Killian-Jamieson Diverticulum

Killian-Jamieson Diverticulum
Other Names	Lateral pharyngoesophageal diverticulum; Anterolateral cervical esophageal diverticulum
Barium esophagram filling a Killian-Jamieson diverticulum
Identifiers
ICD-9	530.6
ICD-10	K22.5
Outside Resources
Radiopaedia	https://radiopaedia.org/articles/killian-jamieson-diverticulum

1. Killian-Jamieson Diverticulum

Killian-Jamieson Diverticulum
Other Names	Lateral pharyngoesophageal diverticulum; Anterolateral cervical esophageal diverticulum
Barium esophagram filling a Killian-Jamieson diverticulum
Identifiers
ICD-9	530.6
ICD-10	K22.5
Outside Resources
Radiopaedia	https://radiopaedia.org/articles/killian-jamieson-diverticulum

1. Killian-Jamieson Diverticulum

Overview

Killian-Jamieson diverticulum (KJD) is a rare pharyngoesophageal diverticulum that herniates through the Killian-Jamieson space, an area of muscular weakness in the anterolateral wall of the proximal cervical esophagus below the cricopharyngeus muscle. This distinguishes it from the more common Zenker diverticulum, which herniates through Killian's dehiscence above the cricopharyngeus.

Killian-Jamieson diverticula account for approximately 20-25% of pharyngoesophageal diverticula. They typically present with dysphagia, regurgitation, and occasionally recurrent laryngeal nerve dysfunction due to their proximity to this nerve. KJD has been described as "the great mimicker" due to its variable presentations, including being frequently mistaken for thyroid nodules. The condition is more common in women and tends to present at an older age than Zenker diverticulum. Surgical management is typically required for symptomatic cases.

History

Killian-Jamieson diverticulum was first described in 1983 by Ekberg and Nylander in their landmark radiological study published in Radiology, where they identified lateral diverticula from the pharyngoesophageal junction area in a series of 17 patients.

The Killian-Jamieson space is named after Gustav Killian (1860-1921), a German laryngologist who made seminal contributions to bronchoscopy and laryngology, and James Jamieson, who together characterized the anatomical weakness in the pharyngoesophageal region in the early 20th century. Killian first described Killian's dehiscence (the gap between the oblique and horizontal fibers of the cricopharyngeus muscle) in 1908. The Killian-Jamieson space, located more anterolaterally and below the cricopharyngeus, was subsequently recognized as a distinct area of weakness separate from Killian's dehiscence.

This recognition helped distinguish anterolateral cervical esophageal diverticula from the more common posterior Zenker diverticula. Despite being recognized for over 40 years, KJD remains rare with fewer than 100 cases reported in the world literature.

Pathophysiology

Relevant Anatomy

Pharyngoesophageal junction anatomy:

Understanding the areas of muscular weakness is essential for distinguishing different diverticula types:

Killian's dehiscence:

• Triangular area between oblique fibers of inferior pharyngeal constrictor and horizontal fibers of cricopharyngeus
• Posterior midline location
• Site of Zenker diverticulum formation

Killian-Jamieson space:

• Triangular area of weakness in anterolateral cervical esophagus
• Located BELOW cricopharyngeus muscle (distinguishing feature)
• Bounded by:
  • Cricopharyngeus (superiorly)
  • Longitudinal esophageal muscle fibers (laterally)
  • Cricoid cartilage (medially)
• Site of Killian-Jamieson diverticulum formation

Laimer triangle (Laimer-Haeckerman area):

• Posterior aspect of cervical esophagus below cricopharyngeus
• Between circular and longitudinal muscle fibers
• Site of Laimer diverticulum (very rare)

Critical adjacent structures:

• Recurrent laryngeal nerve: Runs in tracheoesophageal groove; at risk during surgery
• Inferior thyroid artery: Crosses near esophageal wall
• Thoracic duct (left side): May be injured during surgical approaches

Disease Etiology

Pathogenesis: Killian-Jamieson diverticula are pulsion diverticula resulting from: 1. Increased intraluminal pressure in the hypopharynx/esophagus 2. Muscular weakness in the Killian-Jamieson area 3. Herniation of mucosa and submucosa through the defect

Contributing factors:

• Cricopharyngeal dysfunction (controversial)
• Gastroesophageal reflux disease (GERD)
• Age-related tissue weakening
• Increased swallowing pressures

Distinction from Zenker diverticulum:

• Killian-Jamieson: Below cricopharyngeus, anterolateral location
• Zenker: Above cricopharyngeus, posterior midline location
• The two may coexist in some patients

Histology:

• False diverticulum (pulsion type)
• Mucosa and submucosa only; lacks muscularis propria
• May show inflammatory changes

Diagnosis

Patient History

Presenting symptoms (often milder than Zenker diverticulum):

In the comprehensive literature review of 68 cases by Haddad et al. (2020):

• Dysphagia: Most common symptom (57%, n=39 of 68 cases); usually to solids
• Suspected thyroid nodule: Second most common presentation (35%, n=24); often discovered incidentally on imaging
• Globus sensation: Feeling of lump in throat (21%, n=14 of 68 cases)
• Regurgitation: Of undigested food, may occur hours after eating
• Hoarseness: If recurrent laryngeal nerve affected by inflammation or compression
• Chronic cough: From aspiration
• Halitosis: From retained food debris
• Weight loss: In severe or prolonged cases

Characteristics:

• Often incidental finding on imaging - notably, 35% presented as suspected thyroid nodule; cases have been discovered incidentally during thyroidectomy
• May be asymptomatic
• Symptoms typically less severe than Zenker diverticulum
• Median age at presentation: 58 years
• Female predominance: F:M ratio 39:29 (57% female) in comprehensive literature review

Physical Examination

Physical examination is often unremarkable but may reveal:

• Gurgling sounds in neck during swallowing (rare)
• Neck mass: Unusual, but large diverticulum may be palpable
• Laryngoscopy: May show signs of aspiration, vocal fold weakness
• Voice assessment: Hoarseness if recurrent laryngeal nerve involved

Laboratory Tests

Laboratory testing is generally not specific:

• Nutritional assessment if significant weight loss
• Thyroid function tests if thyroid abnormalities noted on imaging

Imaging

Barium swallow/Esophagram (diagnostic study of choice):

• Findings:
  • Outpouching from anterolateral wall of proximal cervical esophagus
  • Located below cricopharyngeus (distinguishes from Zenker diverticulum)
  • Usually unilateral; more common on left (75% left-sided, 25% bilateral)
  • Typically smaller than Zenker diverticula (average maximal dimension 1.4 cm)
  • Best visualized using dynamic fluoroscopy studies

CT neck with contrast:

• Shows diverticulum location and size
• Relationship to adjacent structures (recurrent laryngeal nerve, thyroid)
• May identify concomitant pathology
• Can be performed in prone position with oral contrast ingestion

Video fluoroscopic swallowing study (VFSS):

• Dynamic assessment of swallowing function
• Evaluates cricopharyngeal function
• Assesses aspiration risk
• May differentiate fixed from transient pouches

Esophagogastroduodenoscopy (EGD):

• May visualize diverticulum opening
• Can be difficult to distinguish from Zenker diverticulum
• Useful to evaluate esophageal mucosa
• Helpful for excluding malignancy

Ultrasonography:

• Alternative imaging modality for detecting diverticula
• Can identify diverticulum and assess for complications

Differential Diagnosis

• Zenker diverticulum: Posterior, above cricopharyngeus
• Laimer diverticulum: Posterior, below cricopharyngeus
• Lateral pharyngeal diverticulum: Different anatomical origin
• Esophageal web or stricture: Narrowing without outpouching
• Cricopharyngeal bar: Muscular prominence without true diverticulum
• Cervical esophageal carcinoma: Malignant mass
• Thyroid nodule: External compression
• Laryngocele: Laryngeal air-filled cavity

Comparison: Killian-Jamieson vs Zenker Diverticulum

Careful radiographic evaluation is essential to distinguish KJD from Zenker diverticulum, as the surgical approach and risks differ significantly.

Feature	Killian-Jamieson Diverticulum	Zenker Diverticulum
Anatomical location	Anterolateral cervical esophagus	Posterior midline hypopharynx
Relation to cricopharyngeus	Below cricopharyngeus muscle	Above cricopharyngeus muscle (through Killian's dehiscence)
Space of herniation	Killian-Jamieson space	Killian's dehiscence
Laterality	75% left-sided, 25% bilateral	Midline posterior
RLN proximity	Critical - directly adjacent, high injury risk	More distant from RLN
Average size	Smaller (mean 1.4 cm)	Typically larger (2-3 cm average)
Prevalence	Rare (<100 cases reported)	More common (20-25% of pharyngoesophageal diverticula)
Symptom severity	Often milder	Typically more symptomatic
Association with thyroid	Often discovered as suspected thyroid nodule (35%)	Rarely confused with thyroid
Preferred surgical approach	Transcervical with RLN monitoring	Endoscopic or transcervical
Cricopharyngeal myotomy	Controversial, role less established	Standard adjunct treatment

Management

Medical Management

Conservative management may be appropriate for:

• Asymptomatic small diverticula
• Elderly patients with significant comorbidities
• Patient preference after informed discussion

Measures include:

• Dietary modification (small bites, thorough chewing, soft foods)
• Upright positioning during and after meals
• Avoidance of foods that worsen symptoms
• Treatment of GERD if present
• Swallowing therapy and techniques
• Regular follow-up to monitor for symptom progression

Surgical Management

Surgical intervention is recommended for symptomatic patients:

Open surgical approaches:

Transcervical diverticulectomy:

• Preferred approach for most symptomatic cases
• Left cervical incision (most diverticula are left-sided; 68 cases had 51 on left, 11 on right, 5 bilateral)
• Identification and preservation of recurrent laryngeal nerve
• Excision of diverticulum with stapled or sutured closure
• May include cricopharyngeal myotomy if dysfunction present
• Average diverticulum size managed transcervically: 3.8 cm

Surgical technique considerations:

• Careful dissection to protect recurrent laryngeal nerve
• Use of intraoperative neural monitoring system recommended
• Ensure adequate mucosal closure with reinforced suture line
• Place drain to prevent hematoma formation
• Typical recovery: discharge 5-7 days post-operatively

Endoscopic approaches:

Flexible endoscopic diverticulotomy:

• Emerging technique
• Division of septum between diverticulum and esophageal lumen
• Uses specialized endoscopic equipment
• May have shorter recovery than open surgery
• Experience more limited than for Zenker diverticulum
• Better suited for smaller diverticula

Rigid endoscopic stapling (endoscopic diverticulotomy with stapler):

• Linear endo-stapler placed at midline of septum
• Cutting depth approximately 2 cm without touching diverticulum base
• Technique similar to that used for Zenker diverticulum
• May be challenging due to anterolateral location
• Less commonly performed than for Zenker
• Average diverticulum size managed endoscopically: 2.8 cm
• Provides adequate visualization and RLN protection during stapling

Cricopharyngeal myotomy:

• Controversial as adjunct procedure
• Role less established than for Zenker diverticulum
• May be considered if cricopharyngeal dysfunction documented (13 of 22 transcervical cases included myotomy)
• Enhances symptom relief when dysfunction is present

Outcomes

Complications

Without treatment:

• Progressive dysphagia
• Aspiration pneumonia
• Weight loss and malnutrition
• Rarely: Diverticulitis, perforation, mediastinitis

Surgical complications:

• Recurrent laryngeal nerve injury: Most important risk due to close anatomical proximity; may cause permanent hoarseness
• Pharyngocutaneous fistula: Leakage from repair
• Esophageal stricture: From scarring
• Mediastinitis: Rare, from perforation or leak
• Recurrence: Reported in 5-10%
• Hematoma: Neck hematoma requiring drainage

Key observation: In the comprehensive literature review by Haddad et al. (2020), both reported recurrences occurred following endoscopic procedures, suggesting that transcervical diverticulectomy with intraoperative RLN monitoring may offer superior long-term outcomes when properly performed.

Prognosis

Outcomes are generally good with appropriate treatment:

• Symptomatic improvement in 85-95% of surgical patients
• Recurrence rate approximately 5-10%
• Mortality from surgical treatment is very low (<1%)
• Most diverticula managed transcervically achieved good outcomes without RLN injury when neural monitoring used

Factors affecting outcomes:

• Surgeon experience and familiarity with technique
• Diverticulum size (larger diverticula may require open approach)
• Patient comorbidities and surgical fitness
• Presence of recurrent laryngeal nerve injury
• Use of intraoperative neural monitoring

Long-term considerations:

• Follow-up imaging if symptoms recur
• Voice therapy if nerve injury occurs
• Continued surveillance for aspiration
• Diet progression as tolerated post-operatively
• Return to normal diet typically achievable in most patients

Epidemiology

• Accounts for 20-25% of pharyngoesophageal diverticula
• Prevalence in general population: approximately 0.025%
• Comprehensive literature review identified 68 cases in 59 reports
• Female predominance: 39 females vs. 29 males (58% female)
• Median age at presentation: 58 years
• Laterality: Left-sided predominance (75% left, 15% right, 7% bilateral)

History

Killian-Jamieson diverticulum was first described in 1983 by Ekberg and Nylander in their landmark radiological study published in Radiology, where they identified lateral diverticula from the pharyngoesophageal junction area in a series of 17 patients.

The Killian-Jamieson space is named after Gustav Killian (1860-1921), a German laryngologist who made seminal contributions to bronchoscopy and laryngology, and James Jamieson, who together characterized the anatomical weakness in the pharyngoesophageal region in the early 20th century. Killian first described Killian's dehiscence (the gap between the oblique and horizontal fibers of the cricopharyngeus muscle) in 1908. The Killian-Jamieson space, located more anterolaterally and below the cricopharyngeus, was subsequently recognized as a distinct area of weakness separate from Killian's dehiscence.

This recognition helped distinguish anterolateral cervical esophageal diverticula from the more common posterior Zenker diverticula. Despite being recognized for over 40 years, KJD remains rare with fewer than 100 cases reported in the world literature.

Pathophysiology

Relevant Anatomy

Pharyngoesophageal junction anatomy:

Understanding the areas of muscular weakness is essential for distinguishing different diverticula types:

Killian's dehiscence:

• Triangular area between oblique fibers of inferior pharyngeal constrictor and horizontal fibers of cricopharyngeus
• Posterior midline location
• Site of Zenker diverticulum formation

Killian-Jamieson space:

• Triangular area of weakness in anterolateral cervical esophagus
• Located BELOW cricopharyngeus muscle (distinguishing feature)
• Bounded by:
  • Cricopharyngeus (superiorly)
  • Longitudinal esophageal muscle fibers (laterally)
  • Cricoid cartilage (medially)
• Site of Killian-Jamieson diverticulum formation

Laimer triangle (Laimer-Haeckerman area):

• Posterior aspect of cervical esophagus below cricopharyngeus
• Between circular and longitudinal muscle fibers
• Site of Laimer diverticulum (very rare)

Critical adjacent structures:

• Recurrent laryngeal nerve: Runs in tracheoesophageal groove; at risk during surgery
• Inferior thyroid artery: Crosses near esophageal wall
• Thoracic duct (left side): May be injured during surgical approaches

Disease Etiology

Pathogenesis: Killian-Jamieson diverticula are pulsion diverticula resulting from: 1. Increased intraluminal pressure in the hypopharynx/esophagus 2. Muscular weakness in the Killian-Jamieson area 3. Herniation of mucosa and submucosa through the defect

Contributing factors:

• Cricopharyngeal dysfunction (controversial)
• Gastroesophageal reflux disease (GERD)
• Age-related tissue weakening
• Increased swallowing pressures

Distinction from Zenker diverticulum:

• Killian-Jamieson: Below cricopharyngeus, anterolateral location
• Zenker: Above cricopharyngeus, posterior midline location
• The two may coexist in some patients

Histology:

• False diverticulum (pulsion type)
• Mucosa and submucosa only; lacks muscularis propria
• May show inflammatory changes

Diagnosis

Patient History

Presenting symptoms (often milder than Zenker diverticulum):

In the comprehensive literature review of 68 cases by Haddad et al. (2020):

• Dysphagia: Most common symptom (57%, n=39 of 68 cases); usually to solids
• Suspected thyroid nodule: Second most common presentation (35%, n=24); often discovered incidentally on imaging
• Globus sensation: Feeling of lump in throat (21%, n=14 of 68 cases)
• Regurgitation: Of undigested food, may occur hours after eating
• Hoarseness: If recurrent laryngeal nerve affected by inflammation or compression
• Chronic cough: From aspiration
• Halitosis: From retained food debris
• Weight loss: In severe or prolonged cases

Characteristics:

• Often incidental finding on imaging - notably, 35% presented as suspected thyroid nodule
• May be asymptomatic
• Symptoms typically less severe than Zenker diverticulum
• Median age at presentation: 58 years
• Female predominance: F:M ratio 39:29 (57% female) in comprehensive literature review

Physical Examination

Physical examination is often unremarkable but may reveal:

• Gurgling sounds in neck during swallowing (rare)
• Neck mass: Unusual, but large diverticulum may be palpable
• Laryngoscopy: May show signs of aspiration, vocal fold weakness
• Voice assessment: Hoarseness if recurrent laryngeal nerve involved

Laboratory Tests

Laboratory testing is generally not specific:

• Nutritional assessment if significant weight loss
• Thyroid function tests if thyroid abnormalities noted on imaging

Imaging

Barium swallow/Esophagram (diagnostic study of choice):

• Findings:
  • Outpouching from anterolateral wall of proximal cervical esophagus
  • Located below cricopharyngeus (distinguishes from Zenker diverticulum)
  • Usually unilateral; more common on left (75% left-sided, 25% bilateral)
  • Typically smaller than Zenker diverticula (average maximal dimension 1.4 cm)
  • Best visualized using dynamic fluoroscopy studies

CT neck with contrast:

• Shows diverticulum location and size
• Relationship to adjacent structures (recurrent laryngeal nerve, thyroid)
• May identify concomitant pathology
• Can be performed in prone position with oral contrast ingestion

Video fluoroscopic swallowing study (VFSS):

• Dynamic assessment of swallowing function
• Evaluates cricopharyngeal function
• Assesses aspiration risk
• May differentiate fixed from transient pouches

Esophagogastroduodenoscopy (EGD):

• May visualize diverticulum opening
• Can be difficult to distinguish from Zenker diverticulum
• Useful to evaluate esophageal mucosa
• Helpful for excluding malignancy

Ultrasonography:

• Alternative imaging modality for detecting diverticula
• Can identify diverticulum and assess for complications

Differential Diagnosis

• Zenker diverticulum: Posterior, above cricopharyngeus
• Laimer diverticulum: Posterior, below cricopharyngeus
• Lateral pharyngeal diverticulum: Different anatomical origin
• Esophageal web or stricture: Narrowing without outpouching
• Cricopharyngeal bar: Muscular prominence without true diverticulum
• Cervical esophageal carcinoma: Malignant mass
• Thyroid nodule: External compression
• Laryngocele: Laryngeal air-filled cavity

Comparison: Killian-Jamieson vs Zenker Diverticulum

Feature	Killian-Jamieson Diverticulum	Zenker Diverticulum
Anatomical location	Anterolateral cervical esophagus	Posterior midline hypopharynx
Relation to cricopharyngeus	Below cricopharyngeus muscle	Above cricopharyngeus muscle (through Killian's dehiscence)
Space of herniation	Killian-Jamieson space	Killian's dehiscence
Laterality	75% left-sided, 25% bilateral	Midline posterior
RLN proximity	Critical - directly adjacent, high injury risk	More distant from RLN
Average size	Smaller (mean 1.4 cm)	Typically larger (2-3 cm average)
Prevalence	Rare (<100 cases reported)	More common (20-25% of pharyngoesophageal diverticula)
Symptom severity	Often milder	Typically more symptomatic
Association with thyroid	Often discovered as suspected thyroid nodule (35%)	Rarely confused with thyroid
Preferred surgical approach	Transcervical with RLN monitoring	Endoscopic or transcervical
Cricopharyngeal myotomy	Controversial, role less established	Standard adjunct treatment

Management

Medical Management

Conservative management may be appropriate for:

• Asymptomatic small diverticula
• Elderly patients with significant comorbidities
• Patient preference after informed discussion

Measures include:

• Dietary modification (small bites, thorough chewing, soft foods)
• Upright positioning during and after meals
• Avoidance of foods that worsen symptoms
• Treatment of GERD if present
• Swallowing therapy and techniques
• Regular follow-up to monitor for symptom progression

Surgical Management

Surgical intervention is recommended for symptomatic patients:

Open surgical approaches:

Transcervical diverticulectomy:

• Preferred approach for most symptomatic cases
• Left cervical incision (most diverticula are left-sided; 68 cases had 51 on left, 11 on right, 5 bilateral)
• Identification and preservation of recurrent laryngeal nerve
• Excision of diverticulum with stapled or sutured closure
• May include cricopharyngeal myotomy if dysfunction present
• Average diverticulum size managed transcervically: 3.8 cm

Surgical technique considerations:

• Careful dissection to protect recurrent laryngeal nerve
• Use of intraoperative neural monitoring system recommended
• Ensure adequate mucosal closure with reinforced suture line
• Place drain to prevent hematoma formation
• Typical recovery: discharge 5-7 days post-operatively

Endoscopic approaches:

Flexible endoscopic diverticulotomy:

• Emerging technique
• Division of septum between diverticulum and esophageal lumen
• Uses specialized endoscopic equipment
• May have shorter recovery than open surgery
• Experience more limited than for Zenker diverticulum
• Better suited for smaller diverticula

Rigid endoscopic stapling (endoscopic diverticulotomy with stapler):

• Linear endo-stapler placed at midline of septum
• Cutting depth approximately 2 cm without touching diverticulum base
• Technique similar to that used for Zenker diverticulum
• May be challenging due to anterolateral location
• Less commonly performed than for Zenker
• Average diverticulum size managed endoscopically: 2.8 cm
• Provides adequate visualization and RLN protection during stapling

Cricopharyngeal myotomy:

• Controversial as adjunct procedure
• Role less established than for Zenker diverticulum
• May be considered if cricopharyngeal dysfunction documented (13 of 22 transcervical cases included myotomy)
• Enhances symptom relief when dysfunction is present

Outcomes

Complications

Without treatment:

• Progressive dysphagia
• Aspiration pneumonia
• Weight loss and malnutrition
• Rarely: Diverticulitis, perforation, mediastinitis

Surgical complications:

• Recurrent laryngeal nerve injury: Most important risk due to close anatomical proximity; may cause permanent hoarseness
• Pharyngocutaneous fistula: Leakage from repair
• Esophageal stricture: From scarring
• Mediastinitis: Rare, from perforation or leak
• Recurrence: Reported in 5-10%
• Hematoma: Neck hematoma requiring drainage

Key observation: In the comprehensive literature review by Haddad et al. (2020), both reported recurrences occurred following endoscopic procedures, suggesting that transcervical diverticulectomy with intraoperative RLN monitoring may offer superior long-term outcomes when properly performed.

Prognosis

Outcomes are generally good with appropriate treatment:

• Symptomatic improvement in 85-95% of surgical patients
• Recurrence rate approximately 5-10%
• Mortality from surgical treatment is very low (<1%)
• Most diverticula managed transcervically achieved good outcomes without RLN injury when neural monitoring used

Factors affecting outcomes:

• Surgeon experience and familiarity with technique
• Diverticulum size (larger diverticula may require open approach)
• Patient comorbidities and surgical fitness
• Presence of recurrent laryngeal nerve injury
• Use of intraoperative neural monitoring

Long-term considerations:

• Follow-up imaging if symptoms recur
• Voice therapy if nerve injury occurs
• Continued surveillance for aspiration
• Diet progression as tolerated post-operatively
• Return to normal diet typically achievable in most patients

Epidemiology

• Accounts for 20-25% of pharyngoesophageal diverticula
• Prevalence in general population: approximately 0.025%
• Comprehensive literature review identified 68 cases in 59 reports
• Female predominance: 39 females vs. 29 males (58% female)
• Median age at presentation: 58 years
• Laterality: Left-sided predominance (75% left, 15% right, 7% bilateral)