Zenker’s diverticulum: a rare clinical condition with unusual oral manifestation

Background

Most of the oral lesions encountered in routine clinical practice arise due to conditions primarily associated within the oral cavity. However, various systemic conditions can adversely affect the oral apparatus. It can clinically manifest as oral ulcers, as seen in dermatological (eg, lichen planus, erythema multiforme, pemphigus vulgaris), haematological (eg, neutropenia, non-Hodgkin’s lymphoma) and gastrointestinal (GI) tract disorders (eg, Crohn’s disease, ulcerative colitis). White patches on oral mucosa are commonly due to candidiasis and can also be associated with the use of drugs like cocaine, pappilomas, white sponge nevus and hairy leukoplakia seen in HIV infection. Mucosal swellings can present as oral manifestation of Crohn’s disease, sarcoiodosis, Sturge-Weber syndrome and tuberous sclerosis. While spontaneous oral bleeding is seen in leukaemias, thrombocytopenia, haemophillia and Christmas disease, erosion and increased sensitivity of teeth can be associated with gastro-oesophageal reflux disease, while hallitosis can be a clinical feature of end-stage renal disease, liver failure and diabetic ketoacidosis. Xerostomia can occur secondary to radiotherapy, uncontrolled diabetes mellitus, Sjogren’s syndrome, sarcoiodosis and HIV infection.1 2

Oral lesions at times can be the first and the only clinical representation of a systemic disease. Therefore, it is imperative that not only the dental surgeon but also the medical practitioner must have adequate understanding of these oral manifestations for efficient diagnosis of these conditions.2 Zenker’s diverticulum (ZD) is an upper aerodigestive tract diverticulum characterised by herniation of the mucosal and submucosal layers through the posterior wall of the pharyngoesophageal junction, known as Killian’s triangle.3 ZD typically occurs in elderly patients, and the most prominent clinical features include dysphagia and regurgitation. Other features of ZD include cough, noisy swallowing, belching and hoarseness of voice. Transoral endoscopic repair with or without diverculectomy is the common treatment for ZD.3 This report highlights an unusual case of severe oral mucosal ulcerations and dysphagia in an elderly male patient. Initial misdiagnosis resulted in failure of treatment. Once the diagnosis of ZD was made and treated, patient was relieved of all oral symptoms. Various differential diagnoses for multiple oral ulcers that must be kept in mind in such situation includes aphthous ulcer, erythema multiforme, pemphigus vulgaris, neutropenia, non-Hodgkin’s lymphoma, Crohn’s disease and ulcerative colitis.

Case presentation

A 66-year-old male patient was referred to oral and maxillofacial surgery clinic with report of burning sensation in the oral cavity, associated with difficulty in eating and swallowing food for last 4 months. General physical examination revealed an otherwise healthy patient with average built. The medical history was non-contributory. Intraoral examination revealed the presence of ulcerative lesions on the lower lip, dorsal surface of tongue and buccal mucosa bilaterally (figures 1 and 2). Lesions were reddish in colour and were covered with whitish slough. Patient reported extreme burning sensation with the lesions, which aggravated during eating. The lesions were tender on palpation and bleed spontaneously. Detailed history revealed that patient had lost almost 10 kg weight in the past 4 months due to burning sensation experienced during eating. Patient had no adverse oral habits and did not give history of any pre-existing systemic condition. Patient had visited many clinicians over the period of last 4 months and received treatment including oral antibiotics, anti-inflammatory agents and oral antifungal therapy. He was also prescribed topical corticosteroid therapy, which did not relieve the symptoms.

On initial examination and considering the possibility of presence of an underlying undiagnosed systemic condition, palliative therapy with topical application of local anaesthetic gel and multivitamin supplements was initiated and the patient was advised to undergo routine blood examination and blood sugar evaluation. After 3 days of palliative therapy, patient reported back with no improvement in the clinical situation. The blood reports were within normal range including the fasting and postprandial blood glucose levels. During the second visit, under topical anaesthesia, the whitish slough was removed from the lesions, and considering the possibility of presence of dermatological disorder, patient was prescribed topical Kenacort (triamcenolone acetonide), along with topical benzocaine gel application for a period of 1 week. On the third visit, patient had slight reduction in the burning sensation. However, the lesions showed no improvement and despite reduction in the burning sensation, the patient reported an increase in dysphagia from the first visit. Considering the possibility of GI tract pathology like oesophageal strictures, presenting with oral manifestation, the patient was referred to a gastroenterologist, for further evaluation.

Investigations

Barium swallow test was advised, which revealed dilation and pouching of the oesophagus, where the barium uptake was more. Narrowing of cricopharyngeus muscle was also evident (figure 3). Based on the radiographic features, the conditioned was diagnosed as ZD.

Treatment

Patient underwent endoscopic diverticulectomy under general anaesthesia. He was advised soft diet and was kept on nutrition supplements and oral antacids (pantoprazole 40 mg 24 hourly) for 3 weeks

Outcome and follow-up

At 1-month postsurgery recall visit, it was noticed that all the ulcerative lesions on the lip, buccal mucsa and tongue had healed. There was no burning sensation while eating and there was no dysphagia (figure 4).