A 72-year-old man reports difficulty swallowing solids, regurgitation of undigested food eaten hours earlier, gurgling sounds in the neck, and recurrent nocturnal cough. Examination shows a soft swelling on the left side of the lower neck that reduces on pressure. Which investigation confirms the diagnosis?

• A Oesophagoscopy with biopsy of the swelling
• B Ultrasound neck showing a cystic lesion
• C CT neck with contrast showing a lymph node mass
• D Contrast swallow showing an outpouching from the pharyngeal wall ✓

Explanation

This is a pharyngeal pouch (Zenker diverticulum), a herniation of mucosa through Killian's dehiscence between the oblique thyropharyngeus and horizontal cricopharyngeus fibres. D barium or water-soluble contrast swallow demonstrates the pouch and is the diagnostic test of choice. Endoscopy risks perforating the pouch and is not the confirmatory investigation, and ultrasound or CT would misclassify it as a cyst or node, which kills the distractors.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.