Chiropractic Intervention of Zenker’s Diverticulum:

A Case Report

William J. Boro, D.C.

Chiropractic Center of Annapolis

Annapolis, Maryland | (410) 266-5054

www.nosnappingnocracking.com

Doc, Ya Gotta Help Me!

I don’t want surgery!

What the Heck is Zenker’s Diverticulum?

• A Zenker's diverticulum is a blind sac (pouch) that branches off the esophagus at the upper esophageal sphincter.

• It is the most common type of esophageal diverticulum. Although its precise etiology is uncertain, it is thought that it is caused by increased intraluminal pressure caused by a dyscoordination of pharyngeal contraction and cricopharyngeal relaxation.

What is Zenker’s Diverticulum?

Normal and Zenker’s SwallowingNormal Zenker’s

Symptoms of Zenker’s Diverticulum

• Sensation of food sticking in the throat• Coughing after eating• Dysphagia• Regurgitation of undigested food hours after eating• Special maneuvers needed to dislodge food• Halitosis, due to trapping of partially digested food• Aspiration of food particles• Unexplained weight loss• Borborygmi (gurgling noises) in the neck

Other Abnormalities Possible

• Hiatal hernia• Gastroesophageal reflux• Schatzki ring—narrowing of the lower part of the

esophagus that can cause difficulty swallowing• Acid-sensitive esophagus

Cranial Nerves Involved in Swallowing

Trigeminal (V)Facial (VII)Glossopharyngeal (IX) Vagus (X)Accessory (XI)Hypoglossal (XII)

wikipedia

Nerve Involvement: CN V Trigeminal Nerve

Exits the skull through the foramen rotundum and foramen ovale (sphenoid bone).

http://www.meddean.luc.edu

Nerve Involvement: CN VII Facial Nerve

Exits via the internal acoustic meatus and facial canal.

http://www.meddean.luc.edu

Nerve Involvement: CN IX & X Glosso-pharyngeal and Vagus Nerves

Exit via the jugular foramen formed by junction of temporal and occipital bones.

http://www.meddean.luc.edu

Nerve Involvement: CN XII Hypoglossal Nerve

Exits via the hypoglossal canal within the occiput bone.

http://www.meddean.luc.edu

V

V

VII

IX, X

XII

Common Treatments

• Surgery is a common treatment• Diverticulopexy—surgical obliteration or fixation of a diverticulum • Staple diverticulostomy • Excision combined with cricopharyngeal myotomy—treatment

involves relieving the source of resistance by cutting the upper esophageal sphincter (cricopharyngeal myotomy) and removing the diverticulum (diverticulectomy)

• Many patients learn to empty the diverticulum by applying gentle manual pressure to the side of the neck

• Others adjust their dietary intake to exclude foods such as peas or corn kernels that easily lodge in the diverticulum

Surgical Intervention—Diverticulopexy

Rhoads

Surgical Intervention—Staple Diverticulostomy

Surgical Intervention—Cricopharyngeal Myotomy

Case History

• Patient presented to my office 11/1/12• 71 year old male• 6’1”, 191 pounds• Problems swallowing, coughing while swallowing

Assessment• Right ilium low, right shoulder low, left ear low• Very limited cervical ranges of motion

• Flexion, 35o

• Extension, 45o

• Rotation, 25o left; 25o right• Lateral flexion, 5o left; 5o right

• Weak muscles: TFL and Gluteus Medius• Positive right Trendelenburg• Positive 3 finger test for jaw opening• Jaw opening was difficult and painful when index

fingers were placed behind angle of mandible

Treatment—Four Treatments Over a Two Week Period

• DeJarnette’s Sutural Protocol (steps 1-5)

1. Cervical Stairstep

Cervical stairstep is a procedure developed by DeJarnette to facilitate cervical articular facet position and motion. He theorized that this method of care could be applied for hypermobile cervical motor units as well as in instances of joint fixation.

Treatment—Four Treatments Over a Two Week Period

• DeJarnette’s Sutural Protocol (steps 1-5)

2. Occipito-Atlantal Fascia Release

3. TMJ Fascia Release• Vault Bone Sutural Release• Facial Bone Sutural Release

4. SCM and Platysma Release

5. Maxilla Adjustment• Maxilla-Palatine Spread• Maxilla Rotation• Maxillary Straddle (“Fruit Jar”)

Treatment—Four Treatments Over a Two Week Period

• Hiatal hernia release (modified Van Rumpt release)• Inferior constrictor muscle and laryngeal soft tissue release• Cat II correction

• Lumbar spine adjustment• Chin to chest exercises

Results

• Mostly symptom free after 2 treatments• After 3rd treatment Johns Hopkins surgeon said it was

too small to require operation• As of October 8, 2013, patient continues to report being

99% symptom free. • Patient performs Shakers exercises daily.

Shakers Exercises

• Patient lies flat on bed or floor and raises head chin to chest for one minute, followed by a one minute rest period.

• After that, patient performs 30 repetitions of head raising.

Conclusion

• The chronicity of the patient symptoms and the temporal relationship between treatment and response to care is of interest.

• While there have been no studies reported utilizing conservative chiropractic methods and the treatment of Zenker’s Diverticulum, it appears that such treatment can provide therapeutic benefit to those suffering from this disorder.

• It is hoped that this study may generate greater interdisciplinary relationships so that patients can have an option of therapy that offers a lower risk than surgery.

Conclusion

• Research should be done to evaluate whether a subset of patients may be better suited for this alternative method of care or whether this case was an anomaly.

What is a Subluxation?

A subluxation is the alteration of the normal dynamics, anatomical or physiological

relationships of contiguous structures.

Could we expand the understanding of subluxation to include all body tissues including nerve

pathways and data storage?

The Brain is Like a Computer

Digital computers operate by turning electrical signals into binary "on and off states" and flexibly manipulating these states by using switches. O'Reilly found the same operating principles in the brain.

"The neurons in the prefrontal cortex are binary—they have two states, either active or inactive—and the basal ganglia is essentially a big switch that allows you to dynamically turn on and off different parts of the prefrontal cortex,"

Science Daily Oct. 6, 2006 Randall O'Reilly, a professor in CU-Boulder's Department of Psychology and Neuroscience

How is the Body Like a Computer?

Our body is like a computer, only able to process the information put into it. If the wrong information is input, the

results will be wrong.

Remember the old acronym GIGO?

Garbage In Garbage Out.

This is true of our bodies too.

How is the Body Like a Computer?

The body acts similar to a computer in that it has the same basic functions:

InputCentral Processing

Output

How is the Body Like a Computer?

Input

Input systems involve our sensory system

Sight

Sound

Smell

Taste

Touch

Other data collection

CPU

CPU is made up of the nervous system and its divisions

Peripheral nervesSpinal Cord

MidbrainCerebellum and Cerebral

Tissues

Output

Output or display function presents the processed information from the CPU in a meaningful way

Muscles

Skin

What is a Subluxation?

Manifestation: in evaluation of this complex phenomenon, we find that it has or may have biomechanical, pathophysiological, clinical, radiological and other manifestations.

Significance: subluxations are of clinical significance as they are affected by or evoke abnormal physiological responses in neuro-muscular skeletal structures and/or other body systems.

D.D. Palmer’s Definition of Subluxation

“Subluxation of a vertebrae is a slight deviation from its normal relation to adjacent vertebrae,” and this is said to

cause “an alteration and narrowing of intervertebral foramina."

Dorland’s Medical Dictionary

Chiropractic is the science of applied neurophysiologic diagnosis based on the theory that health and disease are life processes related to the function of the nervous system. Irritation of the nervous system by mechanical, chemical or psychic factors is the cause of disease. Restoration and maintenance of health depend on the normal function of the nervous system. Diagnosis is the identification of these noxious irritants, and treatment is the removal by the most conservative method.

Can a Subluxation Be More?

What Can We Do?

The neck is made up of bones, ligaments, discs and muscles.

We can and do adjust ANY of these structures.

• D.D. Palmer founder of chiropractic said in 1910 that “too much or not enough nerve energy is disease.”

• Perhaps it might be clearer if he said “too much or not enough nerve energy is present in disease.”

B.J. Palmer’s Definition of Chiropractic

“Chiropractic is a philosophy, science and art of things natural; a system of adjusting the segments

of the spinal column by hand only, for the correction of disease.”

Are Chiropractors Falling Behind?

• Why are PT’s and Massasge therapists ahead of us• We can access specific data in the nervous system and

correct things• This is where biofeedback, pet scans, and medical

neurological research are headed, identifying what circuits are causing the problem

• Why do chiropractors limit themselves to a general approach

Research• Conley RN, Gould SJ, Skiles B. Zenker's diverticulum: plain film radiographic findings; case report. Top Diagn Radiol Adv Imaging. 1995;

3(1):11-13.• DeJarnette, Major B, 1968 Cranial Manual.• DeJarnette, Major B, 1976 Cranial Manual.• DeJarnette, Major B, 1977 Cranial Technique (with Sutural).• DeJarnette, Major B, 1979 Cranial Technique.• DeJarnette, Major B ,1997 Cranial Technique.• Delahunty JE, Margulies SE, Alonso UA, Knudson DH: The relationship of reflux esophagitis to pharyngeal pouch (Zenker’s diverticulum).

Laryngoscope 81:570-577, 1971.• Dohlman G, Mattsson O: The role of the cricopharyngeal muscle in cases of hypopharyngeal diverticula . AJR 81:561-569, 1959.• Ekberg O, Nylander G: Pharyngeal dysfunction after treatment for pharyngeal cancer with surgery and radiotherapy. Gastrointest Radiol

8:97-104, 1983.• Frot-Martin B, Carlier RY, Morand-Blot V, Faye A, Bernard L, Vallée C,Zenker's diverticulum associated with multilevel cervical osteomyelitis.

Spine. 2001 May 1; 26(9):E193 – 7.• Haas I, Gutman M, Paran H, Massive upper GI bleeding: A rare complication of Zenker's diverticulum. J Postgrad Med. 2008 Jul; 54(3):209 –

10.• Hardy, James D. Rhoads Textbook of Surgery, Vol. 1, 5th Edition. J.B. Lippincott Company 1977.• Knuff TE, Benjamin SB, Castell DO: Pharyngoesophageal (Zenker’s) diverticulum: a reappraisal. Gastroenterology 82:734-736, 1982.• Levine, Marc S. Radiology of the Esophagus. W.B. Saunders Company, 1989. page 315-6 • Ludlow A: A case of obstructed deglutition from a preternatural dilatation of and bag formed in the pharynx. Med Obsr Inq 3:85-101, 1769.• Monk R. Level Two Cranial – Sutural and TMJ Techniques. Sacro Occipital Technique Organization – USA: Sparta, NB. 2006.• Monk R. Sacro Occipital Technique Manual. Sacro Occipital Technique Organization – USA: Sparta, NB. 2006.• Ravich WJ, Jones B, Kramer SS, Donner MW: Unexplained pharyngeal dysphagia—the role of esophageal disease. Gastroenterology

84:1282, 1983 (abstract).• Summers LE, Gump WC, Tayag EC, Richardson DE, Zenker diverticulum: a rare complication after anterior cervical fusion. J Spinal Disord

Tech 2007 Apr; 20(2) pp. 172-5.• Tian H, Yuan W, Johnson JS, Chen H, Chen D, Pharyngoesophageal diverticulum: a delayed complication of anterior cervical spine surgery.

Eur Spine J 2011 JUL; 20 Suppl 2: S211 – 6.• Winans CS: The pharyngoesophageal closure mechanism: a manometric study. Gastroenterology 63:768-777, 1972.