Killian–Jamieson Diverticulum—A Rare Cause of Dysphagia in an Adult Male

Abstract

Killian Jamieson diverticulum is a rare diverticulum of the esophagus that out pouches through the Killian Jamieson’s dehiscence. They are relatively rare compared to Zenker's diverticula, although both present similarly. However, both needs to be distinguished separately and treated accordingly given their anatomic variations.

Introduction

Killian Jamieson diverticulum (KJD) is a rare diverticulum of the esophagus that out pouches through the Killian Jamieson’s dehiscence present below the cricopharyngeus muscle and lateral to longitudinal muscles of the esophagus. It was first described by Ekberg and Nylander in 1983 and are also referred to “proximal lateral cervical esophageal diverticula” or as a “lateral diverticula from the pharyngoesophageal junction area” [1]. Though less common than the Zenker’s diverticulum (ZD) in the ratio 1:4, both are structurally similar in being false diverticula involving only the mucosal layer of the esophagus [2]. They are smaller compared to ZD rarely going up to 1.5 cms and most often asymptomatic.

Here we describe a 30-year-old male who presented with dysphagia for both solids and liquids and was diagnosed with KJD on Barium esophagography followed by surgical excision for the same.

Case Report

A 30-year-old male presented to us with symptoms of dysphagia for both solid and liquids for the past 3 months. He also had regurgitation of the ingested particles and cough occasionally. Examination with flexible laryngoscopy revealed no significant abnormality as also the examination of the neck. Barium esophagopgram was done and it revealed an esophageal pouch on the right lateral aspect in front of the 7th cervical vertebra (Fig. 1). CT scan was done to rule out any incidental malignancy and to delineate the pouch anatomically.

Fig.1.

Barium swallow showing diverticulum to the right of the esophagus

After counselling the patient, he was taken up for open surgical excision of the pouch. Endoscopic treatment was not recommended as the recurrent laryngeal nerve has a high chance of getting injured in these cases. Under general anesthesia, a distension laryngopharyngoscope was inserted lifting the arytenoids exposing the esophageal inlet. A 30° Hopkins telescope with camera was passed through the esophageal inlet to visualize the diverticulum which was found to be wide mouthed and to the right side of the normal esophageal lumen. A nasogastric tube was passed, and the pouch was packed with ribbon gauze to help during the surgery. The other end of the ribbon gauze was brought out through the mouth for easy removal.

Neck was painted and draped. A horizontal skin crease incision was taken, subplatysmal skin flaps were raised, the right sternocleidomastoid muscle was dissected and retracted laterally while the strap muscles retracted medially. The great vessels were dissected and retracted laterally while the thyroid gland was retracted medially to expose the diverticulum (Fig. 2). The diverticulum was in close relation to the inferior thyroid artery and the recurrent laryngeal nerve which were cautiously dissected off the diverticulum and saved. The ribbon gauze was pulled out from the mouth at this stage by the anesthetist. The diverticulum was then excised at its neck and sutured with 4-0 monocryl using Connells technique. Cricopharyngeal myotomy was done. A No. 10 jackson pratt drain was placed after irrigating the wound and the surgical site closed in layers. Patient was extubated and was fed with NG tube for 4 days. The drain was monitored for 4 days to look for any loss of suction which in turn would mean dehiscence at the excision site. Once this was confirmed, patient was started on oral feeds.

Fig. 2.

Operative photograph showing the pouch held with non-tooth forceps

Meanwhile, the patient developed hoarseness of voice on 2nd post-operative day and was seen to have paresis of the right recurrent laryngeal nerve. This eventually recovered by 3 weeks of observation and was confirmed by laryngeal examination. He has been on regular follow up and has been completely free of symptoms till his last follow up which was 15 months from the date of surgery. A repeat barium esophagogram was done after 1 year and was shown to be normal.

Discussion

The pharynx is lined by three constrictor muscles—the superior, middle and inferior constrictors. The inferior constrictor muscles are again divided into thyropharyngeus and the cricopharyngeus muscles. All these muscles show some degree of overlap amongst themselves with the inferior overlapping the one that is superior to it. In the process there are some dehiscence's created between these muscles which then pave way for development of diverticula. The dehiscence seen between the thyropharyngeus and cricopharyngeus part of the inferior constrictor muscles is known as the Killian’s triangle and is commonly associated with Zenker’s diverticulum. The area between the transverse and oblique muscles of the cricopharyngeus is known as Killian Jamieson area and as the anatomy would suggest, it is generally found inferior and more lateral to where one would find a Zenkers diverticulum. There is another area of dehiscence between the cricopharyngeus and the longitudinal muscles of the esophagus known as Laimer triangle and the diverticula associated with this is extremely rare.

As mentioned above KJD is an uncommon pharyngoesophageal diverticula arising in the Killian Jamieson triangle. The triangle was first described by G Killian in 1907 and confirmed by EB Jamieson in 1934 [3]. Although the pathogenesis is not clear, it may be due to high intraluminal pressure building against the dehiscent area and that the discordant swallowing against an upper sphincter causes build up in the oropharyngeal pressure leading to a pulsion type diverticulum [4, 5].

The symptomatology of KJD is like ZD like dysphagia, cough, chest pain. However, the reflux symptoms are much less in KJD than ZD [6]. Endoscopic treatment is preferred in ZD when the size is less than 3cms. However, the safety of endoscopic treatment for KJD is not well established partly due to rarity of the disease and the recurrent laryngeal nerve is closely associated to the KJD. Due to close association with the nerve open surgical treatment is preferred. The surgery should also include cricopharyngeal myotomy as it is closely linked to the pathogenesis. Since the treatments of ZD and KJD differ, it is essential that these are diagnosed as separate entities for better management.

Conclusion

Although ZD and KJD appear similar in symptomatology and endoscopy, it is important to distinguish them separately as the treatment for both differ.

Funding

None.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.