LETTER TO THE EDITOR

Esophageal Diverticulum Presenting as a Thyroid Noduleand Diagnosed on Fine-Needle Aspiration

Yolanda C. Oertel,1 Fatemeh Khedmati,2 and A. David Bernanke3

Dear Editor:

Anterior cervical nodules that move with swallowing and areconfirmed as thyroidal by ultrasonography of the neck are notnecessarily of thyroidal origin.

We report a patient who was found to have primary hypo-thyroidism in 1990, at age 64, and was placed on levo-thyroxine. A thyroid sonogram dated February 2001 showed‘‘little change in the overall size of the gland from prior studyof 10=06=1999. There is, however, one nodule in the posteriormedial aspect of the left lobe which has increased in size andnow measures 1.1�1.6�1.4 cm.’’ The patient was referred tous for fine-needle aspiration (FNA) of this thyroid nodule. Wesaw him in April 2001. On physical examination we palpateda 1.0-cm nodule in the left lobe of the thyroid gland. Weperformed a palpation-guided FNA and obtained threesamples in usual manner (1) using 22- and 23-gauge, 1.5-inchneedles. Some smears were fixed in ethanol and stained with

Papanicolaou stain; others were air-dried and stained withDiff-Quik stain (and three were evaluated for adequacy whilethe patient was still in the room). Smears contained birefrin-gent material (consistent with cellulose=vegetable fibers;Fig. 1), skeletal muscle fibers (meat; Fig. 2), benign squamousepithelial cells, and bacteria (cocci and bacilli; Fig. 3). Wemade a diagnosis of esophageal diverticulum and suggested abarium swallow. This confirmed the presence of a ‘‘divertic-ulum projecting off the left aspect of the proximal most cer-vical esophagus slightly anteriorly.’’ The patient has remainedasymptomatic and continues on thyroid replacement therapy(last office visit in September 2008).

Appropriate management of a patient depends on correctdiagnosis. Anterior neck nodules or masses that are clini-cally considered of thyroidal origin (because they move withswallowing) and are ostensibly confirmed by ultrasono-graphy, in fact, may not be thyroidal (2). The differentialdiagnosis includes thyroglossal duct cysts which may be

FIG. 1. Vegetable fiber (coiled structureon the left) and amorphous debris (on theright side). Papanicolaou stain, highmagnification.

1Fine Needle Aspiration Service, Pathology Department, Washington Hospital Center, Washington, District of Columbia.2Pathology Department, Washington Hospital Center, Washington, District of Columbia.3Private Practice, Alexandria, Virginia.

THYROIDVolume 19, Number 10, 2009ª Mary Ann Liebert, Inc.DOI: 10.1089=thy.2009.0136

1121

located laterally (3) and the correct preoperative cytologicdiagnosis will allow the surgeon to perform, as appropriate,the Sistrunk procedure rather than an inappropriate local re-section. Two types of oropharyngeal diverticuli have beendescribed: Zenker’s diverticulum and Killian–Jamieson di-verticulum. Both are rare entities and there are few reports ontheir ultrasound findings (4). There is one case report in which‘‘on the basis of the cytologic findings, origin from the oro-pharynx or a paraesophageal diverticulum was suggested’’(5). Rekhtman et al. (6) reported on an ultrasound-guidedFNA of a nonpalpable thyroid nodule. The authors did notstate how the aspirate was diagnosed but mentioned that‘‘Subsequent clinical and further radiologic workup revealeda Killian–Jamieson diverticulum.’’

There might be some concern as to how safe it is to aspiratean esophageal diverticulum and cause infection in the sur-rounding area. For over 30 years we have performed FNAs ofpalpable lesions from all body sites and in the last 11 years wehave aspirated over 13,000 thyroidal lesions (7). We have in-terpreted aspirates from deep organs performed by radiolo-gists. We have not seen infections from FNAs of pancreaticlesions, even though the needle goes through intestinal lumenand bowel contents may be aspirated. Hence, we attest to thesafety of the procedure.

FNA is the recommended diagnostic test in the initial eval-uation of thyroid nodules (8,9). As we report in the presentcase, FNA can also be useful to diagnose mimics of thyroi-dal lesions.

FIG. 2. Skeletal muscle fiber (noticecross-striations). Papanicolaou stain, highmagnification.

FIG. 3. Benign squamous epithelial cells,bacteria (bacilli and cocci), and erythro-cytes in the background. Diff-Quik stain,high magnification.

1122

Acknowledgments

The authors are grateful to Ms. Ivonne Rivadeneira forphotographic assistance and to Drs. Kenneth D. Burman andLeonard Wartofsky for reviewing the manuscript and offeringvaluable suggestions.

Disclosure Statement

The authors declare that no competing financial interestsexist.

References

1. Oertel YC 2007 Fine-needle aspiration of the thyroid: tech-nique and terminology. Endocrinol Metab Clin North Am36:737–751.

2. Butler SL, Oertel YC 1992 Lipomas of anterior neck simulat-ing thyroid nodules: diagnosis by fine-needle aspiration. Di-agn Cytopathol 8:528–531.

3. Shaffer M, Oertel YC, Oertel JE 1996 Thyroglossal duct cysts.Diagnostic criteria by fine-needle aspiration. Arch Pathol LabMed 120:1039–1043.

4. Komatsu M, Komatsu T, Inove K 2000 Ultrasonography ofZenker’s diverticulum: special reference to differential diag-nosis from thyroid nodules. Eur J Ultrasound 11:123–125.

5. Walts AE, Braunstein G 2006 Fine-needle aspiration of a para-esophageal diverticulum masquerading as a thyroid nodule.Diagn Cytopathol 34:843–845.

6. Rekhtman N, Rekhtman K, Sheth S, Ali SZ 2005 A 62-year-oldwoman with a suspected thyroid nodule. Arch Pathol LabMed 129:1497–1498.

7. Oertel YC, Miyahara-Felipe L, Mendoza MG, Yu K 2007Value of repeated fine needle aspirations of the thyroid: ananalysis of over ten thousand FNAs. Thyroid 17:1061–1066.

8. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee S,Mandel S, Mazzaferri EL, McIver B, Sherman SI, Tuttle RM2006 Management guidelines for patients with thyroid nod-ules and differentiated thyroid cancer. The American ThyroidAssociation Guidelines Taskforce. Thyroid 16:1–33.

9. Gharib H, Papini E, Valcavi R 2006 American Association ofClinical Endocrinologists and Associazione Medici Endo-crinologi Medical Guidelines for clinical practice for the di-agnosis and management of thyroid nodules. Endocr Pract12:63–102.

Address correspondence to:Yolanda C. Oertel, M.D.

Fine Needle Aspiration ServiceDepartment of Pathology

Washington Hospital Center110 Irving St., N.W. (C-1219)

Washington, DC 20010-2975

E-mail: yolanda.c.oertel@medstar.net

1123