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1 Both authors: Department of Radiology, Hospital of the University of Pennsylvania, MRI Bldg. 1, 3400 Spruce St., Philadelphia, PA 19104-4283.
Received October 20, 2000;
accepted after revision December 15, 2000.
Address correspondence to S. E. Rubesin.
Abstract
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MATERIALS AND METHODS. A computerized search of radiology files revealed 16 patients with Killian-Jamieson diverticula and 26 patients with a Zenker's diverticulum. The double-contrast pharyngoesophagograms and medical records were reviewed retrospectively.
RESULTS. Only three (19%) of 16 patients with Killian-Jamieson diverticula had symptoms attributable to the diverticula (suprasternal dysphagia in two and cough in one), and none had aspiration pneumonia. In contrast, 16 (62%) of 26 patients with a Zenker's diverticulum had suprasternal dysphagia and three patients (12%) had aspiration pneumonia. Twenty Killian-Jamieson diverticula were detected on pharyngoesophagograms in 16 patients, including 12 (75%) with unilateral left-sided diverticula and four (25%) with bilateral diverticula. The Killian-Jamieson diverticula had an average maximal dimension of 1.4 cm. Zenker's diverticulum was nearly four times as common as Killian-Jamieson diverticula and had an average maximal dimension of 2.5 cm. Three patients (11%) with a Zenker's diverticulum had reflux of barium from the diverticula into the hypopharynx with overflow aspiration. Finally, gastroesophageal reflux was detected in nearly twice as many patients with a Zenker's diverticulum as with Killian-Jamieson diverticula.
CONCLUSION. Killian-Jamieson diverticula are less common and smaller than Zenker's diverticulum. Killian-Jamieson diverticula are less likely to cause symptoms and are less likely to be associated with overflow aspiration or gastroesophageal reflux than is Zenker's diverticulum.
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Eighteen patients with a Zenker's's diverticula were men, and eight were women. The average age was 66 years (range, 28-90 years). Sixteen patients (62%) presented with suprasternal dysphagia; one (4%), with substernal dysphagia; three (12%), with reflux symptoms; one (4%), with a globus sensation; one (4%), with a cough; and three (12%), with aspiration pneumonia. The remaining patient (4%) was asymptomatic. During the 4-year period in which 26 patients with Zenker's diverticulum were detected, six patients with lateral proximal cervical esophageal diverticula were found.
Radiographic Findings
Twenty Killian-Jamieson diverticula were detected on pharyngoesophagography
in the proximal cervical esophagus in 16 patients, including 12 unilateral
left-sided diverticula (75%) and four pairs of bilateral diverticula (25%)
(Fig.
1A,1B,1C,1D).
(No patient had unilateral right-sided diverticula.) The diverticula had an
average maximal dimension of 1.4 cm (range, 0.2-5 cm). In the 12 patients with
unilateral left-sided diverticula (Fig.
2), the diverticula had an average maximal dimension of 1.9 cm
(range, 0.2-5 cm). In the four patients with bilateral Killian-Jamieson
diverticula, the eight diverticula had an average maximal dimension of 0.7 cm
(range, 0.3-2 cm). All diverticula appeared as smoothly marginated
round-to-ovoid sacs. The size of the openings of the diverticula depended on
the location of the barium bolus in relation to the diverticula. Most of the
diverticula had openings that were broader during swallowing than either
before or after swallowing (Fig.
1A,1B,1C,1D),
but several had openings that were about the same size during and after
passage of the barium bolus. Only two Killian-Jamieson diverticula contained
debris at the time of the barium studies, but the patients had not taken
anything by mouth for at least 8 hr before we performed the examinations.
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Three patients (19%) with Killian-Jamieson diverticula had a coexisting Zenker's's diverticulum; the Zenker's's diverticulum had an average maximal dimension of 1 cm (range, 1-3 cm) (Fig. 3A,3B). Nine patients (56%) with Killian-Jamieson diverticula had normal pharyngeal motility, and seven (44%) had an abnormal pharyngeal phase of swallowing (Fig. 1A,1B,1C,1D). In addition, one patient (6%) had an abnormal oral phase with associated laryngeal penetration. However, no patient had reflux of barium from the diverticulum into the hypopharynx or overflow aspiration. One patient (6%) with a Killian-Jamieson diverticulum had a cervical esophageal web, and one (6%) had a carcinoma of the gastric cardia. Four patients (25%) with Killian-Jamieson diverticula had hiatal hernias and gastroesophageal reflux, one (6%) had gastroesophageal reflux without a hiatal hernia, and 11 (69%) had neither hiatal hernias nor gastroesophageal reflux. Finally, no patient with Killian-Jamieson diverticula had reflux esophagitis, peptic strictures, Schatzki's rings, or abnormal esophageal motility.
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A Zenker's's diverticulum was detected on pharyngoesophagography in 26 patients, with the orifice of the diverticulum arising on the posterior wall of the pharyngoesophageal junction just above the cricopharyngeus. The diverticula had an average maximal dimension of 2.5 cm (range, 0.5-8 cm). Twenty-three patients (88%) with a Zenker's diverticulum had normal pharyngeal motility (except for incomplete opening of the cricopharyngeus), and three (12%) had an abnormal pharyngeal phase of swallowing. Three patients with normal pharyngeal motility had reflux of barium from the diverticulum into the hypopharynx, resulting in overflow aspiration, and another patient with normal pharyngeal motility (4%) had an abnormal oral phase of swallowing. Twelve patients (46%) with a Zenker's diverticulum had hiatal hernias and gastroesophageal reflux, three (12%) had gastroesophageal reflux without hiatal hernias, seven (27%) had neither hiatal hernias nor gastroesophageal reflux, and the remaining four (15%) were not assessed for hiatal hernias or gastroesophageal reflux. Finally, nine patients (35%) with a Zenker's diverticulum had reflux esophagitis or peptic strictures in the distal esophagus, three (12%) had Schatzki's rings, and two (8%) had abnormal esophageal motility.
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The diagnosis of either Zenker's diverticulum or Killian-Jamieson diverticula is based primarily on the radiographic findings, rather than on endoscopy. Whereas the endoscopist may visualize the opening of a Zenker's or Killian-Jamieson diverticulum, the location of the opening of the diverticulum in relation to the cricopharyngeus muscle is best shown on pharyngography when passage of the barium bolus outlines the protruding cricopharyngeal bar. The size of the sac and the relationship of the sac to the cervical esophagus are also best shown on barium studies. Thus, these two types of diverticula can be differentiated on the basis of the radiographic findings.
Ekberg and Nylander [1] originally described 17 patients with proximal lateral cervical esophageal diverticula. Thirteen of the diverticula had wide openings, and four had narrow openings. The 13 with wide openings were recognized on pharyngoesophagography during passage of the barium bolus as transient outpouchings from the lateral wall of the proximal cervical esophagus that disappeared in 5-15 sec after the bolus had passed. In contrast, the four with narrow openings were seen during passage of the barium bolus as true outpouchings that retained barium long after the bolus had passed. Ekberg and Nylander classified the transient outpouchings as "bulges" caused by a weakened esophageal wall and the persistent outpouchings as true diverticula without muscular elements.
We believe that these transient bulges of the lateral wall of the proximal cervical esophagus described by Ekberg and Nylander [1] are in fact pouches similar to those seen on pharyngoesophagography on the anterolateral walls of the hypopharynx below the level of the hyoid bone (also known as lateral pharyngeal pouches) [6, 7] (Fig. 1A,1B,1C,1D). In our experience, these transient outpouchings from the proximal cervical esophagus are a relatively common finding on pharyngoesophagography, often associated with early closure of the upper cervical esophagus and with gastroesophageal reflux. As a result, our series included only persistent outpouchings from the lateral wall of the proximal cervical esophagus similar to the four true Killian-Jamieson diverticula described by Ekberg and Nylander. We found 20 such diverticula in 16 patients during a 7-year period; seven of these diverticula were detected in six patients during the same 4-year period in which 26 cases of Zenker's diverticulum were detected. Our experience, therefore, indicates that Zenker's diverticulum is nearly four times as common as Killian-Jamieson diverticula. Nevertheless, radiologists should be aware of the findings of Killian-Jamieson diverticula on pharyngoesophagography, so they are not mistaken for Zenker's diverticulum.
We are unable to explain why 75% of the Killian-Jamieson diverticula in our series were left sided and 25% were bilateral, whereas Ekberg and Nylander [1] did not describe a greater frequency of diverticula on either the left or right sides of the cervical esophagus. No patient in our series had unilateral left-sided pharyngeal weakness that might account for this predominance of left-sided diverticula. Nevertheless, a left-sided Killian-Jamieson diverticulum can always be differentiated from a Zenker's diverticulum extending to the left of the midline on the basis of the radiographic anatomy.
Patients with a Zenker's diverticulum were more likely to have symptoms (particularly suprasternal dysphagia) attributable to the underlying diverticulum than patients with Killian-Jamieson diverticula, who usually were asymptomatic or had symptoms attributable to abnormal pharyngeal motility. Another feature that distinguished patients with a Zenker's diverticulum from patients with Killian-Jamieson diverticula was the greater risk of aspiration pneumonia, which occurred in three (12%) of 26 cases. In all three, there was reflux of barium from the Zenker's diverticulum into the hypopharynx with overflow aspiration on pharyngoesophagography. In all patients with Killian-Jamieson diverticula, however, pharyngoesophagography revealed closure of the cricopharyngeus above the diverticula, preventing reflux of barium into the hypopharynx. This anatomic relationship of Killian-Jamieson diverticula to the cricopharyngeus presumably accounts for the absence of overflow aspiration or aspiration pneumonia in these patients.
Other investigators have shown that patients with Zenker's diverticulum have a high prevalence of gastroesophageal reflux on pharyngoesophagography [8, 9]. In our series, gastroesophageal reflux was detected on barium studies in nearly twice as many patients with a Zenker's diverticulum as with Killian-Jamieson diverticula. Thus, we also found that Zenker's diverticulum is more likely associated with gastroesophageal reflux than are Killian-Jamieson diverticula.
Two of our patients with Killian-Jamieson diverticula and one of our patients with a Zenker's diverticulum had their diverticula discovered during an upper gastrointestinal examination. We routinely view the cervical esophagus during an upper gastrointestinal series while the patient is drinking the contrast medium in both the erect and prone positions. Our routine prone fluoroscopy of esophageal motility includes examination for gross laryngeal penetration, cricopharyngeal prominence, and diverticula near the pharyngoesophageal segment. We routinely examine the pharyngoesophageal segment in patients with symptoms of gastroesophageal disease because of the strong association between gastroesophageal reflux disease and Zenker's diverticulum or an upper esophageal sphincter that opens abnormally [8, 9]. If a diverticulum is detected during an upper gastrointestinal series, we then either obtain a pharyngogram at that time or recommend obtaining a videopharyngoesophagogram at a later date.
In summary, our experience indicates that Killian-Jamieson diverticula are less common and considerably smaller than Zenker's diverticulum and appear on pharyngoesophagography as persistent left-sided or, less frequently, bilateral outpouchings from the proximal cervical esophagus below the cricopharyngeus. Killian-Jamieson diverticula also are less likely to cause symptoms and are less likely to be associated with overflow aspiration or gastroesophageal reflux than is Zenker's diverticulum.
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