Snapshot A 59-year-old man presents to the clinic for complaints of bad breath and recurrent coughing spells. He complains difficulty swallowing at times and is noted to have a moderately sized neck mass during physical examination. Introduction False diverticulum (sac-like outpouching of only the mucosa and submucosa) of the esophagus true diverticulum contains all layers of the intestinal wall Epidemiology incidence prevalence of 0.01 - 0.11% in the U.S.A. demographics 1.5:1 male predominance typically seen in middle-aged adults and older adults in 7-8th decade of life location occurs at the upper part of the esophagus at Killian triangle (an area of muscular weakness between the cricopharyngeus muscle and lower inferior constriction) Pathogenesis Killian triangle is a natural area of weakness within the muscular wall of the esophagus and is more common in men thought to result from chronic increased pressure on the weakened area due to either high intrabolus pressures during swallowing resistance to swallowing due to abnormalities of the upper esophageal sphincter Prognosis ranges widely depending on health of patient and surgical approach disease itself is rarely life-threatening Presentation Symptoms dysphagia regurgitation choking halitosis (bad breath) chronic cough Physical exam palpable, fluctuant neck mass Imaging Barium swallow preferred method of diagnosis will demonstrate dye collection posterior to the esophagus Transcutaneous ultrasound allows for differentiation from a thyroid/neck mass good alternative for people who have difficulties swallowing barium Esophageal manometry not required for diagnosis may help delineating the pathogenesis of the diverticulum Differential Achalasia distinguishing factor will demonstrate a bird’s beak on barium swallow Diffuse esophageal spasm distinguishing factor will have characteristic findings on esophageal manometry Treatment Conservative treatment if diverticulum is small and asymptomatic, no treatment is necessary Operative myotomy of cricopharyngeus muscle with diverticulum resection indication if the diverticulum is large and symptomatic endoscopic approach has better success rates compared to external approach Complications Aspiration pneumonia Squamous cell carcinoma of the diverticulum prevalence ranges from 0.3-7 % Ulceration and bleeding Increased risk of iatrogenic perforation