Poster 202 Recurrent Pneumonia Complicated by Sepsis Secondary to Silent Aspiration from Zenker's Diverticulum: A Case Report

Abstract

A 73-year-old man with history of recurrent pneumonia complicated by sepsis presented with fevers, chills, and cough to the acute care setting. Chest x ray showed basilar infiltrates in ED suggestive of pneumonia. Following admission ID was consulted and merrem, vancomycin, and micafungin were started. During the hospital course blood cultures were positive for E. coli. On transfer to the rehabilitation hospital the patient was on chopped diet with thin liquids due to dysphagia. Video-fluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) were performed and a Zenker's diverticulum was discovered. Studies demonstrated penetration and aspiration on initial swallow worse with nectar thick than thin liquid from the diverticulum. Setting: Acute inpatient rehabilitation hospital. Results or Clinical Course: The FEES showed residuals in the valleculae, throughout the pharynx, A-E fold, and the intraarytenoid space. Swallowing strategies including chin tuck and multiple swallow cues improved clearance, but residual penetration and aspiration did not trigger cough. Aspiration occurred silently with nectar thick liquids vs. thin liquids, likely due to inadequate clearing. Follow up with a barium esophogram for more detailed assessment was recommended. The patient worked with speech therapy and strategies learned included alternating liquid/solid, throat clearing, controlling rate, and amount. Discussion: Zenker's diverticulum is a rare complication in the elderly population that has a prevalence of 0.01 e 0.11% in the population. It is common in the male population during the 7th to 9th decades. Symptoms include dysphagia, sensation of food or medications sticking in the throat, unexplained weight loss, and chronic halitosis. This patient presented with complications of recurrent pneumonia with sepsis and a long history of pill dysphagia. Conclusion: In the elderly population with chronic dysphagia and the sensation of food sticking in the throat, a Zenker's diverticulum must be ruled out. VFSS and FEES are screening methods that can be done in the rehabilitation setting to rule out mechanical causes of dysphagia which can prompt additional studies and surgical necessity. This patient was subsequently scheduled for barium swallow and surgical evaluation by an ENT specialist.