Esophageal diverticulum presenting as a thyroid nodule and diagnosed on fine-needle aspiration

Pharyngoesophageal diverticulum mimicking thyroid nodules: Some interesting ultrasonographic signs

Objective

To analyze the ultrasonographic features of pharyngoesophageal diverticulum (PED) mimicking thyroid nodules and to explore the clinical value of ultrasonography in the diagnosis of PED.

Method

The sonographic findings of 68 patients with PED were retrospectively reviewed. According to the diverticulum echo intensity characteristics, the lesions were divided into solid nodular diverticulum, gas-containing nodular diverticulum, liquid-containing nodular diverticulum, and atypical diverticular changes; and the ultrasonographic manifestations were compared among the four groups.

Results

30/68 were solid nodular diverticula. The diverticulum cavity was oval or elliptic with a clear border, and the diverticulum wall suggested exhibited a typical hyper-hypo-hyper-echogenic pattern. The diverticulum wall and esophageal wall were seen to be continuous if multiple sections were scanned, and hypoechoic walls showed punctate blood flow. 29/68 diagnosed with air-containing nodular diverticulum, lesions appeared with gas-like hyper-echogenicity internally, with some amount of gas and change in the tail pattern during swallowing. 6/68 patients were diagnosed with liquid-containing nodular diverticulum, and the main ultrasonic manifestations were an anechoic internal diverticulum cavity that was clearly bounded from the thyroid but continuous with the esophageal wall, with a typical hyper-hypo-echoless pattern from the outside to the inside. Another 3/68 were found to have atypical diverticular changes, regional convexities of the esophageal wall with unfashioned nodules. The convex segment was continuous with the hyper-hypo-echogenic esophageal wall and could be seen on slitting scanning.

Conclusion

Overall, PEDs mimicking thyroid nodules have specific ultrasonographic features. Familiarity with them can avoid missed diagnoses and misdiagnoses.

A Killian-Jamieson diverticulum potentially mimicking a thyroid nodule: A case report highlighting the cytology of a pharyngoesophageal diverticulum

The authors highlight the important contribution of rapid on-site evaluation by the cytopathologist of a pharyngoesophageal diverticulum in a mass initially interpreted clinically as thyroidal in origin. They discuss pitfalls in avoiding interpretive diagnostic error and inappropriate thyroid Bethesda reporting.

Presentation and Management of Killian Jamieson Diverticulum: A Comprehensive Literature Review

Objective:

To examine the clinical presentation, diagnostic evaluation, and management of Killian–Jamieson diverticula (KJD) through literature review.

Methods:

A comprehensive literature review was conducted through December 2018 using keywords Killian–Jamieson diverticula/diverticulum. Data extracted included clinical presentation, imaging characteristics, surgical management, and postoperative care.

Sources:

PubMed and Google Scholar.

Results:

Sixty-eight cases of KJD in 59 reports (29M:39F; median 58 years old) were identified for review. The most common presentation was dysphagia (n = 39), suspected thyroid nodule (n = 24) and globus (n = 14). The majority of KJD (n = 51) occur on the left, with rare reports of right side (n = 11) and bilateral (n = 5) presentation. Thirty-two cases describe surgical management: 22 utilizing a transcervical approach, with (n = 13) or without (n = 9) cricopharyngeal myotomy; and 10 reported endoscopic surgery. Diverticula managed transcervically averaged 3.8 cm in size in comparison to average 2.8 cm in the endoscopic group. Time to diet initiation after transcervical surgery averaged 4 days versus 2 days after endoscopic surgery. Complications were reported in 2/68 cases; both were diverticula recurrence after endoscopic surgery.

Conclusion:

Killian–Jamieson diverticula is a rare diagnosis that should be considered in the evaluation of dysphagia, globus, and also suspected thyroid nodule. When patient symptoms warrant intervention, a transcervical approach, with or without cricopharyngeal myotomy, is most commonly utilized. In recent years, an endoscopic approach has been presented as an alternative for smaller diverticula. Further understanding of the optimal treatment and postoperative management for KJD requires larger cohorts.

Level of Evidence:

4

Zenker Diverticulum: A Potential Pitfall in Thyroid Ultrasound Evaluation: A Case Report and Systematic Review of Literature

BACKGROUND AND OBJECTIVE

Zenker Diverticulum (ZD) can sometimes be misinterpreted as a thyroid nodule both at clinical evaluation and at Ultrasound (US).

CASE PRESENTATION

We reported the case of a 46-years-old woman complaining of a lump in the anterior left aspect of the neck. Following clinical examination and US evaluation, a thyroid nodule was initially diagnosed and the patient was referred to our institution to be submitted to a fine-needle aspiration cytology. Management and Outcome: A ZD was suspected by US and diagnosed by gastrografin esophagram, thus an endoscopic diverticulotomy was requested.

CONCLUSION

A correct US evaluation can be crucial for the appropriate management of a neck mass.

Incidental pharyngoesophageal diverticulum mistaken for a thyroid nodule: Report of two cases

Pharyngeal or Zenker's diverticulum is an infrequent disorder that results from an outpouching of pharyngeal mucosa through a weakened area in the posterior pharyngeal wall. As it may mimic a thyroid nodule on ultrasonography (US), accurate diagnosis is important to ensure appropriate treatment. Fine-needle aspiration (FNA) is recommended for the initial evaluation of thyroid nodules. We report the FNA diagnosis of two cases of Zenker's diverticulum that were suspected to be thyroid nodules on US. Pap stained aspirate smears showed findings characteristic of Zenker's diverticulum: benign squamous cells, bacteria, and vegetable debris and the absence of colloid and/or thyroid epithelial cells. US and CT findings were consistent with the diagnosis.

Pharyngoesophageal diverticula simulating thyroid nodules: An unusual occurrence with unique features

Pharyngoesophageal diverticula (PED) of the Zenker's and Killian-Jamieson types arise in close proximity to the thyroid gland, and may rarely be confused with a thyroid nodule on ultrasonography. In this brief report, we detail the cytologic, clinical, and radiologic findings of three PED that were thought to be thyroid nodules, and were subjected to fine-needle aspiration (FNA). The patients were females with an age range of 51-64 years. All three patients had multiple thyroid nodules, and two patients reported symptoms attributable to the diverticulum. Nodule sizes ranged from 1.0 to 2.7 cm, and either the right or left thyroid lobe could be involved. Microcalcifications were present by ultrasonography in all three cases. FNA of these thyroid nodule mimics showed squamous cells with granular or amorphous debris, bacterial and/or fungal colonies, inflammation, and food particles. These cytologic features, particularly the presence of vegetable or meat fragments, are characteristic, and have also been reported in the few previous reports of PED. The presence of a diverticulum was confirmed with imaging studies in all our patients. Although a rare occurrence, the inadvertent FNA of a PED masquerading as a thyroid nodule is important to recognize, as a recommendation for appropriate radiologic studies could potentially avoid inappropriate therapy for thyroid disease.

Bilateral Killian-Jamieson diverticula incidentally found on thyroid ultrasonography

BACKGROUND

Killian-Jamieson diverticulum (KJD) is a rare esophageal diverticulum that protrudes through the muscular gap in the anterolateral wall of the proximal cervical esophagus inferior to the cricopharyngeus. Although several patients with bilateral KJD have been reported, high-resolution ultrasound (US) image of bilateral KJD has never been reported.

SUMMARY

A 71-year-old man visited our hospital for annual follow-up of known thyroid nodules. In addition to the previously noted thyroid nodules, two arc-shaped hyperechoic lesions with reverberation artifacts, which suggested air-containing lesions, were unexpectedly seen posterior to bilateral thyroid lobes. Although the connection between the esophagus and the lesions was not definitely visible on US, our first differential diagnosis was esophageal diverticula. They were confirmed to be bilateral KJD on the following pharyngoesophagography.

CONCLUSIONS

If US features are not enough to differentiate esophageal diverticulum from suspicious thyroid nodule, pharyngoesophagography can be performed instead of invasive fine-needle aspiration to obtain a definite diagnosis of incidentally detected esophageal diverticulum.