Snap Shot A 73-year-old female is being seen at the emergency department after having recurrent coughing spells and regurgitation following meals. Her breath is nearly unbearable upon arrival to the ED. She is also noted to have a palpable, fluctuant neck mass on physical examination. Introduction Pharyngeal pouch that develops in the proximal esophageal wall Pulsion diverticula involving only the mucosa located between thyropharyngeal and cricopharyngeus muscle Etiology is incompletely understood; however, some have suggested that the combination of uncoordinated swallowing and impaired relaxation of the cricopharyngeus leads to an abnormally elevated intrapharyngeal pressure, causing the hernation of mucosa through a weak point in the pharyngeal wall Epidemiology incidence unknown most often occurs in age group (>70 years old) Presentation Symptoms dysphagia regurgitation choking chronic cough bad breath (halitosis) Physical exam palpable, fluctuant neck mass may be appreciable Evaluation Diagnosis is based highly on clinical observations and patient history Avoid upper endoscopy if known or highly suspicious due to risk of rupture Barium swallow confirms diagnosis by visualizing pharyngeal outpouch Differential Achalasia, diffuse esophageal spasm, nutcracker esophagus, carcinoma/malignancy, pneumonia, hiatal hernia Treatment Surgical intervention myotomy of cricopharyngeus muscle with diverticula resection endoscopic has better success rates compared to external approach Prognosis, Prevention, and Complications Prognosis ranges widely depending on health of patient and surgical approach Prevention none Complications surgery can lead to significant complications including death given location of lesion and age/health of average patient population with this pathology may develop carcinoma within the pouch if not resected