Oropharyngeal Dysphagia With Pyriform Sinus Dilatation Mimicking Zenkerʼs Diverticulum

Abstract

Dysphagia is a common complaint amongst the elderly, affecting approximately 16 to 22 percent of individuals over the age of 50, with oropharyngeal dysphagia accounting for the majority of cases. Common causes of oropharyngeal dysphagia include stroke, neuromuscular disease, and obstruction (e.g. malignancy). Abnormalities of the upper esophageal sphincter may lead to high hypopharyngeal pressure, causing Zenker's diverticulum. Here we present a case of oropharyngeal dysphagia secondary to lower motor neuron disease, which resulted in pyriform sinus dilatation mimicking Zenker's diverticulum on video fluorescent swallow study. An 82-year-old lady with a history of type 2 diabetes presented with aspiration pneumonia, which was treated with intravenous antibiotics. On review of systems, she reported progressive dysphagia to solids and liquids for 4 years, and workup for dysphagia was initiated. Video fluorescent swallow study showed premature spillage to level of pyriform recesses and delayed pharyngeal response with a large pouch around the level of the pharyngoesophageal segment, suspected to be Zenker's diverticulum. Subsequent EGD was normal. An esophagram with barium contrast was then attempted, however patient aspirated a large volume of contrast during initial phase of the examination, complicated by acute hypoxic respiratory failure requiring intubation and transfer to the intensive care unit. Bronchoscopy was performed with aspiration of about 5 mL of contrast material. The patient was later successfully extubated without complication, however a follow-up CXR showed residual contrast persisting in the hypopharynx. Laryngoscopy was performed, which visualized pooling of material in bilateral pyriform sinuses, which was successfully suctioned. EMG of bilateral genioglossus muscles were done showing chronic bilateral reinnervation, suspicious of possible lower motor neuron disease. Patient recovered on general medical floor with no further hypoxic episodes. PEG tube was placed for long-term feeding and patient was discharged in stable condition with close follow up with neurology for further workup. This patient posed a diagnostic challenge given symptoms of oropharyngeal dysphagia with evidence of hypopharyngeal pooling on video fluorescent swallow study. While hypopharyngeal contrast extravasation would typically elicit a diagnosis of Zenker's diverticulum, in our patient this was a manifestation of dilated pyriform recesses.1749_A Figure 1. Video fluorescent swallow study (left) showing premature contrast spillage to level of pyriforms with delayed pharyngeal response. Large pouch noted around the level of pharyngoesophageal segment, suspected to be Zenker's diverticulum (red arrow). Subsequent barium esophagram (right) showing markedly dilated bilateral symmetric pyriform sinuses (blue arrow) with no evidence of Zenker's diverticulum.1749_B Figure 2. Computed tomography of the neck without contrast (left) delineating retained residual barium within piriform sinuses (red arrows). Chest X-ray (right) showing retained barium within bilateral pyriform sinuses (blue arrows) and bilateral lower lung fields (green arrows).