Zenker's Diverticulum Visibility on Cookie Swallow (Videofluoroscopic Assessment)
Yes, Zenker's diverticulum would be visible on a typical Cookie Swallow (videofluoroscopic swallowing study), as barium studies permit better detection of structural abnormalities including Zenker's diverticulum compared to endoscopy. 1
Why Videofluoroscopy Detects Zenker's Diverticulum
Videofluoroscopy (VFS) is the gold standard diagnostic tool for confirming Zenker's diverticulum, as it directly visualizes the posterior outpouching at the pharyngoesophageal junction during real-time swallowing 2, 3, 4
The American College of Radiology explicitly states that barium studies have superior sensitivity for detecting structural pharyngeal abnormalities like Zenker's diverticulum compared to endoscopy 1
The diverticulum fills with barium contrast during the swallowing sequence, making it readily apparent as a posterior pouch extending from the hypopharynx through Killian's dehiscence 2, 4
Important Technical Considerations
A complete pharyngoesophageal examination is essential - the American College of Radiology recommends combining the modified barium swallow (Cookie Swallow) with complete esophageal imaging, as this combination has higher diagnostic value than either study alone 5
The diverticulum appears as a posterior outpouching typically located 2-3 cm from the epiglottis at the level of C5-C6, filling with contrast during the pharyngeal phase of swallowing 4
Dynamic imaging is crucial - sequential images during active swallowing demonstrate not only the structural abnormality but also functional consequences including retention of material, delayed emptying, and potential aspiration risk 2
Clinical Pitfalls to Avoid
Do not rely on endoscopy alone - endoscopy has lower sensitivity for detecting Zenker's diverticulum compared to barium studies, and the American College of Radiology guidelines emphasize that barium studies are superior for structural pharyngeal lesions 1
Ensure adequate esophageal evaluation - because distal esophageal or gastric cardia lesions can cause referred dysphagia to the pharynx, the entire esophagus should be examined even when a Zenker's is suspected 5, 6
Watch for aspiration - videofluoroscopy can identify silent aspiration (present in 55% of aspiration cases without protective cough) that may result from overflow of the diverticulum 5, 6
Diagnostic Accuracy
Barium videofluoroscopy has excellent sensitivity for Zenker's diverticulum and provides both anatomic detail (size, location) and functional information (pharyngeal transit, retention, aspiration risk) 2, 3
The study also evaluates associated swallowing dysfunction including cricopharyngeal muscle dysfunction, pharyngeal constriction abnormalities, and hyolaryngeal elevation deficits that contribute to diverticulum formation 7