A rare cause of dysphagia and simultaneous hoarseness of voice in the octogenarian: a Killian–Jamieson diverticulum, management, and review of literature
Authors: Chaudhry Ikram U. H. , Al Ghamdi Abdullah M. , Al Qahtani Yousif , Algazal Thabet , Razzaq Beenish , Al Abdulhai Meenal A. , Al Fraih Othman M. 
Published: April 2023

Killian-Jameson diverticulum:
An 82-year-old male presented with progressive dysphagia and simultaneous hoarseness of voice for the past 6 months. He had mitral valve repair and a permanent pacemaker for a heart block 5 years ago. A computed tomographic scan of the neck demonstrated a cervical esophageal diverticulum. Oral Gastrogrifin contrast study confirmed esophageal diverticulum in Killian–Jamieson space. Open surgical diverticulectomy was performed safely. Patient’s dysphagia resolved immediately, and he regained his normal voice after 6 weeks.

Introduction:
Killian–Jamieson’s esophageal diverticulum is a rare form of pulsion diverticulum which originate through a muscular gap in the anterolateral wall of the esophagus, inferior to the cricopharyngeus muscle and superior to the circular and longitudinal muscle of the esophagus. Killian–Jamieson defined this area where the recurrent laryngeal nerve enters the pharynx, called Killian–Jamieson triangle. Ekberg and Nylander, in 1983, described an esophageal diverticulum in Killian–Jamieson space. The most common clinical manifestations in such patients are dysphagia, cough, epigastric pain, recurrent respiratory tract infections, and rarely hoarseness of voice. In symptomatic patients, surgical or endoscopic resection of the diverticulum is mandatory. We report this case in line with SCARE (Surgical CAse REport) criteria.

Case Report:
An 82-year-old male presented to our outpatient clinic with a history of progressive dysphagia for solid food and hoarseness of voice for the last 6 months. He denied gastroesophageal reflux, cough, and shortness of breath. On examination of the neck, there was swelling on the left side but no tenderness or lymphadenopathy. Basic blood investigations, including complete blood count, liver, and renal panels, were normal. An echocardiogram showed mild impairment of left ventricle function and normally functioning mitral valve. Chest X-ray showed a pacemaker in position. Computed tomography scan of the neck showed esophageal diverticulum. Gastrogrifin contrast study showed esophageal Killian–Jamieson diverticulum (KJD).

Discussion:
The acquired esophageal diverticulum is categorized into three types based on its anatomical location. Zenker’s and Killian–Jamieson (pulsion diverticulum) in the proximal part, traction diverticulum in the middle part, due to pulling from fibrous adhesions following the lymph node infection and epiphanic pulsion type in the distal esophagus. Although the KJD and Zenker’s diverticulum (ZD) arise close to each other in the pharyngoesophageal area, they are anatomically distinct. Although ZD and KJD have the same demographic features, they are more commonly found in older men (60–80 years) and women, respectively. The incidence of ZD is 0.01–0.11%, and KJD is 0.025% of the population. Rubesin et al. reported radiographic findings in 16 KJD cases. They found the majority of them were on the left side (72%), followed by 20% on the right side and 8% bilateral.

Conclusion:
In conclusion, we report a rare case of dysphagia and simultaneous hoarseness of voice in an octogenarian due to KJD, who was treated with open diverticulectomy, and dysphagia resolved; he regained his voice back after 6 weeks. In our opinion, endoscopic surgery in such a patient with KJD can put recurrent laryngeal at risk of injury since an endoscopic approach operator cannot visualize and dissect away the recurrent laryngeal nerve, particularly when KJD already compresses it.