Imaging

Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.

The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.

Rick Robbins, M.D. 7/5/17 Rick Robbins, M.D. 7/5/17

Medical Image of the Week: Zenker’s Diverticulum

Figure 1. Panel A: PA view chest x-ray shows possible cavitation with air-fluid level in the right upper lobe (arrow). Panel B: lateral view chest x-ray shows possible cavitation with air-fluid level in the right upper lobe (arrow).

Figure 2. Coronal section of the thoracic CT scan shows focal dilation of the upper thoracic esophagus which contains fluid (arrow).

Figure 3. Endoscopic view of the upper esophagus showing the diverticulum with impacted food bolus.

A 71-year-old man with history of recurrent aspiration pneumonia and previous esophageal surgery presented to the Emergency Department with acute hypoxia and leukocytosis. Imaging, above, showed a consolidation in the RUL and on lateral view an air fluid level. This was suspicious for infection or malignancy. For the ongoing concern for possible esophageal pathology given previous surgery, GI was consulted and upper endoscopy performed. He was found to have an esophageal dilation at repair site of a previous Zenker’s diverticulum filled with food.

Zenker’s Diverticulum is a defect in the muscular wall of the hypopharynx in an area known as Killian's triangle. This condition is male predominant mainly occurring in the 3^rd to 4^th decade and/or the 7^th to 8^th decade of life. The out pouching created will accumulate food and eventually lead to high incidences of aspiration pneumonia. Treatment is usually surgical in nature and can cause vocal cord damage and even recurrence of the outpouching (1).

Chandra Stockdall MD and Roberto Swazo MD

Department of Internal Medicine

Banner University Medical Center South Campus

Tucson, AZ USA

Reference

Mulder C, Van Delft F. Zenker’s diverticulum. UpToDate. May, 2017. Available at: http://www.uptodate.com/contents/zenkers-diverticulum (requires subscription, accessed 6/30/17).

Cite as: Stockdall C, Swazo R. Medical image of the week: Zenker's diverticulum. Southwest J Pulm Crit Care. 2017;15(1):15-6. doi: https://doi.org/10.13175/swjpcc075-17 PDF

Rick Robbins, M.D. 11/19/14 Rick Robbins, M.D. 11/19/14

Medical Image of the Week: Killian-Jamieson Diverticulum

Figure 1. Chest x-ray showing worsening consolidation in both lungs.

Figure 2. Anterior (panel A) and lateral (panel B) fluoroscopic images showing retained contrast material in the anterior esophageal diverticulum in the hypopharynx.

An 89 year old female nursing home resident with a past medical history of hypertension and coronary artery disease was admitted with generalized weakness and vomiting for two days. Chest x-ray revealed consolidation in the left lung suggestive of pneumonia and she was started on broad spectrum antibiotics. Due to worsening consolidation in both lung fields (Figure 1) a video swallow was done for possible aspiration, which revealed contrast retained within the proximal esophagus within a diverticula in the anterior aspect (Figure 2). After excision of the diverticulum her pneumonia resolved and she was discharged back to the nursing home.

Killian-Jamieson diverticulum is a mucosal protrusion through a muscular gap in the anterolateral wall of the cervical esophagus; inferior to the cricopharyngeus and lateral to the longitudinal muscle of the esophagus just below its insertion on the posterior lamina of cricoid cartilage (gap also known as Killian-Jamieson space). This differentiates it from the Zenker’s diverticulum which arises from the muscular gap in the posterior portion of cricopharyngeus muscle (also known as Killian’s dehiscence). Killian-Jamieson diverticulum causes more non-specific symptoms than Zenker's diverticulum. Because these diverticula occur in close proximity to the recurrent laryngeal nerve, it should be carefully preserved during surgical resection.

Chandramohan Meenakshisundaram, MD and Nanditha Malakkla, MD

Medical Education

Saint Francis Hospital

Evanston, IL

References

Kim DC, Hwang JJ, Lee WS, Lee SA, Kim YH, Chee HK. Surgical treatment of killian-jamieson diverticulum. Korean J Thorac Cardiovasc Surg. 2012;45(4):272-4. [CrossRef] [PubMed]
Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (Zenker's diverticulum). Postgrad Med J. 2001;77:506-11. [CrossRef] [PubMed]
Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Lippincott Williams & Wilkins. (2007) ISBN:0781765188

Reference as: Meenakshisundaram C, Malakkla N. Medical image of the week: killian-jamieson diverticulum. Southwest J Pulm Crit Care. 2014;9(5):287-8. doi: http://dx.doi.org/10.13175/swjpcc134-14 PDF