What is the next step for outpatient GI management of a 67-year-old male with a small right lateral pharyngeal diverticulum and a subcentimeter Zenker diverticulum?

Management of Small Pharyngeal and Zenker's Diverticula

For a 67-year-old male with small right lateral pharyngeal diverticulum and subcentimeter Zenker's diverticulum, observation with regular follow-up is the recommended approach, as these small asymptomatic diverticula typically do not require immediate intervention. 1

Assessment of Symptoms and Severity

When evaluating pharyngeal and Zenker's diverticula, the management approach depends primarily on:

• Presence and severity of symptoms:

  • Dysphagia (difficulty swallowing)
  • Regurgitation of undigested food
  • Halitosis (bad breath)
  • Coughing, especially after eating
  • Aspiration risk

• Size of the diverticula:

  • Small/subcentimeter diverticula (as in this case)
  • Moderate (2-4 cm)
  • Large (>4 cm)

Management Algorithm

1. For Asymptomatic Small Diverticula (Current Case)

• Conservative management with observation is appropriate for small, asymptomatic diverticula 1, 2
• Schedule follow-up in 6-12 months with repeat barium swallow to assess for progression
• Provide patient education regarding potential symptoms that would warrant earlier reassessment

2. For Mildly Symptomatic Small Diverticula

• Dietary modifications:
  • Recommend eating slowly and chewing thoroughly
  • Suggest semi-solid diet if dysphagia is present
  • Advise upright position during and after meals
• Swallowing therapy referral to speech-language pathologist 1
• Follow-up in 3-6 months with repeat imaging if symptoms persist

3. For Moderate to Severely Symptomatic Diverticula

• Endoscopic evaluation to assess for complications and rule out other pathologies
• Treatment options (for future reference if the diverticula enlarge or become symptomatic):
  • Endoscopic techniques: Preferred for higher-risk patients 1, 2
    • Endoscopic stapled diverticulotomy
    • Flexible endoscopic septotomy
  • Open surgical approaches: For larger diverticula or when endoscopic approach is not feasible 3, 4
    • Diverticulectomy with myotomy
    • Diverticulopexy
    • Cricopharyngeal myotomy alone

Important Considerations

Monitoring for Complications

• Aspiration risk: Patients with pharyngeal diverticula are at increased risk of aspiration. Monitor for signs of aspiration pneumonia, especially in elderly patients 1
• Malnutrition: Weight loss may occur with significant dysphagia
• Progression: Small diverticula may enlarge over time, requiring intervention

When to Consider Intervention

Intervention should be considered when:

• Diverticula become symptomatic
• Evidence of aspiration occurs
• Significant enlargement is noted on follow-up imaging
• Quality of life is impacted

Pitfalls to Avoid

• Overtreatment: Small asymptomatic diverticula rarely require intervention 2
• Delayed diagnosis of symptoms: Patients may attribute mild symptoms to aging or other causes
• Inadequate follow-up: Even small diverticula should be monitored periodically
• Overlooking aspiration risk: Especially important in elderly patients

Conclusion

For this 67-year-old male with small right lateral pharyngeal diverticulum and subcentimeter Zenker's diverticulum found on barium study, the appropriate next step for outpatient GI management is observation with regular follow-up, as these small asymptomatic diverticula typically do not require immediate intervention. Should symptoms develop or the diverticula enlarge significantly on follow-up imaging, referral for consideration of endoscopic or surgical management would be warranted.