Bi-Lobed Zenker's Diverticulum

In the not so distant past, I saw a patient who suffered from a bi-lobed Zenker's Diverticulum. Zenker's diverticulum for those who don't know is the abnormal development of a pouch in the throat causing symptoms of phlegm in the throat, food regurgitation, swallowing difficulties, and aspiration.

Most Zenker's Diverticulum is composed of a single central pouch. However, there are more rare varieties such as this bi-lobed pouch seen on barium swallow.

However, at time of surgery (endoscopic staple diverticulostomy), the bi-lobed nature of the pouch essentially disappeared.

Video of how the surgery is performed:

Lithium Disc Battery Danger for Kids (and Hot Dogs)

In the last 10 years, 13 deaths related to swallowed batteries have been reported, 12 of which were due to disc batteries (20 millimeter lithium cells).

The danger is that when a disc battery is inserted into a nose (for example), a localized electric current is created between the positive and negative poles of the battery within the nose. This electric current basically "electrocutes" the lining inside the nose leading to tissue damage and ultimately necrosis (tissue death) within an hour. The same applies even if the battery is swallowed or put into the ear canal.

When swallowed, it can burn through the esophageal/intestinal lining causing a perforation which can lead to death if not promptly treated (or even in spite of it if too much time passes before treatment).

Treatment is IMMEDIATE removal... as soon as possible. Regardless of the day or time. STAT...

For illustrative purposes, lets see what happens to a hot dog when a lithium disc battery is placed inside it. This example was created by Dr. Stephen Marcus who is the director of the New Jersey Poison Information Center and published in the Pediatrics Blog here. You can also do this at home... give it a try (make a slit in the hot dog and push a lithium button battery into it... than watch).

Just 3 hours later, this is what you would see...

Keep disc batteries away from kids!!!

Please!!!

References:
A lithium battery in a hot dog is no picnic. Pediatrics Blog 7/2/2012


Pediatric Battery-Related Emergency Department Visits in the United States, 1990–2009. PEDIATRICS Vol. 129 No. 6 June 1, 2012 pp. 1111-1117

Preventing Battery Ingestions: An Analysis of 8648 Cases Published online May 24, 2010 PEDIATRICS (doi:10.1542/peds.2009-3038)

A Review of Esophageal Disc Battery Ingestions and a Protocol for Management Arch Otolaryngol Head Neck Surg. 2010;136(9):866-871. doi:10.1001/archoto.2010.146

Saliva Test for Laryngopharyngeal Reflux (LPR)

Various groups have been developing a fast, cheap, non-invasive saliva swab test to determine whether laryngopharyngeal reflux (LPR) is present or not. LPR may cause symptoms of:

• Hoarseness
• Chronic (ongoing) cough
• Frequent throat clearing
• Constant mucus or phelgm in the throat
• Dry or sandpaper like sensation in the throat
• Pain or burning sensation in the throat
• Feeling of a lump in the throat (globus pharyngeus)
• Problems swallowing
• Bad/bitter taste in the mouth (especially in morning)
• Asthma-like symptoms
• Ear pain and/or persistent ear infections
• Post-nasal drip
• Large lingual tonsils

When you compare a spit test to the current way of how reflux is determined via barium swallow, upper endoscopy (EGD), and 24 hour ph/impedance testing, it sounds quite attractive.

How does such a test work?

It basically looks for a stomach protein called pepsin.

Given reflux is when stomach contents moves up towards the mouth and pepsin is a protein ONLY produced in the stomach... pepsin should NOT be found in the throat/mouth.

As such, the test can state yes or no whether LPR is present or not.

How good is the test?

Depending on the study, sensitivity ranges in the 80-100% (can actually detect reflux if truly present) and specificity is around 85% (truly no reflux if test is negative).

Unfortunately, such testing is not offered is most labs. (Currently working on getting such testing available in our office.)

One test company is rdbiomed using their Peptest kit. This test is not yet available in the United States per company representative (7/18/12).

References:
Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope. 2005 Aug;115(8):1473-8.

Rapid salivary pepsin test: Blinded assessment of test performance in gastroesophageal reflux disease. Laryngoscope. 2012 Jun;122(6):1312-6. doi: 10.1002/lary.23252. Epub 2012 Mar 23.