A man was 99% symptom free of Zenker's diverticulum after 4 treatments. Presented at the Sherman College of Chiropractic IRAPS symposium October 2013.

1. 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

2. Doc, Ya Gotta Help Me!

3. I don’t want surgery!

4. What the Heck is Zenker’s Diverticulum?

5. What 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.

8. Normal and Zenker’s Swallowing
Normal
Zenker’s

9. Symptoms of Zenker’s Diverticulum
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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

10. 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

11. Cranial Nerves Involved in Swallowing
Trigeminal (V)
Facial (VII)
Glossopharyngeal (IX)
Vagus (X)
Accessory (XI)
Hypoglossal (XII)
wikipedia

12. Nerve Involvement: CN V
Trigeminal Nerve
Exits the skull through the foramen rotundum and foramen
ovale (sphenoid bone).
http://www.meddean.luc.edu

13. Nerve Involvement: CN VII
Facial Nerve
Exits via the internal acoustic meatus and facial canal.
http://www.meddean.luc.edu

14. 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

15. Nerve Involvement: CN XII
Hypoglossal Nerve
Exits via the hypoglossal canal within the occiput bone.
http://www.meddean.luc.edu

16. V
V
VII
IX, X
XII

17. 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

18. Surgical Intervention—
Diverticulopexy
Rhoads

19. Surgical Intervention—
Staple Diverticulostomy

20. Surgical Intervention—
Cricopharyngeal Myotomy

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

22. 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

23. 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.

24. 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”)

25. 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

26. 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.

27. 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.

28. 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.

29. 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.

30. 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?

31. 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

32. 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.

33. How is the Body Like a Computer?
Remember the old acronym GIGO?
Garbage In Garbage Out.
This is true of our bodies too.

34. How is the Body Like a Computer?
The body acts similar to a computer in that it has the same
basic functions:
Input
Central Processing
Output

35. Input
Input systems involve our sensory system
Sight
Sound
Smell
Taste
Touch
Other data collection

36. CPU
CPU is made up of the nervous system and its
divisions
Peripheral nerves
Spinal Cord
Midbrain
Cerebellum and Cerebral
Tissues

37. Output
Output or display function presents the processed
information from the CPU in a meaningful way
Muscles
Skin

38. 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 neuromuscular skeletal structures and/or other body
systems.

39. 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."

40. 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.

41. Can a Subluxation Be More?

42. What Can We Do?
The neck is made up of bones, ligaments, discs
and muscles.
We can and do adjust ANY of these structures.

43. • 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.”

44. 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.”

45. 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

46. Research
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