The treatment of patients with a Zenker's diverticulum is endoscopic or surgical. Whichever procedure is chosen, the most important component of the procedure is a thorough cricopharyngeal myotomy. This can be accomplished either externally through a neck incision or internally with an endoscope. The endoscopic approach, which accomplishes only a myotomy and not a resection of the diverticulum, is most useful when the diverticulum is moderate in size. If the pouch is small, the endoscopic approach is riskier because there may be an inadequate protection against perforation of the pharynx; an external myotomy alone is preferable. If the pouch is large, then an external approach can accomplish both the myotomy as well as a diverticulopexy. If the pouch is extremely large, then an external myotomy and diverticulectomy would be the procedures of choice.