Cricopharyngeus muscle dysfunction: a poorly defined disorder from diagnosis to treatment.

PURPOSE: Cricopharyngeus muscle dysfunction (CPMD) is a common clinical occurrence with very few clear diagnostic criteria and multiple pathways for treatment. Incidence of CPMD is not known, but some data suggest around 25% of people with dysphagia experience some degree of CPMD, which negatively impacts swallowing safety and efficiency. Workup and treatment of CPMD can require multidisciplinary collaboration across laryngologists, speech-language pathologists with training in dysphagia management, and gastroenterologists. The purpose of this paper is to review what is known about CPMD and identify areas of future research in CPMD diagnosis and treatment. METHODS: An overview of CPMD, relative treatments and disorders, and a discussion of future areas of research needed to improve clinical care of CPMD. RESULTS: Details regarding historical background, pathophysiology and treatment practiced for CPMD are included. CONCLUSION: In summary, CPMD is a poorly defined disease due to a lack of understanding of its pathophysiology and the lack of consensus diagnostic criteria. Well-designed, prospective clinical trials are necessary to develop a better understanding of clinical incidence of CPMD, impact of the disorder on oropharyngeal swallowing, and how to approach treatment of the disorder surgically or in conjunction with therapy directed by a specialized speech-language pathologist.

Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative.

OBJECTIVES: The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. METHODS: Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. RESULTS: There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26). CONCLUSIONS: Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. LEVEL OF EVIDENCE: Level III Laryngoscope, 134:2678-2683, 2024.

Pleomorphic Hyalinizing Angiectatic Tumor of the Larynx.

Pleomorphic hyalinizing angiectatic tumor (PHAT) is a rare, benign soft tissue tumor with uncertain pathogenesis and lineage most commonly found in the lower and upper extremities. No reports exist of this tumor metastasizing, though local recurrence is common. To date, only approximately 100 cases have been reported. We present the case of a patient presenting with hoarseness and dyspnea found to have PHAT of the larynx, a location previously unreported in the literature and requiring unique management considerations.

A Novel Instrument Holder to Improve Operative Efficiency in Endoscopic Laryngeal and Airway Surgery.

OBJECTIVE: Receiving instruments from surgical technicians during endoscopic laryngeal and airway microsurgery (ELAM) has challenges including repeated, expeditious handling of delicate instruments and passing them to the surgeon's hand opposite of where the surgical assistant is standing. Optimizing this interaction may reduce surgical errors and improve operative efficiency. METHODS: A proprietary ELAM instrument holder was attached to both sides of the operating room bed. The device consisted of an articulating arm with custom silicone inserts mounted on a tray (storing up to three endoscopic instruments). ELAM cases were randomized to be performed either with (device) or without the holder (control). Using custom software, instrument pass time (IPT), instrument drop rate (IDR), and communication errors (eg handing incorrect instruments) were manually recorded. Qualitative use metrics relating to overall device satisfaction were also obtained. RESULTS: Data were collected from 25 device and 23 control cases among three different laryngologists. Average IPT was nearly three times quicker for the device (0.80 s, n = 1175 passes) compared with controls (2.09 s, n = 1208 passes) [p < 0.001]. IPT interquartile range was five times higher for control (1.65 s) versus device cases (0.42 s). IDR was not significantly different [p = 0.48]; however, device cases had significantly lower communication errors compared to control cases [p = 0.01]. Surgeons and surgical assistants were similarly satisfied with the device on a 5-point Likert scale (mean: 4.2/5, standard deviation: 0.92). CONCLUSION: The proposed endoscopic instrument holder can improve ELAM operative workflow by reducing instrument passing time and variability without increasing IDR. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:3492-3498, 2023.

Comparative Treatment Outcomes for Idiopathic Subglottic Stenosis: 5-Year Update.

The North American Airway Collaborative (NoAAC) previously published a 3-year multi-institutional prospective cohort study showing variation in treatment effectiveness between 3 primary surgical techniques for idiopathic subglottic stenosis (iSGS). In this report, we update these findings to include 5 years of data evaluating treatment effectiveness. Patients in the NoAAC cohort were re-enrolled for 2 additional years and followed using the prespecified published protocol. Consistent with prior data, prospective observation of 487 iSGS patients for 5 years showed treatment effectiveness differed by modality. Cricotracheal resection maintained the lowest rate of recurrent operation (5%), followed by endoscopic resection with adjuvant medical therapy (30%) and endoscopic dilation (50%). These data support the initial observations and continue to provide value to providers and patients navigating longitudinal decision-making. Level of evidence: 2-prospective cohort study.

Factors Related to Treatment Attendance for Patients Seeking Gender-Affirming Voice Therapy.

OBJECTIVE: The purpose of this study was to investigate factors related to treatment attendance for patients seeking gender-affirming voice therapy (GAVT). METHOD: We completed retrospective chart reviews of 50 patients (43 transgender women, three transgender men, four nonbinary patients; aged 18-67 years, M = 34.92 years, SD = 12.32 years) referred for GAVT at a Midwest outpatient center from 2016 to 2021. Data extraction included patient demographics, therapy visit specifics (e.g., number of sessions attended, treatment completion status, and in-person vs. virtual visits) and treatment timing (in relation to the onset of the COVID-19 pandemic), and psychosocial and socioeconomic information. RESULTS: There was no impact of treatment-timing relative to the onset of the pandemic on any attendance measure; however, patients were 1.9 times more likely to complete therapy with each virtual telehealth session attended. Individual factors of outside social support and hormone replacement therapy were positively related to the number of therapy sessions attended, whereas insurance provider and employment status were related to therapy completion. CONCLUSIONS: Telehealth attendance during the COVID-19 pandemic was positively associated with GAVT completion. Future research should investigate psychosocial and socioeconomic factors to understand how to identify patients at risk for poor treatment adherence and facilitate access to clinical care.

Voice Acoustics and Vocal Effort in Mask-Wearing Healthcare Professionals: A Comparison Pre- and Post-Workday.

OBJECTIVE: We evaluated voice acoustics and self-perceptual ratings in healthcare workers required to wear face masks throughout their workday. METHODS: Eighteen subjects (11 cisgender female, 7 cisgender male; M = 33.72 years, SD = 8.30) completed self-perceptual ratings and acoustic recordings before and after a typical workday. Chosen measures were specific to vocal effort, dysphonia, and laryngeal tension. Mixed effects models were calculated to determine the impact of session, mask type, sex, and their interactions on the set of perceptual and acoustic measures. RESULTS: The subjects self-reported a significant increase in vocal effort following the workday. These perceptual changes coincided with an increase in vocal intensity and harmonics-to-noise ratio, but decrease in relative fundamental frequency offset 10. As expected, men and women differed in measures related to fundamental frequency and vocal tract length. CONCLUSION: Healthcare professionals wearing masks reported greater vocal symptoms post-workday compared to pre-workday. These symptoms coincided with acoustic changes previously related to vocal effort; however, the degree of change was considered mild. Further research is needed to determine whether vocal hygiene strategies may reduce vocal symptoms in mask-wearing workers.

Cricopharyngeus Muscle Dysfunction and Hypopharyngeal Diverticula (e.g., Zenker): A Multicenter Study.

OBJECTIVE: To describe demographics and imaging and compare findings and symptoms at presentation in a large cohort of persons with cricopharyngeus muscle dysfunction (CPMD) with and without hypopharyngeal diverticula. METHODOLOGY: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeal Hypertonicity (POUCH) Collaborative. Patient survey, comorbidities, radiography, laryngoscopy findings, and patient-reported outcome measures (e.g., Eating Assessment Tool [EAT-10]) data were abstracted from a REDCap database and summarized using means, medians, percentages, and frequencies. Diagnostic categories were compared using analysis of variance. RESULTS: A total of 250 persons were included. The mean age (standard deviation [SD]) of the cohort was 69.0 (11.2). Forty-two percent identified as female. Zenker diverticula (ZD) was diagnosed in 85.2%, 9.2% with CPMD without diverticula, 4.4% with a Killian Jamieson diverticula (KJD), and 1.2% traction-type diverticula. There were no differences between diagnostic categories in regard to age, gender, and duration of symptoms (p = 0.25, 0.19, 0.45). The mean (SD) EAT-10 score for each group was 17.1 (10.1) for ZD, 20.2 (9.3) for CPMD, and 10.3 (9.4) for KJD. Patients with isolated CPMD had significantly greater EAT-10 scores compared to the other diagnostic groups (p = 0.03). CONCLUSION: ZD is the most common, followed by CPMD without diverticula, KJD, and traction-type. Patients with isolated obstructing CPMD may be more symptomatic than persons with ZD or KJD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1349-1355, 2023.

Surgical Treatment of Acquired Velopharyngeal Insufficiency in Adults With Dysphagia and Dysphonia.

OBJECTIVES: Velopharyngeal insufficiency (VPI) is a form of velopharyngeal dysfunction caused by abnormal or insufficient anatomy. This process is known to be associated with dysphagia and dysphonia but surgical interventions for these complex patients have not been well studied. The current study characterized a small cohort of adult patients with acquired VPI, dysphonia, and dysphagia, as well as associated surgical interventions. METHODS: A retrospective descriptive case series of 22 (N = 22) adult patients over a 6-year period with acquired VPI and varying degrees of dysphagia and dysphonia was described from a multi-disciplinary voice and swallowing clinic. Perceptual assessment, nasopharyngoscopy, fluoroscopic swallowing assessment, and patient reported outcomes were reviewed to characterize the cohort. RESULTS: VPI etiologies included: stroke (n = 4), head and neck cancer (n = 5), brainstem lesions (n = 5), trauma (n = 5), and other/unknown (n = 3). All 22 patients underwent nasopharyngoscopy and were categorized as having unilateral (n = 13), central (n = 4), or no (n = 5) velopharyngeal deficits. Seventeen patients (77.2%) underwent modified barium swallow studies, revealing that soft palate elevation scored least impaired among patients with no VPI, and most impaired among patients with unilateral VPI deficits. All 22 patients underwent some form of surgical intervention for VPI, with 14 (63.6%) of those patients requiring additional surgical revision. CONCLUSION: This series is one of the first to the authors' knowledge to characterize a cohort of individuals with VPI, dysphagia, and dysphonia and associated surgical interventions.

Impact of Face Masks on Speech Acoustics and Vocal Effort in Healthcare Professionals.

OBJECTIVES/HYPOTHESIS: We investigated speech acoustics and self-reported vocal symptoms in mask-wearing healthcare professionals. We hypothesized that there would be an attenuation of spectral energies and increase in vocal effort during masked speech compared to unmasked speech. STUDY DESIGN: Within and between subject quasi-experimental design. METHODS: We prospectively enrolled 21 healthcare providers (13 cisgender female, 8 cisgender male; M = 32.9 years; SD = 7.9 years) and assessed acoustics and perceptual measures with and without a face mask in place. Measurements included: 1) acoustic Vowel Articulation Index (VAI); 2) cepstral and spectral acoustic measures; 3) traditional vocal measures (e.g., fundamental frequency, intensity); 4) relative fundamental frequency (RFF); and 5) self-reported ratings of vocal effort and dyspnea. RESULTS: During masked speech, there was a significant reduction in VAI, high-frequency information (>4 kHz), and RFF offset 10, as well as a significant increase in cepstral peak prominence and perceived vocal effort. Further analysis showed that high-frequency attenuation was more pronounced when wearing an N95 mask compared to a simple mask. CONCLUSIONS: Face masks pose an additional barrier to effective communication that primarily impacts spectral characteristics, vowel space measures, and vocal effort. Future work should evaluate how long-term mask use impacts vocal health and may contribute to vocal problems. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:391-397, 2022.

Developing Educational Health Modules to Improve Vocal Wellness in Mask-Wearing Occupational Voice Users.

OBJECTIVE: To develop educational modules to improve vocal wellness and optimize communication in mask-wearing occupational voice users. METHODS: Module development focused on identifying accurate, understandable, and actionable steps to improve vocal wellness in the workplace. We i) interviewed eight voice-specialized speech-language pathologists and researchers on current speech and voice recommendations for mask-wearers, ii) developed educational content using the standardized Patient Education Materials Assessment Tool (PEMAT), iii) assessed the ability of nine mask-wearing community members to learn educational content, and iv) compared behavioral, acoustical, and perceptual changes in four mask-wearing healthcare professionals following educational training. RESULTS: We created three educational modules that described key vocal health and communication strategies, including microphone amplification, postural alignment, clear speech, hydration, vocal naps, and vocal warm-ups. PEMAT scores were 96% and 93% on understandability and actionability, respectively. Mask-wearing healthcare professionals increased use of 4 out of the 6 strategies following educational training and were able to retain information at rates >90% at 1-week follow-up. CONCLUSIONS: We developed a set of free-to-use educational modules to promote vocal wellness among mask-wearing occupational voice users (see VSMechLab.com). Future work should examine the impact of these strategies on voice measures in a larger group of mask-wearing community members.

Modified Head and Neck Swallow Scale: Using EORTC-QLQ-H&N35 to Predict Overall Survival.

OBJECTIVES/HYPOTHESIS: Dysphagia is a treatment-related complication of head and neck cancer (HNCA). We demonstrate the predictive value of a modified head and neck swallow scale (m-HNSW) adapted from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck 35 (EORTC-QLQ-H&N35). STUDY DESIGN: Retrospective Cohort Study. METHODS: Retrospective, single-center cohort study utilizing a prospectively collected database of HNCA patients in a high-volume tertiary referral center. 736 HNCA patients more than 2 years from completion of treatment were identified. EORTC-QLQ-H&N35 data collected from at least one of three defined episodes of care were used. The m-HNSW uses three questions to form a 9-point dysphagia scale. A Cox proportional hazards model was used to determine the effect of the m-HNSW while controlling for demographics, tumor staging, site, and treatment. RESULTS: Using data from 3, 6, 12 months from treatment, we analyzed a subset that included 328 patients. Three months after the completion of therapy, the m-HNSW score had a significant association with 1 (HR = 1.24, P = .0005) and 5 year survival (HR = 1.19, P = .0002) after accounting for body mass index. Six (HR = 1.14, P = .014) and 12 month (hazard ratio (HR) = 1.33, P < .0001) scores post completion of therapy predict 5-year survival. An increase of the m-HNSW score by 1 point was associated with an increase in death by 24%, and 19% at 1 and 5 years following therapy. CONCLUSIONS: The m-HNSW is a simple assessment of dysphagia using previously validated EORTC-QLC-H&N35 data that when taken at 3, 6, and 12 months after completion of therapy is predictive of overall survival. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2478-2482, 2021.

Association of Social Determinants of Health with Time to Diagnosis and Treatment Outcomes in Idiopathic Subglottic Stenosis.

OBJECTIVES: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients. METHODS: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence. RESULTS: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression. CONCLUSIONS: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

Predicting No Show in Voice therapy: Avoiding the Missed Appointment Cycle.

INTRODUCTION: Voice therapy plays a critical role in the treatment of voice disorders. Despite positive outcomes in patients who attend voice therapy, otolaryngologists, and speech-language pathologists continue to struggle with patient compliance. Previous studies evaluating the multidisciplinary clinic model have shown better completion, VHI-10 scores, and fewer cancelation and no-shows (NS). We sought to review our own patient experience to better identify factors that predict NS rates in voice therapy. METHODS: A retrospective chart review of patients at a tertiary medical center were included if they had a scheduled appointment during a 6-month period that was cancelled or a NS. Charts were reviewed for age, gender, race, diagnosis, number of sessions attended, reason for discharge, and attending physician. NS percentage is calculated as a ratio of number cancellations to total number sessions scheduled. A multivariable general linear model was used to examine the association between NS and the listed covariates. FINDINGS: The study included 146 patients mean (SD) age 52.7 (16.6), where 62% were female and 72.6% were white. There is evidence that not being seen in a multidisciplinary clinic is significantly associated with NS rates in voice therapy (χ2 = 4.09, P = 0.0431). There is also evidence that non-white race is significantly associated with NS rates in voice therapy (χ2 = 11.76, P = 0.0006). CONCLUSIONS: Data presented in this study further support the use of a multidisciplinary model to improve NS rates in voice therapy. The relationship between nonwhite patients and lower NS suggests another determining factor in nonadherence to voice therapy.

Moving Forward with Dysphagia Care: Implementing Strategies during the COVID-19 Pandemic and Beyond.

Growing numbers of SARS-CoV-2 cases coupled with limited understanding of transmissibility and virulence, have challenged the current workflow and clinical care pathways for the dysphagia provider. At the same time, the need for non-COVID-19-related dysphagia care persists. Increased awareness of asymptomatic virus carriers and variable expression of the disease have also focused attention to appropriate patient care in the context of protection for the healthcare workforce. The objective of this review was to create a clinical algorithm and reference for dysphagia clinicians across clinical settings to minimize spread of COVID-19 cases while providing optimal care to patients suffering from swallowing disorders. Every practitioner and healthcare system will likely have different constraints or preferences leading to the utilization of one technique over another. Knowledge about this pandemic increases every day, but the algorithms provided here will help in considering the best options for proceeding with safe and effective dysphagia care in this new era.

Impact of Vertical Stiffness Gradient on the Maximum Divergence Angle.

INTRODUCTION: During vocal fold vibration, the medial surface of both folds forms a convergent shape during opening and a divergent shape during closing. A greater maximum divergence angle is associated with greater closing forces which will increase the closing speed of the glottis. An increased closing speed results in a greater acoustic intensity and greater vocal efficiency. Indentation testing showed that as the strain increases, the inferior aspect of the folds becomes stiffer than the superior aspect, resulting in the vertical stiffness gradient (VSG). We hypothesize that a reduction of the vertical stiffness gradient will reduce the maximum divergence angle. METHODS: Four excised canine larynges were tested. Stress-strain curves of the superior and inferior aspects of the fold in the mid membranous plane of the baseline larynges were taken using the indentation method. Calcium hydroxylapatite (CaHA) crystals were then injected into the superior aspect of the fold. The stress-strain tests were repeated. Particle imaging velocimetry (PIV) of the intraglottal velocity fields was performed in three larynges at different subglottal pressures in the mid coronal plane for the baseline and CaHA-injected larynges. RESULTS: CaHA injection reduced the inferior-superior stiffness gradient in all larynges. The maximal divergence angle was markedly reduced. In some cases, there was not a divergent angle. DISCUSSION: Marked reduction of the vertical stiffness gradient significantly reduces the maximum divergence angle. Clinical implications will be discussed. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E1934-E1940, 2021.

Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis.

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

Open Versus Endoscopic Surgery of Zenker's Diverticula: A Systematic Review and Meta-analysis.

Most Zenker's diverticula (ZD) cohort studies are single-institution retrospective observational studies of recurrence rates. There is a gap in the literature regarding patient-reported outcomes after ZD surgery. This study was conducted to compare if open transcervical diverticulectomy (OD) is better than endoscopic laser diverticulectomy (ELD) or endoscopic stapler-assisted diverticulectomy (ESD). The study design is of systematic review and meta-analysis. The following databases were searched: SCOPUS, EMBASE, PubMed, and Word of Science through December 2017. The quality of the studies was evaluated using 22-item STROBE checklist with 3 independent physician reviewers. The Inter-rater reliability was calculated both as a percent and utilizing Cohen's Kappa. For the meta-analysis, Cohen's d for an effect size was calculated for all studies comparing dysphagia results before and after surgery. A total of 865 patients were treated across 11 selected publications, of which 106 patients were treated OD, 310 ELD, and 449 with an ESD approach. Patient-reported dysphagia outcomes were reported as Cohen's d (confidence interval): OD, ELD, and ESD were 1.31 (0.88, 1.74), 1.91 (1.62, 2.20), and 2.45 (2.04, 2.86), respectively. The pooled effect of all studies for dysphagia was 2.22 (1.85, 2.59) and regurgitation 2.20 (1.80, 2.59). We did not prove that OD has superior outcomes compared to ESD and ELD. Any method of surgical intervention yields a large effect (i.e., improvement in dysphagia and regurgitation) comparing patient-reported symptoms before and after surgery. Future research, currently underway, includes a prospective, multi-institutional study comparing standardized outcomes between treatments of ZD including symptom resolution, complications, and recurrences using validated measures to define long-term outcomes.Level of Evidence 3.