Figure 5 - uploaded by Badi Rawashdeh
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Diagram of the posterior view of pharyngeal muscles. Killian's triangle is located above the cricopharyngeus and below the inferior constrictor muscles. Laimer's triangle is located below the cricopharyngeus and above the confluence of the longitudinal esophageal muscle layer.
Source publication
Hypopharyngeal esophageal diverticula are rare with the most common type being the Zenker’s diverticulum.
This diverticulum arises from Killian’s triangle above the cricopharyngeus muscle; however there are two much rarer
hypopharyngeal diverticula distinct from the Zenker’s diverticulum, the Killian-Jamieson diverticulum and the Laimer’s
diverticu...
Contexts in source publication
Context 1
... is described as a pulsion diverticulum caused by esophageal dysmotility and inadequate relaxation of the cricopharyngeus muscle. It is hypothesized that when pharyngeal pressures increase against the contracted cricopharyngeus, a diverticulum forms in the weakest region above the cricopharyngeus, Killian's Triangle [7] (Figure 5). ...
Context 2
... less common is Laimer's diverticulum which arises inferior to the cricopharyngeus in the posterior midline ( Figure 5) in Laimer's triangle, located in the posterior aspect of the esophagus covered only by the circular layer of esophageal muscle [13]. Laimer's diverticulum has been documented in three cases in the literature [2][3][4]. ...
Similar publications
Pharyngoesophageal diverticulum have many subtypes, Zenker's diverticulum being the most common of them. Accounting from 70 to 75% of all esophageal diverticula. The 50% of these occur between the seventh and eighth decade of life. The most common symptom is dysphagia. The predominant symptom of ZD is dysphagia and the most serious is pulmonary asp...
Citations
... After identifying the cricopharyngeal muscle superior to the diverticulum, diverticulectomy was undertaken and the cervical esophagus was repaired with three la yers of manual sutures. Nguyen dissected the diverticulum and conducted a myotomy just distal to the inferior margin of the diverticulum, e xtending it 3 cm distally (26). The last method was the most similar to the technique implemented in our case report. ...
A pharyngoesophageal diverticulum (PED) is a rare clinical entity. This paper reports on a 79-year-old male patient with PED and symptoms of dysphagia, regurgitation and chronic cough. The diverticulum was located on the dorsal side of the cervical esophagus, midline, inferior to the cricopharyngeal muscle. These findings were consistent with Laimer’s diverticulum (LD), the rarest type of PED. This case proposes a surgical treatment of LD via an external transcervical approach.
... Boysen M et al., reported a single case of the co-existence of Zenker's and Laimer's diverticula out of more than 1000 reports of hypopharyngeal-oesophageal diverticula [7]. Laimer's diverticulum can be differentiated from Zenker's diverticulum by the fact that this diverticulum originates below the crico-pharyngeal muscle, has a broad base, and is a full-thickness true diverticulum [8]. Pharyngeal pouches are more frequent in those over the age of 70. ...
Laimer’s or Laimer-triangle Hackerman’s area is a potentially weak location behind the cricopharyngeal muscle, where the posterior oesophageal wall is thin because of a single layer of circular fibres. Dysphagia, odynophagia, and hoarseness of voice are the predominant symptoms, although they can also be asymptomatic and get worsen to aspiration and pharyngeal pouch rupture. The authors here present a case report of a rare, normal anatomical variation in a 76-year-old male patient, which was diagnosed accidentally as Laimer Hackermann diverticulum when he arrived to seek a treatment for missing teeth. Clinically, it presented as an asymptomatic palatal pouch in the left faucial pillar region. The asymptomatic presentation of Laimer-Hackermann diverticulum has rarely been reported previously in the literature and this report is the first of its kind to add a unique asymptomatic presentation of the Laimer-Hackermann pharyngeal pouch.
... Laimer's diverticula are rare, with only four cases described in the literature. 5,11,12,13 These arise inferior to cricopharyngeus in Laimer's triangle at the posterior aspect of the oesophagus, an area covered only by the circular layer of the oesophageal muscle. 14 A Laimer's diverticulum can be differentiated from a Zenker's diverticulum, as a Laimer's diverticulum: originates below the cricopharyngeus muscle, is broad based, occurs in a younger population and is a full thickness true diverticulum. ...
... 14 A Laimer's diverticulum can be differentiated from a Zenker's diverticulum, as a Laimer's diverticulum: originates below the cricopharyngeus muscle, is broad based, occurs in a younger population and is a full thickness true diverticulum. 12 Given the low incidence of this type of diverticula, the exact aetiology is unclear. The four reported cases suggest a pulsion mechanism secondary to an intrinsic oesophageal dysmotility disorder. ...
Background
Pharyngoesophageal diverticula have many subtypes, with Zenker's diverticulum being the most common. First described in 1983, a Killian–Jamieson diverticulum is an outpouching in the anterolateral wall at the pharyngoesophageal junction. This is located inferiorly to the cricopharyngeus muscle, unlike Zenker's diverticula which occur superiorly. Killian–Jamieson diverticula are rare and are commonly misdiagnosed as Zenker's diverticula. Less than 30 reports of Killian–Jamieson diverticula have been described in the literature.
Case report
A 69-year-old man presented with a 2-year symptomatic history, and was found to have simultaneous Zenker's diverticulum and Killian–Jamieson diverticulum. He was treated successfully with open surgical excision of both pouches.
Conclusion
Zenker's diverticulum and Killian–Jamieson diverticulum are diagnosed using radiological studies and endoscopy. Their differentiation is important, as surgical management differs. This paper reviews the literature on Killian–Jamieson diverticula and the management options available.
Esophageal reconstruction is a difficult operation. The difficulty arises from the fact that the operation concerns the neck, chest, and abdomen, and many organs, such as the thyroid gland, recurrent laryngeal nerves, thoracic duct, and pleura, are at particular risk. The parietal pleura is firmly attached to both sides of the vertebral column, thus forming a recessed protruding relationship with the esophagus. This configuration makes it difficult to dissect the esophagus in the thorax. Therefore, pleural rupture is dangerous during surgery. Another difficulty is that the organs used for esophageal reconstruction or replacement vary according to the tumor’s location. The stomach is used for esophageal reconstruction for tumors in the middle or lower third of the esophagus. In superior mediastinal segment tumors, the use of the stomach is not appropriate and a flap formed between the terminal ileum and right colon is used for esophageal reconstruction. Due to its vascular structure, the right colon is used more frequently. The suitability of abdominal structures for esophageal reconstruction or interposition primarily depends on their ability to be mobilized to the extent permitted by their self-supplying vessels. In addition, the lumen diameter and length of the organ to be interposed, whether there are intrinsic diseases, and its ability to maintain aboral peristalsis are also important factors. Therefore, it is necessary to know especially the vascular anatomy and other anatomical features of the stomach, the duodenum, the jejunum, and the colon used in reconstruction after esophagotomy.
It is essential to know the anatomy of the neck, as extensive neck dissection is performed during esophagotomy. Although the cervical part of the esophagus is located behind the trachea, it usually protrudes toward the left lateral. Therefore, in esophageal surgery, neck dissection is performed on the left side. Thus, only the thoracic duct, the left thyroid lobe, and the left recurrent nerve located on the left side of the neck become meaningful. The thyroid gland needs excellent attention during neck surgery owing to its relations and its variational structure. Since esophagectomy is performed on the left side of the neck, anatomical abnormalities or variations of the left recurrent laryngeal nerve are also significant for esophagus surgery. Another vital structure for esophageal surgery is the thoracic duct. Any injury to the thoracic duct can cause chylothorax, which is sometimes fatal. In recent years, thoracoscopic esophagectomy applications in the prone position have become widespread due to the precise dissection around the thoracic canal.
Objective:
To describe demographics and imaging and compare findings and symptoms at presentation in a large cohort of persons with cricopharyngeus muscle dysfunction (CPMD) with and without hypopharyngeal diverticula.
Methodology:
Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeal Hypertonicity (POUCH) Collaborative. Patient survey, comorbidities, radiography, laryngoscopy findings, and patient-reported outcome measures (e.g., Eating Assessment Tool [EAT-10]) data were abstracted from a REDCap database and summarized using means, medians, percentages, and frequencies. Diagnostic categories were compared using analysis of variance.
Results:
A total of 250 persons were included. The mean age (standard deviation [SD]) of the cohort was 69.0 (11.2). Forty-two percent identified as female. Zenker diverticula (ZD) was diagnosed in 85.2%, 9.2% with CPMD without diverticula, 4.4% with a Killian Jamieson diverticula (KJD), and 1.2% traction-type diverticula. There were no differences between diagnostic categories in regard to age, gender, and duration of symptoms (p = 0.25, 0.19, 0.45). The mean (SD) EAT-10 score for each group was 17.1 (10.1) for ZD, 20.2 (9.3) for CPMD, and 10.3 (9.4) for KJD. Patients with isolated CPMD had significantly greater EAT-10 scores compared to the other diagnostic groups (p = 0.03).
Conclusion:
ZD is the most common, followed by CPMD without diverticula, KJD, and traction-type. Patients with isolated obstructing CPMD may be more symptomatic than persons with ZD or KJD.
Level of evidence:
Level 4 Laryngoscope, 2022.
Zenker diverticula are the most common diverticula arising from the hypopharynx. Other diverticula are rare in this region and are not necessarily treated in the same way. While there has been a move toward more endoscopic methods of treating Zenker diverticula, this minimally invasive approach is not always possible in other hypopharyngeal diverticula such as Killian-Jamieson, Laimer, iatrogenic, and traction diverticula. This chapter will break down the subtle differences between the different hypopharyngeal and esophageal diverticula involving diagnosis, etiology, and treatment.
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.
Zenker diverticulum is the most common hypopharyngeal diverticulum. Alternate types of hypopharyngeal diverticula are uncommon; however, recognition and proper diagnosis is imperative, as treatment may be quite different. Hypopharyngeal diverticula are typically diagnosed using barium esophagography and differences between types of diverticula can be subtle. Although endoscopic management of Zenker Diverticula has become very popular recently, endoscopic exposure of other hypopharyngeal diverticula is not as straightforward. In this article, traction, iatrogenic, Killian-Jamieson, and Laimer diverticula would be discussed. Treatment options for each would also be explored and compared with treatment of the more common Zenker diverticulum.