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Journal of The Association of Physicians of IndiaVol. 63November 2015 65

Killian-Jamieson Diverticulum:Cervical Oesophageal Diverticulum

Vinay G Zanwar1, Pravir A Gambhire1, Ajay S Choksey2, Pravin M Rathi3

Abstract

Killian-Jamieson (K-J) diverticulum is an outpouching from the lateral wall ofthe proximal cervical oesophagus and isless commonly encountered comparedto Zenkers diverticulum (ZD). These diverticulae arise between the fibers of thecricopharyngeus muscle superiorly and longitudinal muscle of the oesophagusinferiorly. In this report we present a case of a symptomatic Killian Jamiesondiverticulum and review the clinical presentation, differential diagnosis andradiological findings that distinguish it from the more common Zenkersdiverticulum.

1Resident, 2Lecturer, 3Prof. and Head, Department of Gastroenterology, TNMC and B.Y.L. Nair Hospital, Mumbai, Maharashtra

Received: 05.08.2014; Revised: 11.12.2014; Accepted: 18.12.2014

Introduction

K illian Jamieson (K-J) is a cervicaloesophageal diverticulum, whichis encountered rarely as compared

to Zenkers diverticulum (ZD), with

an incidence rat io of 1 :4 . 1 These

diverticulae arise between the fibers

o f t h e c r i c o p h a r y n g e u s m u s c l e

superiorly and longitudinal muscle

of the esophagus inferiorly.2 This gap

was first described by Killian3 and it

represents the area where the recurrent

laryngeal nerve enters the pharynx

(Figure 1). This finding was later

confirmed by Jamieson4 and is now

termed as Killian-Jamieson triangle.5

Case Report

A t w e n t y t w o y e a r o l d l a d y

presented with progressive dysphagia

to solids and liquids which developed

over four months; she also experienced

night time coughing and hoarsenessaccompanied by reflux symptoms.

She denied having odynophagia ,

halitosis, weight loss or anorexia. She

enjoyed good health till the onset of

these symptoms for which she was

prescribed pantoprazole 40 mg twice

a day and domperidone 10 mg three

times a day and was doing well with

above medications. An examination of

the head and neck was unremarkable.

Contrast oesophagogram revealed a

large sac at the level of D1 vertebra with

no cricopharyngeal bar. Axial CT neck

and thorax (Figure 2) demonstrated

31.3 cm outpouching of right lateral

oesophageal wall at level of C7-D1

vertebra having a broad neck (24 6

mm) with evidence of pooling of orally

administered contrast. There was no

evidence of perilesional fat stranding.

Oesophagogastroscopy revealed a large

pharyngoesophageal diverticulum

at 16 cm from incisors (Figure 3).

Oesophageal motility disorders were

ruled out by oesophagogram. Her

symptoms got relieved and hence

patient was not willing to undergo

surgical treatment.

Discussion

A K - J d i v e r t i c u l u m i s o f t e n

un reco gn iz ed a n d mis d ia gn o s ed

a s a Z e n k e r s d i v e r t i c u l u m o n

endoscopy. It has also been referred

to as a proximal lateral cervicaloesophageal diverticulum or as a

l a t e r a l d i v e r t i c u l u m f r o m t h e

pharyngoesophageal junction area.2 It

is not a true diverticulum as it does not

involve all layers of the gastrointestinal

wall.6 Its pathogenesis is unclear.

D y s c o o r d i n a t i o n o f p h a r y n g e a l

constrictors, cricopharyngeal spasm,

fa i lure of relaxat ion of sphincter

and premature contract ions have

been implicated. But manometr ic

and radiographic studies have failed

to unleash underlying mechanism

of such pulsion-type diverticulum.

Cervical oesophageal diverticulae

C A S E R E P O R T S

Fig. 1: Anatomic location of Zenkers and Killian-Jamieson diverticulum

Inferior Constrictor Muscle

Zenkers Diverticulum

Cricopharyngeus Muscle

Esophagus

Kilian JamiesonDiverticulum

Recurrent LaryngealNerve

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Journal of The Association of Physicians of IndiaVol. 63November 201566

Fig. 2: CT (neck and thorax)demonstrated (bold red arrow)

outpouching of right lateralesophageal wall with pooling oforally administered contrast

Fig. 3: Diverticulum (bold blue

arrow) seen duringoesophagogastroscopy onlateral wall of true lumen

(vertical black arrow)

typically present with oropharyngealdysphagia. Retention of food material

and secretions in the diverticulum

can result in regurgitation, halitosis,

chronic cough, and even aspiration

pneumonia in large diverticulum. These

symptoms are more likely with ZD.

However overflow aspiration do not

occur in patients with Killian-Jamieson

diverticulae as oesophagography has

shown cricopharyngeus muscle closure

in all patients with Killian-Jamieson

diverticulae.7

Dysphagia, cough and epigastric

pain are the most common symptomsexperienced by patients with Killian-

Jamieson diverticulum. In 2001, Rubesin

and Levine reviewed the records and

pharyngoesophagogram of sixteen

patients with K-J Diverticulum and

found eleven with symptoms.1Accurate

differentiation of K-J and Zenkers

diverticulum requires radiographic

studies. On barium oesophagogram,

Zenkers d ivert iculum is seen on

latera l v iew, 7 often with contrast

retained within the diverticulum.

A prominent cricopharyngeal bar is

often observed. A Killian-Jamieson

diverticulum is seen on the lateral wall

of the pharyngoesophageal junction

on anteroposterior view and with

contrast possibly being retained. 2, 7

At times this differentiation becomes

difficult in large diverticulum with

extension below. More precise type and

location of diverticulum can only be

obtained with the axial CT scan of neck.

Additional advantage being detection

of an occult malignancy arising in the

wall of long standing diverticulum, the

reported incidence of same being 0.4%. 8

Only symptomatic patients or those

having large diverticulae should be

treated. Due to the rare presentation

of Killian-Jamieson diverticulae, its

suggested management is scarce inliterature.2,8,9 The treatment options

are ei ther surgica l or endoscopic

diverticulotomy or diverticulectomy

w i t h o e s o p h a g o m y o t o m y . 6 , 9

Diverticulectomy has been the preferred

approach in patients who are good

surgical candidates. The only major

concern in this is the risk of causing

mediastinitis. The diverticulotomy

creates a communication between the

diverticular sac and the esophageal

lumen for free drainage of food material

without retention inside. Additional

o es o ph a go myo t o my re l iev es t h epotential functional obstruction in the

circular oesophageal muscle inferior to

the diverticula. Endoscopic treatment

of lateral diverticulae poses inherent

risk of recurrent laryngeal nerve injury

because of their intimate relationship

in t h e K- J t r ia n gle . H o w ev er in

recent times, the surgical approach

is being challenged by endoscopic

diverticulotomy. 6,9 It has been proved

to be safe and successful. The method

involves the use of a needle-knife, an

isolated-tip needle-knife papillotome

(Iso-Tome) for the dissection of the

tissue bridge of the diverticulum and

the use of fitted overtube, a nasogastric

tube, diverticulosope for adequate

visualization of the tissue bridge and

protection of the surrounding tissue.10

Diverticulopexy can be considered

alternative to diverticulectomy.6

However definitive recommendation

cannot be made and the approach hasto be individualized according to local

expertise and patient preference.

References

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Radiographic findings in 16 patients. Am J Roentgenol

2001; 177:859.

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3. Killian G. ber den Mund der Speiserhre. Zeitschrift fr

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4. Jamieson EB. In: Illustrations of regional anatomy.

Edinburgh: EandS Livingstone Ltd, 1934; (Section 2):44

5. Zaino C, Jacobson HG, Lepow H, Ozturk C. Thepharyngoesophageal sphincter. Springfield: CC Thomas,

1950; 29-144.

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Killian-Jamieson Diverticulotomy and literature review

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