in the picture, when the epiglottis becomes infected, it can swell in size to even obstruct the airway leading to death by asphyxiation. Indeed, epiglottitis is what is thought to have killed our first President George Washington.

Fortunately, epiglottitis is quite rare ever since the introduction and regular use of the Hib vaccine in the 1980s. Although rare, it is a problem that still occurs intermittently even today. Each time I've encountered it in the past, I unfortunately was always in a situation whereby video recording of the endoscopic exam was not possible.

Until one day, a patient with epiglottitis did walk into my clinic and I WAS able to video-record the endoscopic exam.

Briefly, this patient developed a severe sore throat with difficulty swallowing that occurred suddenly over a 24 hour period of time. Patient reported the severe sore throat was localized to the base of tongue region.

Without further ado, here's the endoscopic examination both before treatment and than again 1 week later after a course of antibiotics and steroids.

Note the markedly swollen epiglottis before treatment. Even after treatment, the epiglottis is still mildly swollen though much improved. Normal is shown in the picture above.

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Dr. Chang Featured in Regional Newspaper Regarding Balloon Sinuplasty

Dr. Chang was recently featured inside a regional quarterly newspaper regarding balloon sinuplasty in the treatment of chronic sinusitis.

Sinus surgery has come a long way compared to even just 5-10 years ago and great patient experiences after this type of surgery is not uncommon now.

A few key features of sinus surgery of the 21st century that is provided at Fauquier ENT include:

• Nasal packing rarely occurs

• Most patients are surprised by how little pain there is

• No facial swelling or bruising... your best friend won't be able to tell you just had sinus surgery

• Fast recovery

• No incisions on the face or in the mouth

• GPS-like image guidance to make sinus surgery even safer is available
• In select patients, can even be performed in the office without sedation using local anesthesia only

Balloon sinuplasty is a relatively new innovation that allows sinus surgery to even be performed even more comfortably in the office without any sedation (not all patients are candidates).

Such advanced sinus surgery techniques have been available at Fauquier ENT since 2005.

Read more about sinus surgery and balloon sinuplasty.

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Nasal Sounding Speech

There are actually TWO different flavors of nasal sounding speech.

HYPO-nasal speech is due to reduced or no nasal airflow and HYPER-nasal speech due to too much nasal airflow.

HYPO-nasal speech is by far the most common cause of nasal-sounding speech. It is similar to how a person would sound if they pinched their nose shut while talking. As such, ANY anatomic nasal obstruction would by definition lead to such hypo-nasal speech. Treatment, obviously, is to remove this anatomic nasal obstruction whatever it may be either with medications or surgery. Examples of hypo-nasal speech causes include:

• Adenoid Hypertrophy (Very Common)
• Turbinate Hypertrophy (Common)
• Significant Deviated Septum (Uncommon)
• Nasal Polyps (Uncommon)
• Allergies (Common)
• Infection (upper respiratory illness and/or bacterial infections) (Common)
• Rarely, genetic conditions like cystic fibrosis and immotile ciliary syndrome
• Rarely, anatomic conditions such as choanal atresia
• Rarely, a sino-nasal tumor
  

HYPER-nasal speech itself has several different flavors, but the key concept is the presence of an opening between the mouth and nose when it should be sealed shut during speech. Normally, complete closure should occur with certain sounds like /s/, /sh/, /b/, and /p/. Such sounds are called plosives and sibilants. This link provides a cartoon animation of how each sound in the English language is produced from an anatomical standpoint.

Now what are some of the causes of HYPER-nasal speech? Causes can be divided broadly into either anatomic and functional variants.

Anatomic HYPER-nasal speech include:

• Cleft Palate
• Palate Fistula
• Submucus Cleft

Functional HYPER-nasal speech include:

• Velopharyngeal insufficiency without anatomic cause. Velopharyngeal insufficiency or VPI occurs when the soft palate does not seal against the back of the mouth during appropriate speech sounds.
• Poor articulation (person is not correctly pronouncing words)

Treatment of HYPER-nasal speech may include speech therapy and surgery depending on the cause.

Given the subtleties involved in differentiating the different causes of nasal speech, workup typically involves not only just looking in the nose or mouth, but also performing a nasal endoscopic examination.

Below is a video showing a young child undergoing just such an endoscopic exam. Here are some other videos containing audio of abnormal endoscopic exams.

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Bi-Lobed Zenker's Diverticulum

In the not so distant past, I saw a patient who suffered from a bi-lobed Zenker's Diverticulum. Zenker's diverticulum for those who don't know is the abnormal development of a pouch in the throat causing symptoms of phlegm in the throat, food regurgitation, swallowing difficulties, and aspiration.

Most Zenker's Diverticulum is composed of a single central pouch. However, there are more rare varieties such as this bi-lobed pouch seen on barium swallow.

However, at time of surgery (endoscopic staple diverticulostomy), the bi-lobed nature of the pouch essentially disappeared.

Video of how the surgery is performed:

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Motley Crue Bassist Facing Sinus Surgery

Dr. Feelgood may be just a song by Motley Crue, but the band's bassist, Nikki Sixx may be facing sinus surgery.

Per his twitter comment on June 27, 2012:

"Spent a lot of the day at the doctors. The 80s and the damage done. Yes the sinuses are a mess. Eventual surgery. The price we pay."

Typically, before sinus surgery is considered in a patient who is suffering from recurrent sinus infections, a workup is required followed by maximal medical management.

A typical workup includes a CT sinus scan, allergy testing, and nasal endoscopy. If allergy testing is significant, aggressive allergy management is required prior to surgical consideration.

Depending on the CT scan and endoscopic findings, there are two "flavors" of sinus surgery: traditional and balloon sinuplasty.

In traditional sinus surgery, otherwise known as functional endoscopic sinus surgery, is when all sinus disease is physically removed endoscopically from the nose and sinus entrances are enlarged.

Balloon sinuplasty is when the sinus openings are enlarged using a balloon and can potentially be performed in the office assuming no anatomic contraindications (significant deviated septum, nasal polyps, etc).

Exactly what type of sinus surgery Nikki Sixx will pursue is not clear, but regardless of what method is selected, there will be a period of recovery afterwards which almost certainly will include saltwater sinus rinses.

Our office provides both sinus surgery options as well as in-office sinus surgery.

Source:
Nikki Sixx needs surgery for sinus problems. SFGate 6/28/12

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Video on Zenker's Diverticulum Surgery (Endoscopic Staple Diverticulostomy)

Our office has produced a new video describing Endoscopic Staple Diverticulostomy to treat Zenker's Diverticulum.

We have the unusual honor of having treated patients throughout the United States for this rare condition. Patients we have successfully treated have come from as far away as Oregon, New York, Florida, Pennsylvania, Louisiana, Arizona, etc.

For more information, please visit us here.

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Unnecessary Sinus Surgery

A well-respected ENT surgeon, Dr. Salah Salman, recently wrote a book, "Scrubbed Out," critical of the American health system with its links to corporation, powerful lobbies, administrators, and bureaucrats resulting in care driven by money rather than by medical necessity.

In particular, he focuses in one part of his book on endoscopic sinus surgery in the treatment of chronic sinusitis. The excerpt from the book is quite lengthy and I encourage anybody interested to read a lightly edited version here.

In essence, there are a few unscrupulous sinus surgeons who perform sinus surgery for every patient with facial pain and pressure even though there's no evidence for any chronic sinus infection whether on CT, endoscopic exam, and other objective testing.

Indeed, in my practice, perhaps only 10% (if not less) of patients with chronic "sinus" complaints actually have pathology related directly to the sinuses that merits consideration of sinus surgery. More commonly, symptoms suggestive of a chronic sinus infection are more commonly related to allergies and atypical facial pain syndromes (ie, migraines, sluder's neuralgia, contact point headaches, etc).

Unfortunately, in many physicians' minds including patients, if multiple courses of antibiotics do not resolve pan-facial pain/pressure, the sinuses must be horrible and something more aggressive geared towards the sinuses must happen.

And there's a few ENT surgeons willing to do just that... and mistakenly so.

It's not just ENTs, but allergists and infectious disease specialists who also may accommodate what the patient wants for treatment, even if it is incorrect.

If such patients see an allergist in the belief that their symptoms are due to allergies, they will get allergy testing and allergy shots.

If they see an infectious disease specialist, they will get antibiotics.

A much neglected specialist for patients with "sinus" problems are the neurologists given so many of these patients are actually suffering from atypical facial pain syndromes... but nobody (physicians, pharmaceutical companies, hospitals, bureaucrats) gets paid much for this particular problem... and so it gets ignored.

Though sinus surgery has been abused in the past into the present, a more recent, highly reimbursed, and "sexy" sinus procedural development is balloon sinuplasty, also ripe for being abused.

Traditional sinus surgery and now balloon sinuplasty certainly have their place in the treatment of true chronic sinus pathology with astounding success, but only in highly selected patients.

As with everything, the right treatment in the right patient is the right way of doing things.


Source:
Book Excerpt: A Saga Of ‘Fishy’ Surgery For Chronic Sinus Trouble. WBUR.ORG March 2, 2012

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Northern Virginia Balloon Sinuplasty for Chronic Sinusitis

In the past month, local residents of Northern Virginia may have received a magazine newsletter from Prince William Hospital (Manassas, Virginia) that contained a feature story about sinus surgery and about balloon sinuplasty specifically.

It was a great story about how far sinus surgery has come compared to even just 5-10 years ago and great patient experiences after this type of surgery is not uncommon now.

A few key features of sinus surgery of the 21st century that is provided at Fauquier ENT include:

• Nasal packing rarely occurs

• Most patients are surprised by how little pain there is

• No facial swelling or bruising... your best friend won't be able to tell you just had sinus surgery

• Fast recovery

• No incisions on the face or in the mouth

• GPS-like image guidance to make sinus surgery even safer is available
• In select patients, can even be performed in the office without sedation using local anesthesia only

Balloon sinuplasty is a relatively new innovation that allows sinus surgery to even be performed even more comfortably in the office without any sedation (not all patients are candidates).

Such advanced sinus surgery techniques have been available at Fauquier ENT since 2005.

Read more about sinus surgery and balloon sinuplasty.

Source:

Balloon Sinuplasty. Perspectives Winter 2011 Pages 2-3.

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In-Office Sinus Surgery Without General Anesthesia

There has been tremendous advances in sinus surgery over the past decade. From the elimination of nasal packing after most routine sinus surgery to the more recent use of balloons to open the sinus cavities, patient comfort has improved greatly after this particular operation. What used to be a several week recovery may now only be a few days.

Balloon sinuplasty in particular has been revolutionary in the surgical treatment of chronic sinusitis. Though sinus surgery normally is performed under general anesthesia, balloon sinuplasty now allows this operation to be performed awake WITHOUT sedation using local anesthesia only.

At its essence, sinus surgery "opens" up blocked sinus cavities to allow drainage and ventilation. Traditional sinus surgery "removes" tissue to accomplish this goal whereas balloon sinuplasty stretches open the sinus cavity without the need for tissue removal.

Given the lack of tissue removal with balloon sinuplasty, there is less pain and faster recovery after the procedure.

What are the steps?

After adequate anesthesia of the nose using both topical and injectable numbing medicine... Step 1 Under endoscopic guidance, the balloon catheter is introduced into the nasal cavity and guided towards the target sinus cavity opening. Depending on the system used, a sinus guidewire or sinus illumination may be used to help with the guidance.
Step 2 Once the sinus balloon catheter is correctly positioned across the blocked sinus opening, the balloon is gradually inflated to stretch open the ostia.
Step 3 After several seconds, the sinus balloon catheter is then deflated and removed leaving an enlarged sinus opening allowing for the return of sinus drainage. There is little to no disruption to mucosal lining.

Of course, not all patients are candidates for balloon sinuplasty, let alone this procedure to be done awake with local anesthesia alone.

In particular, balloon sinuplasty can only address blockages involving the frontal, maxillary, and sphenoid sinus cavities. Ethmoid sinus cavities can NOT be corrected using this method.

Also, balloon sinuplasty does not allow for tissue biopsies (by definition, the advantage of balloon sinuplasty is the lack of need to remove any sinus or nasal tissues). As such, if there are any masses present including nasal polyps, traditional sinus surgery is the better way to go.

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