Clinical History
A 42-year-old gentleman presented with recurrent lower respiratory tract infections. He had a background of sarcoidosis and marked congenital kyphoscoliosis with associated chest wall deformity and previous Harrington rod fixation.
Imaging Findings
A chest X-ray (CXR) confirmed the kyphoscoliosis, chest wall deformity and Harrington rod fixation. There was right lower zone (RLZ) air space opacification and loss of volume. In the right upper zone (RUZ), adjacent to the mediastinal contour and obliterating the para-tracheal stripe, there was a soft tissue density lesion with calcification in the inferior margin (Fig. 1).
Within the RUZ there was a 7 x 5.5 cm cavity containing an air/debris level with an associated pleural reaction. Multiple pockets of gas were seen within the soft tissue component with ovoid calcified elements in the more dependent aspect (Fig. 2).
A repeat volume acquired CT with 100 ml dilute water-soluble oral contrast showed the "cavity" filled with contrast. There was no evidence of aspiration of oral contrast on the study (Fig. 3 & 4). Volume loss and cylindrical bronchiectasis was also noted in the apical segment of the RLL (Fig. 4).
Discussion
Background
Dr. Abraham Ludlow first described an oesophageal diverticulum in 1764 [1]. Overall, they are uncommon and generally affect middle-aged or elderly people. Pulsion diverticula are outpouchings of oesophageal mucosa through weak points of the muscle wall caused by high intraluminal pressures, a result of oesophageal motility disorders [2, 3]. During the act of swallowing, the muscles of the pharynx contract and pressure in the pharynx increases. If the cricopharyngeus muscle does not open at the appropriate time, pressure builds up immediately above it and the pharyngeal mucosa may herniate through a potential area of weakness in the posterior wall of the pharynx at ‘Killian’s dehiscence’, between the cricopharyngeus and thyropharyngeus muscles [2, 3]. Traction diverticula are rare and occur as a result of perioesophageal inflammation pulling on the oesophageal wall. Oesophageal diverticula are most commonly classified by anatomical position: pharyngoesophageal (Zenker's diverticula), mid-thoracic and epiphrenic [4].
Clinical Perspective
Symptoms are often non-specific but may include dysphagia, regurgitation and pain [2]. Complications are rare but may include aspiration pneumonia, rupture and cancer.
Imaging Perspective
Imaging plays a vital role in the diagnosis of oesophageal diverticula. Fluoroscopic oral contrast swallows are the main diagnostic tool, although patients may alternatively undergo oesophagoscopy [2]. Oesophageal manometry may be used in patients found to have diverticula to further assess for dysmotility, as this may influence treatment options.
In the case described above, CT with oral contrast was performed rather than the more commonly used fluoroscopic swallow due to diagnostic uncertainty and the patient’s spinal deformity. The CT confirmed a large cervical oesophageal diverticulum, which contained food debris and tablets. It is likely that, as a result of the diverticulum, the patient developed pulmonary aspiration given the presentation of recurrent episodes of lower respiratory tract infections and the CT findings of right lower lobe volume loss and bronchiectasis.
Outcome
Asymptomatic and minimally symptomatic oesophageal diverticula often do not require treatment [3, 4]. Surgery is reserved for patients with complications or symptoms causing disruption of their life. Treatment for co-existing oesophageal motility disorders should also be considered [2]. Historically an open diverticulectomy with a cricopharyngeal myotomy was performed, however, transoral endoscopic division of the separating wall between the pouch and the oesophagus with myotomy is now the procedure of choice [2].
The patient subsequently elected to have no therapeutic intervention and remains under follow up.
Differential Diagnosis List
Oesophageal diverticulum
CAVITATING LUNG LESION
Carcinoma
TB
Abscess
SUPERIOR MEDIASTINAL MASS
Thymic mass
Teratoma
Aneurysm
Lympadenopathy
