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Laryngoceles. Otolaryngology Grand Rounds Anne Conlin, MD, PGY-4 November 5, 2008. Objectives. To discuss 2 case presentations of laryngocele To understand the anatomy and etiology of laryngoceles & related saccular disorders

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laryngoceles

Laryngoceles

Otolaryngology

Grand Rounds

Anne Conlin, MD, PGY-4

November 5, 2008

objectives
Objectives
  • To discuss 2 case presentations of laryngocele
  • To understand the anatomy and etiology of laryngoceles & related saccular disorders
  • To discuss work-up and management options for laryngoceles & related saccular disorders
case 1
Case #1
  • ID: 2 y.o. male in-patient
  • RFC: stridor & neck swelling
  • HPI:
    • 1 wk Hx URTI Sx (fever, rhinorrhea)
    • 1 d Hx acute stridor, rapid neck swelling x10 cm w/ erythema, dysphagia, and inability to lie flat d/t air hunger
    • Admitted to ICU
case 15
Case #1
  • PMHx: DCR, otherwise healthy
  • DevtHx: unremarkable L&D, N dev’t
  • Meds/Allergies: nil
case 16
Case #1
  • Physical Exam
    • Toxic looking, stridorous, distressed patient
    • 10 cm warm, erythematous L/midline/R neck swelling
case 18
Case #1
  • What do you do?
case 2
Case #2
  • ID: 68 y.o. male out-patient
  • CC: “When I cough, something pops up into the back of my throat, and I have to push it down with my fingers”
case 210
Case #2
  • HPI:
    • CC ongoing several times per day for 2 months
    • Transient dysphonia, resolved with digital displacement of mass in his mouth
    • No dyspnea or stridor
  • PMHx: Zenker’s diverticulum, otherwise healthy
  • Habits: denied EtOH, smoking, musical instruments or glass-blowing
case 215
Case #2
  • What do you do?
laryngoceles17
Laryngoceles
  • Historical Context
    • 1st described in 1829 by Napoleon’s surgeon-in-chief: observed in the man calling the masses to prayer in Egypt
laryngoceles18
Laryngoceles
  • Definition
    • Abnormal dilation of the saccule of the laryngeal ventricle
  • Spectrum of disorders characterized by abnormal dilatation of the laryngeal saccule
anatomy of the saccule
Anatomy of the Saccule
  • Saccule: aka laryngeal appendix
  • The normal out-pouching at the anterior end of the laryngeal ventricle
  • A blind sac that extends upwards between the false VCs and the thyroid cartilage
anatomy of the saccule20
Anatomy of the Saccule
  • Contains many mucous glands
  • Vestigial air sac
  • Possible function is lubrication of true vocal folds
anatomy of the saccule21
Anatomy of the Saccule
  • Burke & Golden:
    • Laryngocele is a saccule which extends beyond the superior border of the thyroid cartilage
  • Broyles: height of “normal” saccule
    • <8 mm in 75% pop
    • 10-15 mm in 17% pop
    • >15 mm in 8% pop
  • Burke’s def’n accepted
slide26

A: Normal anatomy

B: Anterior saccular cyst

C: Lateral saccular cyst

D: Laryngocele (external and mixed types)

laryngocele
Laryngocele
  • Saccule filled only with air
  • Orifice remains patent
classification of laryngoceles
Classification of Laryngoceles
  • Classification
    • Internal (40%): lies within the confines of the larynx beneath the mucosa of the false cords & AEFs
    • External (25%): extends beyond thyroid cartilage & protrudes through thyrohyoid membrane at point of insertion of SLN
    • Mixed (45%): abnormal dilatation of saccule on both sides of the thyrohyoid membrane
slide29

Normal anatomy

Internal laryngocele

External laryngocele

Mixed laryngocele

saccular cyst
Saccular Cyst
  • Saccule filled with glandular secretions & orifice becomes obstructed
  • Symptoms are constant
laryngopyocele
Laryngopyocele
  • Contents of a saccular cyst become infected
  • Air & fluid seen on imaging
  • 8-10% of laryngoceles
etiology true or false
Etiology: True or False?
  • Laryngoceles are caused by playing wind instruments, such as the trumpet.
true or false
True or False?
  • Laryngoceles are caused by glass blowing.
etiology
Etiology
  • Uncertain & controversial
  • Commonly felt due to use of the voice in unusually forceful ways & high transglottic pressures
    • Trumpet players
    • Glass blowers
etiology transglottic pressure
Etiology: Transglottic Pressure
  • Stell & Maran, J Laryngol Otol, 1975
    • Reviewed 139 cases
    • Only 1 case associated w/ prolonged & repeated blowing against resistance (trumpet playing)
etiology carcinoma
Etiology: Carcinoma
  • Celin et al, Laryngoscope, 1991
    • Pathology specimens:
      • Laryngeal carcinoma: 19% w/ laryngocele
      • Pharyngeal carcinoma: 2% w/ laryngocele
    • CT findings:
      • Laryngeal carcinoma: 29% w/ laryngocele
      • Normal larynx: 9% w/ laryngocele
      • (Laryngocele defined as saccule detectable 10 mm above superior aspect of thyroid cartilage; comparable to Broyles’ descriptions of the saccule)
etology carcinoma
Etology: Carcinoma
  • Theory:
    • Ball-valve obstruction of neck of saccule by tumour
    • Air admitted into saccule
    • However, air cannot escape
etology carcinoma38
Etology: Carcinoma
  • Limitations to the Theory:
    • Half of laryngoceles are ipsilateral to laryngeal carcinoma; half are contralateral
  • Alternative theory:
    • Abnormal intralaryngeal pressures d/t coughing, altered phonation, etc.
carcinoma laryngoceles
Carcinoma & Laryngoceles
  • Micheau et al, 1976, Cancer
  • Laryngocele present in 22 of 120 cases
  • Thyroid cartilage invasion in 50% & cricoid invasion in 10%
  • Upward spread
  • Very invasive
carcinoma laryngoceles40
Carcinoma & Laryngoceles
  • Canalis et al, J Otol, 1976
  • 131 patients w/ symptomatic laryngoceles
  • Occult ca. 4-15%
  • Inaccuracy of endoscopic evaluation
  • CT mandatory
etiology congenital
Etiology: Congenital
  • Congenital presence of abnormally large saccule
  • Broyles studies on height of saccule:
    • <8 mm in 75% pop
    • 10-15 mm in 17% pop
    • >15 mm in 8% pop
etiology weird wonderful
Etiology: Weird & Wonderful
  • Complication of surgical tracheostomy
  • Complication of laser excision SCCa larynx
  • Voice abuse
  • IV drug user neck injections
  • Amyloidosis
  • Scleroderma
clinical presentation
Clinical Presentation
  • Epidemiology
    • Incidence: 1 per 2.5 million people per year
    • Male:female = 5:1 (between 2 and 7:1)
    • Most commonly affects Caucasian men in their 50s
  • Pattern
    • Unilateral (75%)
    • Mixed (45%)
symptoms
Symptoms
  • Symptoms intermittent for laryngoceles
  • Depend whether the laryngocele is internal, external, or combined
    • Hoarseness
    • Neck swelling
    • Stridor
    • Dysphagia
    • Sore throat
    • Snoring
    • Cough
    • Globus
symptoms45
Symptoms
  • Congenital & Pediatric Cases:
    • Airway obstruction
    • Feeding difficulties
    • Weak cry
signs
Signs
  • Swelling of the false VCs & aryepiglottic folds
  • Palpable mass in lateral neck which increases w/ Valsalva maneuver (external type)
  • Bryce sign: gurgling or hissing sound on compression of the neck mass
investigations
Investigations
  • CT scan
    • Traditionally, the primary imaging study
    • Fluid- or air-filled, sharply defined sac
investigations48
Investigations
  • CT scan
    • Definitive dx: connection btwn air sac & airway
    • Useful for mapping & surgical planning
investigations49
Investigations
  • MRI
    • Useful, especially to distinguish btwn mucus/inflammation and malignancy
    • Visualization of thyrohyoid membrane, paralaryngeal space, true cord, false cords
investigations50
T1W MRI w/ gad

Thin rim of enhancing mucosa

T2W MRI

Hyperintense cyst contents (fluid)

Investigations
management
Management
  • Options:
    • Observation/Conservative
    • Direct laryngoscopy
    • External approach
    • Endoscopic approach
management52
Management
  • Direct laryngoscopy
    • Often reveals swelling of the false cord and AEF
    • May be misleading b/c laryngocele relies on airway pressure to keep the cystic structure distented
    • Apnea: airway pressure is allowed to equalize & the mass may decompress spontaneously
    • Biopsiesof any suspicious lesions
management53
External

Laryngofissure

Lateral laryngotomy

Lateral thyrotomy via thyrohyoid membrane

Especially for….

Large internal laryngoceles

Combined (mixed) laryngoceles

Internal laryngoceles

Endoscopic

CO2 laser

Especially for….

Small internal laryngoceles

Role expanding

Management
management external approach
Management: External Approach
  • Direct laryngoscopy +/- biopsy
  • External portion of the sac followed through thyrohyoid membrane
  • Possibly w/ removal of the superolateral portion of the thyroid cartilage for easier access
management external approach55
Management: External Approach
  • Thome et al, 2000, Laryngoscope
    • 26 yr prospective & retrospective study
    • 10 patients w/ lateral thyrotomy, through thyrohyoid membrane
    • V-shaped full-thickness resection of the thyroid lamina for exposure to paraglottic space & submucosal dissection
    • 2 patients had tracheotomy d/t “problems unrelated to the procedure”; also 2 pre-op tracheotomized pts
    • Decannulation at 3-20 days
    • Better visibility of and access to paraglottic space
    • No recurrence, F/U >1 yr
management endoscopic
Management: Endoscopic
  • Laryngeal ventricle examined w/ 0o & 90o scopes +/- biopsy
  • Mucosa retracted medially
  • Incision w/ laser over superior aspect ventricle
  • Lateral component drawn into laryngeal lumen
  • If only marsupialized, higher recurrence rates
management endoscopic57
Management: Endoscopic
  • Martinez Devesa et al, 2002, Laryngoscope
    • 15 yr retrospective study, f/u 6mos-5 yrs
    • 12 patients treated w/ endoscopic CO2 laser (internal & external components)
    • Mean post-op stay: 1.8 days (range: 1-4)
    • 2 pts w/ pre-op tracheotomy were decannulated post-op; no primary tracheotomy required
    • 1 complication: local wound infection
    • No recurrences
management endoscopic58
Management: Endoscopic
  • Szwarc & Kashima, Annal Oto Rhin Laryn 1997:
    • Combined laryngocele
    • Vestibulectomy
    • Complete excision w/ CO2 laser excision of internal portion
    • External portion allowed to drain into laryngeal lumen
    • Useful in select cases
management sequential external endoscopic approach
Management: Sequential External & Endoscopic Approach
  • Ettema, Carothers & Hoffman, Annals Oto Rhin Laryn, 2003
    • Combined laryngoceles
    • Case report; “6-years of experience”
    • External segment dissected & ligated w/ silk
    • Silk suture detected on laryngoscopy
    • Laser resection while retracting w/ silk suture
management advantages disadvantages
External

Advantages

Low recurrence

Easy access

Disadvantages

Scar

Longer in-pt stay

Anterior commissure morbidity w/ laryngofissure

Endoscopic

Advantages

Shorter in-pt stay

Disadvantages

Possible damage to neurovascular bundle (RLN)

Management: Advantages & Disadvantages
case 1 revisited
Case #1 Revisited
  • Urgent OR
    • Midline neck incision at level of cricoid ring
    • Cyst encountered, 35 mL of pus drained
    • 2 large cystic masses on both sides of trachea & anterior to larynx
    • Laryngoscopy: frank pus spilling into a/w
    • Penrose drain placed
case 1 revisited63
Case #1 Revisited
  • Post-op
    • Clindamycin & cefuroxime IV x10 days
    • Home on clindamycin PO
  • 1 month later…
    • Returned to OR for “neck dissection”: dissected out fibrous sac, LNs & possible tract to piriform fossa
  • 11 years later….
    • Presented w/ neck abscess in same area-> I&D
case 2 revisited
Case #2 Revisited
  • The laryngocele was actually detected intra-operatively during surgery for Zenker’s diverticulum
  • “Chief complaint” had been obtained pre-operatively by the Anesthesia medical student
  • In the OR:
    • Laryngoscopy
    • ETT accidentally dislodged -> +ve pressure into upper airway
    • Laryngoscopy & reintubation: “What the…?!!!”
case 2 revisited65
Case #2 Revisited
  • Zenker’s surgery successful
  • Only 1 published report of simultaneous Zenker’s diverticulum & laryngocele
  • Pt presently recovering from surgery for Zenker’s; management of the laryngocele is pending
important clinical points
Important Clinical Points
  • Laryngocele is a potential cause of airway obstruction
  • Occult laryngeal carcinoma present in up to 15% of patients
  • CT scan as initial investigation
  • Consider MRI to investigate for carcinoma when debris present within the saccule (T2W)
  • Laryngoscopy can look falsely good; suspicion and a low threshold for biopsies is essential
discussion
Discussion
  • Thank-you