Case of the Week #2

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Case Presentation #1

Patient with a history of known Zenker’s diverticulum (ZD) s/p hernia repair who presents for surgical consultation. States dysphagia and regurgitation of undigested food hours after a meal.

Although the patient brought a disc of their scope findings, I suggested we re-scope the patient since they had their hernia repair.

Nasal endoscopy revealed velopharyngeal insufficiency (VPI)/fullness of the soft palate on the left as well as bubbling in pyriform sinus.

The patient was given the option on endoscopic repair/stapling technique (quick recovery time, the incidence of Zenker’s return) vs open approach/diverticulectomy (longer recovery time, cure of ZD. The patient ultimately decided on an endoscopic repair.


Zenker’s Diverticulum (ZD): Rare disease Defect in the posterior pharyngeal wall at the junction of the pharynx and the esophagus. Essentially, there’s a false pouch/herniation – as a result, the patient has difficulty swallowing food (dysphagia).

zenkers-diverticulum-anatomy-1
https://abdominalkey.com/zenkers-diverticulum/

Signs & Symptoms:

  • Dysphagia to both liquids and solids
  • Choking; globus sensation
  • Hoarseness
  • Halitosis (bad breath)
  • Weight loss
  • Recurrent pneumonia due to aspiration

Diagnosis:

  • Barium esophageal to determine the degree of obstruction
  • CT neck: ZD will present as an air-filled sac; rule out other causes of obstruction
  • Upper endoscopy to show the diverticulum

Treatment:


Case Presentation #2:

Patient presents with nasal pain and issues with eye inflammation/dryness.  Nasal endoscopy exam revealed deviated septum, dry, nasal crusting, inflamed mucosa, but no concerns for masses or lesions.

Given the patient’s risk factors, Behcet’s syndrome is part of our differentials. Recommended patient try antibiotic ointment for 3 weeks.  If no improvement would consider switching to a different antibiotic and autoimmune workup, possible soft tissue biopsy.

*Side note: Never did I imagine working in ENT, that I would also have to ask about genital lesions/urination.


Behcet’s syndrome AKA Silk Road Disease: First described by 1930s by a Turkish Dermatologist. Behcet’s syndrome is a rare disorder that causes blood vessel inflammation throughout the body.

  • Signs & Symptoms: Triad of aphthous oral ulcers, genital lesions, and recurrent eye inflammation.
  • Risk Factors: Affects men/women in their 20s and 30s; people from the Middle East, East Asia (Turkey, Iran, Japan, and China)
  • Diagnosis: Blood tests to rule out other conditions (autoimmune workup)
  • Treatment: Treating symptoms (creams, ointments, drops, mouthwashes), steroids

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