Journal of The Association of Physicians of India Vol.

63 November 2015

65

Case Reports

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 of
the proximal cervical oesophagus and is less commonly encountered compared
to Zenkers diverticulum (ZD). These diverticulae arise between the fibers of the
cricopharyngeus muscle superiorly and longitudinal muscle of the oesophagus
inferiorly. In this report we present a case of a symptomatic Killian Jamieson
diverticulum and review the clinical presentation, differential diagnosis and
radiological findings that distinguish it from the more common Zenkers
diverticulum.

Introduction

illian Jamieson (K-J) is a cervical

oesophageal diverticulum, which
is encountered rarely as compared
to Zenkers diverticulum (ZD), with
an incidence ratio of 1:4.1 These
diverticulae arise between the fibers
of the cricopharyngeus muscle
superiorly and longitudinal muscle
of the esophagus inferiorly. 2 This gap
was first described by Killian 3 and it
represents the area where the recurrent
laryngeal nerve enters the pharynx
( F ig u r e 1 ) . T h i s f i ndi n g wa s l a t e r
confirmed by Jamieson 4 and is now
termed as Killian-Jamieson triangle. 5

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

Discussion
A K-J diverticulum is often
unrecognized and misdiagnosed
as a Zenkers diverticulum on
endoscopy. It has also been referred
to as a proximal lateral cervical
oesophageal diverticulum or as a
lateral diverticulum from the
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.
Dyscoordination of pharyngeal
constrictors, cricopharyngeal spasm,
failure of relaxation of sphincter
a n d p r e m a t u r e c o n t r a c t i o n s h a ve
been implicated. But manometric
and radiographic studies have failed
to unleash underlying mechanism
of such pulsion-type diverticulum.
Cervical oesophag eal divert iculae

Inferior Constrictor Muscle

Case Report
A twenty two year old lady
presented with progressive dysphagia
to solids and liquids which developed
over four months; she also experienced
night time coughing and hoarseness
accompanied 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

symptoms got relieved and hence

patient was not willing to undergo
surgical treatment.

Zenkers Diverticulum
Cricopharyngeus Muscle
Kilian Jamieson
Diverticulum

Esophagus

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

Resident, 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

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Journal of The Association of Physicians of India Vol. 63 November 2015

Fig. 2: CT (neck and thorax)

demonstrated (bold red arrow)
outpouching of right lateral
esophageal wall with pooling of
orally administered contrast

typically present with oropharyngeal

dysphagia. 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 symptoms
experienced by patients with KillianJamieson diverticulum. In 2001, Rubesin
and Levine reviewed the records and
pharyngoesophagogram of sixteen
patients with K-J Diverticulum and
found eleven with symptoms.1 Accurate
differentiation of K-J and Zenkers
diverticulum requires radiographic
studies. On barium oesophagogram,
Z e n k e r s d i ve r t i c u l u m i s s e e n o n
lateral view,7 often with contrast
r e t a i n e d w i t h i n t h e d i ve r t i c u l u m .
A prominent cricopharyngeal bar is
often observed. A Killian-Jamieson
diverticulum is seen on the lateral wall
of the pharyngoesophageal junction

Fig. 3: Diverticulum (bold blue

arrow) seen during
oesophagogastroscopy on
lateral wall of true lumen
(vertical black arrow)

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 in
literature. 2,8,9 The treatment options
are either surgical 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
oesophagomyotomy relieves the
potential 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 the K-J triangle. However 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 has
to be individualized according to local
expertise and patient preference.

References
1.

Rubesin SE, Levine MS. Killian-Jamieson diverticula:

Radiographic findings in 16 patients. Am J Roentgenol
2001; 177:859.

2.

Ekberg O, Nylander G. Lateral diverticula from the

pharyngoesophageal junction area. Radiology 1983;
146:11722.

3.

Killian G. ber den Mund der Speiserhre. Zeitschrift fr

Ohrenheilkunde 1908; 55:1-44.

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. The

pharyngoesophageal sphincter. Springfield: CC Thomas,
1950; 29-144.

6.

CH Chea, SL Siow, TW Khor, NA Nik Azim. KillianJamieson Diverticulum: The Rarer Cervical Esophageal
Diverticulum. Med J Malaysia 2011; 66:73-4.

7.

Eckberg O. Radiology of the Pharynx and the Esophagus.

Berlin: Springer-Verlag, 2003.

8.

Rogers PJ, Armstrong WB, Dana E. Killian-Jamieson

diverticulum: A case report and a review of the literature.
Ann Otol Rhinol Laryngol 2000; 109:1087-97.

9.

Tang SJ, Tang L, Chen E, Myers LL. Flexible endoscopic

Killian-Jamieson Diverticulotomy and literature review
(with video). Gastrointest Endosc 2008; 68:7903.

10.

Chang Kyun Lee. Endoscopic diverticulotomy with an

isolated-tip needle-knife papillotome (Iso-Tome) and a
fitted overtube for the treatment of a Killian-Jamieson
diverticulum. World J Gastroenterol 2008; 14:6589-92.