CHARACTERISTICS OF KILLIAN JAMIESON DIVERTICULA MIMICKING A THYROID NODULE

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1 CASE REPORT CHARACTERISTICS OF KILLIAN JAMIESON DIVERTICULA MIMICKING A THYROID NODULE Hee Kyung Kim, MD, 1 Ji In Lee, MD, 1 Hye Won Jang, MD, 1 So Young Bae, MD, 2 Jun Haeng Lee, MD, PhD, 2 Young-sun Kim, MD, PhD, 3 Jung Hee Shin, MD, PhD, 3 Sun Wook Kim, MD, PhD, 1 Jae Hoon Chung, MD, PhD 1 1 Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. thyroid@skku.edu 2 Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea 3 Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea Accepted 9 July 2010 Published online 12 November 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: /hed Abstract: Background. Killian Jamieson (K J) diverticula have been incidentally detected on neck ultrasonography and could be misdiagnosed as thyroid nodules. The purpose of this study was to define the clinical and ultrasonographic characteristics of K J diverticula. Methods. We analyzed 13 patients with K J diverticula mimicking thyroid nodules including 4 of our patients and 11 previously reported cases between 1984 and August Results. Seven patients (54%) were women, and all patients were asymptomatic. The average lesion s diameter was 1.5 cm (range, ). Most of the lesions (92%) were located in the left thyroid lobe. Ultrasonography showed heterogeneous echogenic masses with echogenic foci and hypoechoic rims. A connection with the adjacent esophageal wall was found in 7 diverticula (54%) at the time of initial diagnosis. Conclusion. The K J diverticula had unique ultrasonographic findings. Awareness of the fact that K J diverticula can be misdiagnosed as thyroid nodules is important to avoid unnecessary interventions. VC 2010 Wiley Periodicals, Inc. Head Neck 34: , 2012 Keywords: esophageal diverticulum; Killian Jamieson diverticulum; thyroid; nodule; esophagography; ultrasonography Killian Jamieson (K J) and Zenker diverticula are rare pharyngoesophageal diverticula which protrude through a muscular gap of anatomic weakness in the cervical esophagus near the cricopharyngeus muscle. Zenker diverticula originate in the posterior wall above the cricopharyngeus (Killian s dehiscence), whereas K J diverticula originate in the anterolateral wall just below the cricopharyngeus (Killian Jamieson space). 1 Because of the proximity of the upper esophagus to the thyroid gland, pharyngoesophageal diverticula may mimic thyroid nodules on thyroid Correspondence to: J. H. Chung The authors declare that no competing financial interests exist. VC 2010 Wiley Periodicals, Inc. ultrasonography. 2 9 The thyroid nodule incidentally detected by ultrasonography is increasing, because ultrasonographic screening of the thyroid or carotid artery is commonly performed. The misdiagnoses of esophageal diverticula as thyroid nodules could increase if an ultrasonography was performed without the information of physiological findings, especially by the paramedics. In this study, we examined 4 cases of K J diverticula that mimicked thyroid nodules on ultrasonography, andweanalyzedpreviouslyreportedcasestodefinethe clinical and ultrasonographic characteristics of K J diverticula so that unnecessary invasive procedures such as needle aspiration biopsy or surgery can be avoided. CASE REPORTS Case 1. A 55-year-old woman visited Samsung Medical Center because a thyroid nodule detected 3 years before had increased in size. She did not complain of dysphagia, neck discomfort, or fever. Physical examination revealed a non-tender, firm, 2-cm nodule on the left side of the thyroid gland. No abnormalities were noted in her biochemical tests. Serum T4, T3, and thyroid-stimulating hormone (TSH) concentrations were 77 nmol/l, 1.8 nmol/l, and 6.27 mu/l, respectively, and no thyroid autoantibodies were detected. Thyroid ultrasonography demonstrated a 3-cm nodule with heterogeneous echogenicity in the posterior aspect of the left thyroid gland. The rest of the thyroid was normal. The lesion had a smooth hypoechoic rim and internal microcalcifications with acoustic shadows (Figures 1A and 1B). The posterior border was vaguely visible because of an acoustic shadow. No pathologic lymphadenopathy was noted at the time. Ultrasound-guided fine-needle aspiration (FNA) was performed to exclude the possibility of Diverticula Mimicking a Thyroid Nodule HEAD & NECK DOI /hed April

2 FIGURE 1. Case 1 with Killian-Jamieson esophageal diverticulum. (A) A transverse sonographic image shows a well-demarcated, oval hypoechoic nodule with hypoechoic rim and echogenic foci in the left thyroid gland. (B) A sagittal sonographic image shows a 4-cm lesion in the longest diameter in the left thyroid gland. (C) Precontrast neck CT scan demonstrates a low attenuated lesion containing food material and air in the posterior aspect of the left thyroid gland of the proximal esophagus level. (D) The esophagogastroscopy shows a large outpouching lesion (black arrow) below the upper esophageal sphincter, containing food material. (E) The esophagography confirms a barium-filled sac protruding from the left anterolateral wall of the cervical esophagus. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] malignancy. Pus-like fluid was aspirated, and cytologic examination of the aspirated specimen showed necrotic material, a few follicular cells, and numerous bacterial forms. There was no evidence of malignancy. Cultures were positive for Bacillus species. On subsequent neck CT scan and esophagogastroscopy, an esophageal diverticulum was detected (Figures 1C and 1D) near the left thyroid lobe and was misdiagnosed as a thyroid abscess on thyroid ultrasonography. Subsequent esophagography demonstrated a 3-cm K J diverticulum originating from the left anterolateral wall of the esophagus (Figure 1E). Case 2. A 50-year-old man was referred to our institution for further evaluation of a 1-cm left thyroid nodule detected incidentally on a thyroid ultrasonography. He was asymptomatic. The ultrasonographic images showed a 1.2-cm oval, hypoechoic nodule containing some bright foci in the posterior aspect of the left thyroid. Fine-needle aspiration was performed to obtain a pathological diagnosis. The cytology showed scattered nucleated squamous epithelial cells, and the differential diagnosis included epidermal inclusion cyst and metastatic well-differentiated squamous cell carcinoma. Thyroid ultrasonography was repeated 3 months later, and it revealed a connection to the esophagus. Additional real-time ultrasonography showed transient changes in the size, margin, and echogenicity of the lesion, independently of the thyroid tissues, during the ingestion of water. To diagnose the esophageal 600 Diverticula Mimicking a Thyroid Nodule HEAD & NECK DOI /hed April 2012

3 FIGURE 2. Case 3 with Killian Jamieson esophageal diverticulum. (A) A transverse sonographic image shows a well-demarcated, oval hypoechoic nodule (white arrow) with hypoechoic rim and internal echogenic foci in the left thyroid gland. (B) A sagittal sonographic image looks like an intrathyroidal nodule (white arrow) in the posterior aspect of the left thyroid gland. A hypoechoic rim seen at a digestive wall can be misinterpreted as the hypoechoic halo of a thyroid nodule. (C) A sac-like outpouching (white arrow) is noted in the upper cervical esophagus at esophagography. diverticulum, an esophagography was performed and showed a K J diverticulum originating from the left anterolateral wall of the cervical esophagus. Case 3. An asymptomatic 55-year-old man was referred to our institution for further evaluation of a left thyroid nodule detected incidentally on a thyroid ultrasonography. The ultrasonography images showed a 1.2-cm left thyroid nodule with heterogeneous internal echogenicity and a hypoechoic halo (Figures 2A and 2B). Although a connection to the esophagus could not be found on the ultrasonography, the lesion seemed to be extrathyroidal. Consequently, an esophagography was performed, and a K J diverticulum was identified (Figure 2C). Case 4. A 59-year-old woman was referred to our institution for further evaluation of a left thyroid nodule detected incidentally on thyroid ultrasonography. On ultrasonography, the lesion was suspicious for an extrathyroidal lesion such as an esophageal diverticulum. An esophagography revealed a K J diverticulum. DISCUSSION When K J and Zenker diverticula are large, they can be found in proximity to the thyroid gland and may mimic thyroid nodules on ultrasonography. K J diverticula originate in the anterolateral wall of the esophagus, whereas Zenker diverticula originate in the posterior wall of the esophagus. Although Zenker diverticula are generally reported to be approximately 4 times as common as K J diverticula, K J diverticula are more easily misdiagnosed as thyroid nodules because of their anatomic location In our experience, all of the esophageal diverticula misdiagnosed as thyroid nodules by neck ultrasonography were K J diverticula. We searched for previously reported cases of K J diverticula mimicking thyroid nodules to determine the clinical and ultrasonographic characteristics of K J diverticula. We found 9 cases of K J diverticula in which the ultrasonography and esophagography were performed between 1984 and August 2009 using PubMed and KoreaMed. 2 9 Ultimately, 13 cases of K J diverticula, including our 4 cases, were analyzed (Table 1). Of the 13 patients with K J diverticula, 7 patients were women and 6 were men. Their mean age was 57 years old, with a range of 41 to 70 years (mean SD; years). All of the patients were initially diagnosed as having thyroid nodules. Twelve patients were referred for aspiration of a thyroid nodule, and Diverticula Mimicking a Thyroid Nodule HEAD & NECK DOI /hed April

4 Table 1. Clinical characteristics of 13 cases of Killian Jamieson diverticula mimicking thyroid nodules. Author Age /sex Chief complaint Size, cm FNA (cytology) Case 1 55/F Increased size of known thyroid nodule 4.0 Yes (necrotic material admixed with a few nests of follicular cells and microorganisms) Case 2 50/M For FNA of nodule incidentally detected 1.2 Yes (scattered nucleated squamous epithelial cells) Case 3 55/M For FNA of nodule incidentally detected 1.2 No Case 4 59/F For FNA of nodule incidentally detected 1.7 No Pang et al 2 54/M For FNA of nodule incidentally detected 1.1 Yes (few squamous cells, amorphous material, vegetal cells without follicular cells) Mercer et al 3 58/F For FNA of nodule incidentally detected 2.5 No Kim et al 4 50/F For FNA of nodule incidentally detected 1.0 No Kim et al 5 41/M For FNA of nodule incidentally detected 0.6 No Kim et al 6 70/M For FNA of nodule incidentally detected 2.5 Yes (air aspiration) Yoon et al 7 62/F For FNA of nodule incidentally detected 1.0 Yes (squamous cells, bacteria) Park et al 8 64/M For FNA of nodule incidentally detected 0.9 Yes (blood only) Park et al 8 55/F For FNA of nodule incidentally detected 0.5 No Rekhtman et al 9 62/F For FNA of nodule incidentally detected 1.2 Yes (squamous cells, bacteria, vegetable matter) Abbreviation: F, female; M, male; FNA, fine-needle aspiration. the other patient was referred for increased size of a pre-existing nodule. All patients were asymptomatic and were not experiencing dysphagia, difficulty swallowing, or reflux. The average diameter of the diverticula measured by ultrasonography was 1.5 cm, with a range of 0.5 to 4.0 cm. The diverticula of 12 patients (92%) were located in the posterior aspect of the left thyroid lobe, and the other diverticulum (8%) was found in the right lobe. On ultrasonography, all of the diverticula showed heterogeneous echo-texture. A hypoechoic rim was found in 11 (85%) of 13 diverticula, and an echogenic focus similar to that of a microcalcification was detected in 12 diverticula (92%). A connection with the adjacent esophageal wall was found in 7 diverticula (54%), and it was detected in 2 diverticula with second-look ultrasonography. Transient changes in size, margins, and echogenicity during swallowing were detected in 5 diverticula (Table 2). Ultrasonography guided aspiration was performed in the 7 patients. On cytological examination, squamous epithelial cells were detected in 3 patients, follicular cells with necrotic material were found in 1 patient, and numerous bacteria were detected in 2 patients. Zenker diverticula initially protrude posteriorly; however, as they enlarge, backward extension is prevented by the prevertebral fascia, and they project to 1 side. The left carotid artery is attached to the prevertebral fascia less tightly than the right carotid artery, whereas the cervical esophagus is curved to the left. Consequently, approximately 90% of Zenker diverticula extend to the left side. 17 Rubesin and Levine 18 reported that 75% of K J diverticula originate in the left esophageal wall, whereas the other 25% are bilateral. In this study, most of the K J diverticula originated in the left esophageal wall. Unfortunately, it is not known why K J diverticula more often originate on the left side. Esophageal diverticula are usually detected incidentally by an esophagography. Recently, diverticula have Table 2. Ultrasonographic findings of 13 cases of Killian Jamieson diverticula. Ultrasonographic findings No. of patients % Location (left) Hypoechoic rim Multilayered rim 1 8 No well defined posterior wall of nodule 9 69 Heterogenic internal echo Echogenic foci Connected to the esophagus 7 54 Change in internal echo during swallowing 6 46 also been detected by thyroid ultrasonography. It has also been found that diverticula may sometimes mimic thyroid nodules on thyroid ultrasonography. 10,11,13 17,19 21 Occasionally, ultrasonography guided aspiration could be performed in esophageal diverticula in which a connection to the esophagus was not found at the time of diagnosis. Additionally, the patient in case 1 was admitted to the hospital under the incorrect diagnosis of thyroid abscess, and unnecessary antibiotics were administered. Food material in the esophageal diverticulum was regarded as pus or necrotic material during aspiration. It is important to recognize the characteristic ultrasonographic findings of diverticula to avoid unnecessary procedures or treatments. Following are the principal ultrasonographic characteristics of esophageal diverticula. First, heterogeneous internal echo with strong echogenic foci caused by air bubbles or other particles are observed in almost all cases. These findings could be regarded as microcalcifications of papillary thyroid cancer, but there is stronger echogenicity and irregularity of the post acoustic shadow. Second, a hypoechoic rim with or without a multilayered pattern. This finding suggests that the digestive tract is the origin of the lesion (mucosa, submucosa, and muscular layers). The observation of a 602 Diverticula Mimicking a Thyroid Nodule HEAD & NECK DOI /hed April 2012

5 connection to the esophagus is also helpful in making the correct diagnosis. Third, an irregular boundary of the posterior wall of the lesion at the posterior portion of the thyroid gland. Fourth, chronological changes in the internal echo which are associated with changes in the contents of the diverticulum, such as air, water, or debris. These changes result during compression with a probe or during the swallowing of air or water. 13,16 In this study, a connection with the esophageal wall was not detected in any of our 4 patients. The possibility of K J diverticula should be considered when a thyroid nodule is detected adjacent to the esophagus, even if ultrasonographic changes during or after swallowing are not observed. Approximately 25% of K J diverticula do not empty quickly after swallowing because they have narrow necks. 1,22 An esophagography should be performed to confirm the diagnosis and to evaluate the anatomic information required for treatment planning. Recently, the detection of esophageal diverticula by thyroid ultrasonography has been increasing. Esophageal diverticula have characteristic findings different from those of true thyroid nodules. Suspicion of extrathyroidal lesions, such as diverticula, is important so that misdiagnoses and unnecessary interventions can be avoided. REFERENCES 1. Ekberg O, Nylander G. Lateral diverticula from the pharyngoesophageal junction area. Radiology 1983;146: Pang JC, Chong S, Na HI, Kim YS, Park SJ, Kwon GY. Killian- Jamieson diverticulum mimicking a suspicious thyroid nodule: sonographic diagnosis. J Clin Ultrasound 2009;37: Mercer D, Blachar A, Khafif A, Weiss J, Kessler A. Real-time sonography of Killian-Jamieson diverticulum and its differentiation from thyroid nodules. J Ultrasound Med 2005;24: Kim ES, Lee K, Yoon HS, et al. Killian-Jamieson diverticulum mimicking a thyroid nodule on ultrasonography: a case report. J Korean Soc Med Ultrasound 2007;26: Kim KH, Son EJ, Kim E, Kwak JY, Oh KK. Pharyngoesophageal (Killian-Jamieson) diverticulum mimicking thyroid nodule on ultrasonography: a case report. J Korean Radiol Soc 2006;55: Kim SJ, Lee MW. Killian-Jamieson diverticula mimicking thyroid nodule on ultrasound: radiographic findings in two patients. J Korean Radiol Soc 2006;55: Yoon HD, Shon HS. Killian-Jamieson diverticulum mimicking a thyroid nodule. Korean J Med 2005;68: Park CS, Lee JW, Oh SJ, et al. Killian-Jamieson diverticula mimicking a right thyroid nodule on ultrasonography: a case report. J Korean Soc Ultrasound Med 2008;27: Rekhtman N, Rekhtman K, Sheth S, Ali SZ. A 62-year-old woman with a suspected thyroid nodule. Arch Pathol Lab Med 2005;129: DeFriend DE, Dubbins PA. Sonographic demonstration of a pharyngoesophageal diverticulum. J Clin Ultrasound 2000;28: Kim J, Kim YJ, Kim EK, Park CS. Incidentally found pharyngoesophageal diverticulum on ultrasonography. Yonsei Med J 2002; 43: Kwak JY, Kim EK. Sonographic findings of Zenker diverticula. J Ultrasound Med 2006;25: Kumar A, Aggarwal S, Pham DH. Pharyngoesophageal (Zenker s) diverticulum mimicking thyroid nodule on ultrasonography: report of two cases. J Ultrasound Med 1994;13: Biggi E, Derchi LE, Cicio GR, Neumaier CE. Sonographic findings of Zenker s diverticulum. J Clin Ultrasound 1982;10: Hayashi N, Tamaki N, Konishi J, et al. Lateral pharyngoesophageal diverticulum simulating thyroid adenoma on sonography. J Clin Ultrasound 1984;12: Kang HC. A case of Zenker s diverticulum masquerading as a thyroid nodule. The Korean Journal of Medicine 2004;67: Westrin KM, Ergun S, Carlsöö B. Zenker s diverticulum a historical review and trends in therapy. Acta Otolaryngol 1996;116: Rubesin SE, Levine MS. Killian-Jamieson diverticula: radiographic findings in 16 patients. AJR Am J Roentgenol 2001; 177: Seiberling KA, Dutra JC, Gunn J. Ultrasound-guided fine needle aspiration biopsy of thyroid nodules performed in the office. Laryngoscope 2008;118: Komatsu M, Komatsu T, Inove K. Ultrasonography of Zenker s diverticulum: special reference to differential diagnosis from thyroid nodules. Eur J Ultrasound 2000;11: Chu H-R, Lee J-S, Han D-H, Jin H-W. A case of Killian-Jamieson diverticulum simulating thyroid mass. Korean J Head Neck Oncology 2006;22: Rubesin SE. Pharynx. 2nd ed. Philadelphia: W.B. Saunders; p 190. Diverticula Mimicking a Thyroid Nodule HEAD & NECK DOI /hed April