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The location of Zenker's diverticulum along with the inherent risks of aspiration at any given stage of surgery (pre-, intra- or postoperative periods) adds an element of unique difficulty in the anesthetic approach to these patients. This chapter explores the anesthetic considerations for this unique procedure. The surgical procedure is generally curative and a majority of the patients live symptom-free for the rest of their lifetime. A main concern during the induction period is to safely secure the airway without increasing the risk of aspiration. While regurgitation and aspiration may occur during induction of anesthesia and during intubation, they might still happen even after successful uneventful intubation. Pertinent perioperative evaluation should include detailed cardiovascular and nutritional status evaluation and optimization. Perforation of Zenker's diverticulum may occur during a difficult intubation, or during blind placement of a nasogastric tube.