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Dysphagia in an elderly patient

      1. Introduction

      A 75-year-old female presented to the Otolaryngology department with a history of sudden onset dysphagia and choking sensation while having chicken rice for lunch. She was edentulous and had no significant medical history. On examination, she appeared uncomfortable with drooling of saliva. There was no stridor, cyanosis or palpable neck mass. Flexible nasoendoscopy findings revealed a fullness in the post cricoid region but were otherwise unremarkable. She had stable vitals signs with normal peripheral oxygenation saturations. Interestingly, her symptoms resolved spontaneously within an hour of presentation. A lateral neck radiograph was performed (Fig. 1A ).
      Fig. 1
      Fig. 1Pharyngeal pouch. (A) Lateral neck radiograph showing an air fluid level, with a triangular lucency in the prevertebral tissues, with the apex at the level of the cricoid cartilage. This is due to the presence of air in the upper part of the pouch (B) Repeat lateral neck radiograph after demonstrating resolution of the air fluid level.

      2. What is the diagnosis?

      2.1 Discussion

      The radiograph revealed an air fluid level, with a triangular lucency in the prevertebral tissues, with the apex at cricoid cartilage level (Fig. 1A). This finding is consistent with a pharyngeal pouch, most likely undiagnosed prior to her presentation. A repeat neck radiograph after improvement of the patient's symptoms showed resolution of air fluid level (Fig. 1B). Although unusual, we believe this occurred because the neck of the sac was relatively wide.
      A symptomatic pharyngeal pouch commonly presents in the sixth and seventh decades of life [
      • Gregoire J.
      • Duranceau A.
      Surgical management of Zenker's diverticulum.
      ]. The pharyngeal pouch, also known as Zenker diverticulum, is formed as a herniation of the pharyngeal mucosa through the potential weakness at Killian's triangle, between the cricopharyngeus muscles and the inferior constrictor muscles [
      • Killian G.
      The mouth of the oesophagus.
      ].
      This phenomenon may result in the creation of a sac with a narrow neck that can trap liquid and food, leading to compression of the cervical oesophagus. Symptoms include dysphagia, regurgitation, halitosis, chest infections, aspiration and weight loss. Barium swallow test is performed to confirm diagnosis. Treatment is indicated if the pharyngeal pouch is symptomatic and management usually consists of endoscopic stapling or open surgery [
      • Stewart K.
      • Sen P.
      Pharyngeal pouch management: an historical review.
      ].
      Hence, in the event of an oropharyngeal dysphagia in an elderly patient, clinicians should have a high index of suspicion of a Zenker diverticulum. This uncommon case illustrates the versatility of a neck radiograph in revealing unexpected pathologies.

      Conflict of interest

      Nil.

      References

        • Gregoire J.
        • Duranceau A.
        Surgical management of Zenker's diverticulum.
        Hepatogastroenterology. 1992; 39: 132-138
        • Killian G.
        The mouth of the oesophagus.
        Laryngoscope. 1907; 17: 421-428
        • Stewart K.
        • Sen P.
        Pharyngeal pouch management: an historical review.
        J Laryngol Otol. 2016 Feb; 130: 116-120