Pharyngoesophageal diverticulum mimicking thyroid nodules: Some interesting ultrasonographic signs

Abstract

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.

Keywords: Killian–Jamieson diverticulum; Zenker’s diverticulum; pharyngoesophageal diverticulum; thyroid nodules; ultrasonographic features.

Figure 1

Compared with the echogenicity of the thyroid gland, solid nodular diverticula are classified as solid hypoechoic nodular diverticula (A), image from a 29-year-old woman), solid isoechoic nodular diverticula (B), image from a 56-year-old man), and solid high-low echogenic intermixed nodular diverticula (C), image from a 34-year-old woman). Air-containing nodular diverticulum. The lesion contains a central strongly echogenic area associated with a comet-tail artifact. The presence of gas can be seen, and the tail pattern changed during swallowing (D), image from a 32-year-old man). Liquid-containing nodular diverticulum with echoless interior (E), white arrow, image from a 46-year-old man). Atypical diverticular changes: Regional convexities of the esophageal wall with no obvious nodules (F), image from a 64-year-old man; (G), image from a 51-year-old man; (H), image from a 53-year-old woman).

Figure 2

PED was found in combination with thyroid nodules in 73.5% (50/68) of cases (A), image from a 56-year-old man). After thyroidectomy, a PED appeared in the thyroid region (B), image from a 42-year-old man).

Figure 3

The solid nodular diverticulum wall has a typical hyper-hypo-hyper echogenic pattern (image from a 37-year-old woman).

Figure 4

The solid nodular diverticulum wall and esophageal wall are continuous if viewed with multiple sections such as crosscut and then cut scanned (A), image from a 21-year-old man: (B), image from a 39-year-old man).

Figure 5

Punctate blood flow can be seen in the middle hypoechoic layer of the solid nodular diverticular (image from a 42-year-old woman).

Figure 6

Some air-containing nodular diverticula are full of gas-like hyperechoicity internally and have a typical “V” tail sign (A), image from a 35 year-old woman). Some have a hyperechoic linear appearance and sometimes have a typical “T” tail sign (B), image from a 63-year-old woman).