What features suggest a pharyngoesophageal diverticulum rather than a stricturing lesion?

• A. Progressive solid food dysphagia.
• B. Halitosis due to regurgitated material.
• C. Intermittent regurgitation of undigested food.
• D. A posterior bulge on exam at the pharyngoesophageal area.

Answer: (D)

A pharyngoesophageal (Zenker) diverticulum is an outpouching at the junction just above the upper esophageal sphincter, and the hallmark finding is a posterior bulge in that area. This physical sign reflects the actual pouch protruding behind the pharynx, which is the key clue that the problem is a diverticulum rather than a fixed narrowing of the esophagus.

In diverticulum, you often see regurgitation of undigested food and halitosis from retained material in the pouch, and patients may have intermittent regurgitation or coughing, especially at night. These are classic symptoms but can be produced by other issues as well. A stricture, by contrast, is a fixed narrowing inside the lumen and typically presents with progressive dysphagia to solids (and sometimes liquids later), without a posterior pharyngoesophageal bulge on exam. So the distinctive physical exam finding of a posterior bulge directly points to an extra-luminal pouch rather than a luminal narrowing, making it the best clue that this is a diverticulum rather than a stricture.