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INTRODUCTION Pharyngeal pouches were first described by Ludlow in 1769, and after more than a century, Zenker published a full clinical pathological description in 1877 [1,2]. The occurrence of squamous cell carcinoma (SCC) arising in Zenker's diverticulum is a very rare entity. However, the published incidence rates fall between 0.3% and 7% among occasional reports in the literature [3]. SCC in the pouch is diagnosed mainly after obtaining full histopathologic examination of the specimen following surgical resection [4]. For this reason, the procedure of choice for suspected SCC in the pouch is by complete surgical excision of the pouch. We report a rare case of recurrent Zenker's diverticulum and SCC development in the pouch. CASE PRESENTATION A 71-year-old British male patient presented to our institute with a history of dysphagia and regurgitation for the past 20 years. Endoscopy was done earlier, and he was diagnosed with Zenker's diverticulum. He underwent endoscopic stapling of the diverticulum in the years 2006, 2009, and 2011 without any symptomatic improvement. At that time, he denied any history of weight or appetite changes. He complained of new symptoms such as dysphagia and regurgitation mostly to soft food and liquids, which aggravate with coughing, and also of a decrease in weight and appetite. The patient is a smoker and an occasional alcohol consumer. On physical examination, it was found that he was healthy, and all systems exam were unremarkable. All laboratory investigations were normal. Barium swallow showed pharyngeal pouch as Zenker's diverticulum (Figures 1, 2). A written consent was obtained from the patient for surgery and publications. The patient underwent left neck incision, diverticulectomy, and cricopharyngeal myotomy under general anesthesia. Postoperative recovery was uneventful. He was discharged home after few days in a good stable condition. Histology results showed an esophageal pouch consisting of a cyst-like lesion measuring 4.03.51.0 cm 3 (Figure 3). The cyst wall was thickened. The inner mucosal surface showed fungating mass lesion measuring 1.51.00.5 cm 3 , tan white in color, and friable in consistency. The resection margins were free of the lesion and were marked with staples. Microscopic results showed moderately differentiated SCC (Figures 4a, b).