- Clinical science
Esophageal diverticula are abnormal pouches that arise from the wall of the esophagus. They most commonly occur in middle-aged and older men and are classified based on localization, pathophysiology, and histological findings. The most common type of esophageal diverticula is Zenker diverticulum, which extends posteriorly in the hypopharynx directly proximal to the upper esophageal sphincter. Esophageal diverticula can be caused by either an underlying motility disorder that exerts high intraluminal pressures on a weak esophageal wall or from forces pulling on the outside of the esophagus. The clinical presentation varies with pouch size and localization, with the most common symptoms being dysphagia, regurgitation, retrosternal pain, and pulmonary symptoms secondary to aspiration. The diagnosis is confirmed by barium swallow, which also aids in determining the size of the diverticulum and potential malignancy. Surgical treatment is rarely required and only recommended in symptomatic patients (primarily those with ).
Esophageal diverticula are classified according to their localization, histology, and pathophysiology. 
- Upper esophageal diverticulum
- Middle esophageal diverticulum: diverticulum at the tracheal bifurcation
- Lower esophageal diverticulum: epiphrenic diverticulum
Zenker diverticulum arises from the hypopharynx, although it is classified as an esophageal diverticulum.
- True diverticula: All layers of the esophageal wall protrude.
- False diverticula: Increased intraluminal pressure causes only the mucosa and submucosa to bulge through weak points in the muscularis propria (e.g., Zenker diverticulum).
- Inadequate relaxation of the esophageal sphincter (e.g., caused by achalasia or spastic motility) and increased intraluminal pressure → outpouching of the esophageal wall → pulsion diverticulum
- Inflammation of the mediastinum with scarring and retraction (e.g., secondary to tuberculosis or fungal infection) → traction diverticulum 
Clinical presentation depends on diverticulum size and localization. 
- Dysphagia (most common)
- Regurgitation of undigested food
- Coughing after food intake
- Retrosternal pressure sensation and pain
- Weight loss
- Neck mass
Elder MIKE has bad breath: Elderly, Male individuals, Inferior pharyngeal constrictor, Killian triangle, Esophageal dysmotility, halitosis.
Barium swallow (best confirmatory test) with dynamic continuous fluoroscopy 
- Visualization of diverticula via barium swallow or gastrografin (soluble in water)
- Allows for the detection of underlying motor abnormalities and diverticulum size 
- A traction diverticulum presents as a pointed, triangular bulge arising from the esophageal wall; the base of the triangle is oriented towards the wall.
- Endoscopy 
Esophageal manometry 
- Usually not required
- Useful for identifying underlying motor abnormalities in patients with dysphagia
- Transcutaneous ultrasound 
- Medical treatment 
Surgical treatment 
- Endoscopy; (rigid or flexible, with the former requiring general anesthesia) with diverticulostomy and myotomy
- Open surgery