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Modified Monday: Another Zenker's-with a side of patient perspective

It's been a minute since we shared a Zenker's video, so here we are with not only a good example of this finding, but also with a side story of how the patient feels about it.

To recap: a Zenker's diverticulum is an outpouching/herniation of the esophageal mucosa into Killian's triangle, a tiny spot of less resistance in the posterior pharygeal wall-a little gap between the cricopharyngeus and the thyropharyngeus muscles. This lower resistance spot in an area just FULL of muscles can sometimes result in a blow out of the tissue and creates a little pouch right above the CP. Sometimes it stays small and any food or liquid that gets caught in there pops right out and goes where it should-we see these little guys sometimes and we always let the patient and physician know... because they can get bigger and eventually food and liquid will accumulate and stay.

Which was exactly the case with our patient this week. Our Wisconsin team had a patient with a known Zenker's. It had been noted in the past via prior MBS study and the patient described it as "not a real big problem". He was now having some worsening symptoms, including coughing toward the end of meals, had a recent pneumonia, and had lost weight because he "stopped eating when the coughing started". Our team found a decent size Zenker's with a lot of retention that increased in volume as the study went on. Our SLP did note less retention with smaller sips, alternating solids and liquids, and partial clear of the retention with multiple swallows. She also recommended a follow up with GI to explore treatment of the Zenker's. (See link below for a description of different approaches to surgical intervention.) When this was mentioned to the patient however, he was willing and interested in the strategies-but not in the surgery. He told our team that at the age of 92 he didn't want any surgery and was fine with just knowing what the problem was.

We obviously still made the recommendation, but the important point here is that it is always the patient's decision regarding following up on the recommendation-regardless if that recommendation is a referral, surgery, medication, test, or diet change. We thought this story was worth bringing up, since patient decision making in some areas seem to be not only accepted, but expected (think use of pain drugs, quitting smoking, exercising more or eating healthy

)... while other decisions like choosing to continue to drink coffee thin are so "shocking" that we hear stories about patients being told they have to choose DNR or hospice status to get that coffee (this is easily considered coercion and is NOT ok).

Our role is not to enforce, coerce, shame, or dictate what the patient "should" do, but to provide solid education on WHAT we recommend and WHY we are recommending it (including the pros and cons of the recommendation). From there, it becomes the patient's decision.

Finally, we document. Document our findings, our recommendations, and the education that was provided to the patient (and we continue to provide) as well as the patient response to our recommendations and education. It's hard sometimes if a patient doesn't take our "advice", but we have to remember that even though historically patient perspective has been a side note in medical settings.... for the patient, it's the main point.

Flexible endoscopic treatment for Zenker’s diverticulum: from the lumen to the third space - PMC (

28770 AskrenLeslie_SeminarsinSLP_Ethics.pdf (

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