External Laryngocele

: Points to remember
Tiara Rachmaputeri Arianto 07120100100
Abstract
Laryngocele
rare cystic swelling
Saccule of the larynx
Seen mostly
Often associated with underlying malignancy
Case
external laryngocele in a young farmer who did not have any of the
above mentioned associations.
Keywords
Laryngocele, malignancy, Neck swelling, resection
Introduction
Laryngocele Cystic dilatation of the saccule of the larynx
Generally filled with air
Communication cyst-laryngeal
lumen occluded
Fluid accumulate within the sac
Saccular cyst
= mucus retention arise from
mucus gland of the saccule
filled ONLY with mucus
Incidence
1 in 2.5 million population
Males 50 and 60 years of age
Possible mechanism
Increase in intraluminal laryngeal pressure
Case Report
25 yo male
Complaints
Painless swelling in the upper right side of the neck for the
past 3 years
Increase in size during coughing and straining
Examination
Compressible swelling 3 x 4 cm
Right anterior triangle of neck
Non-tender, soft, cystic, fluctuant, mobile
Swelling increased in size coughing, valsava
maeuver
Radiograph
Antero-posterior view
Air-filled sac suggestive of external laryngocele
Ultrasonogram confirmed
EXCISION
Procedure
1. General anesthesia and endotracheal intubation
2. Aseptic precautions
3. Horizontal skin incision, over the swelling
4. After raising skin flaps and dissecting soft tissues, laryngocele was identified
5. Seperated from surrounding tissues
6. Mobilized up to its neck as far as the thyrohyoid membrane
7. Neck (or fundus) was transected
8. Skin was closed after placing a drain
Post operative sutures removed after 7 days
Histopatologic Examination
Confirmed laryngocele and exclude malignancy
Discussion
Etiology Congenital
Acquired
Large ventricular appendix causes respiratory distress
Increase in intra-glottic pressure
Excessive caughing, playing a wind instrument, glass
blowing, valsava maneuver
causes
Extend
Internally
Into the airway
Externally
Through the thyroid membrane
Medial to thyroid
cartilage
Lateral to thyroid
cartilage
Laryngocele expands
Air-filled communication
become tenous
Pressure changes still be
transmitted through it
Increase in size with cough and
valsava maneuver
Symptoms
Internal Mixed
Globus sensation
Sore throat
Cough
Pain
Snoring
Increasing stridor
Hoarseness
Airway obstruction (if large)
External
Visible or palpable mass in the neck
Laryngoscopic Examination
Globular swelling in the
laryngeal
lumen/submucosal
fullness
But may miss internal
component of mixed
laryngocele (if it small)
Differentiated
True cyst classified as
Epithelial
Most common! Include
saccular cyst
Oncocytic In ventricle, elderly, higher
rate of recurance, behave
like benign neoplasm
Tonsillar
Region of vallecula,
epiglottis/pyriformis
sinus
Laryngeal pseudocyst
Discrete
Unilateral
Localized area of Reinkes edema
Occuring mid-portion of the free-edge striking zone
Diagnostic
Most accurate!
Defining spatial relationships between the
laryngocele and laryngeal structures and
extra-laryngeal soft-tissues
Differentiating the laryngocele from other
cystic formations and
Identifying the coexistence of a laryngeal
malignancy.
Computed tomography
Marsupialization CO
2
laser
Done through an endolaryngeal, endoscopic, or microscopic approach
For internal or mixed laryngoceles
External cervical approach with or without tracheotomy
Employed for mixed and external laryngocele
Should be dissected carefully
To prevent damage to the neurovascular bundle
Penetrates the thyrohyoid membrane at the site of exit to
the external laryngocele
Learning Point
Laryngocele should be considered in any patient presenting with a
compressible neck swelling
Laryngoscopic examination must be repeated determine wheter is internal,
external or mixed for appropriate treatment
References
1. Michael M, Parikh S. Benign laryngeal lesions. Ballengers Otorhinolaryngology, Head
and Neck Surgery. 17th ed. CBS Publishers & Distributors Pvt. Ltd.; 2009. p. 880.
2. Drozd M, Szuber K, Szuber D. The significance of the valve mechanism in pathology of
laryngocele. Otolaryngol Pol 1996;50:17-20.
3. Dray TG, Waugh PF, Hillel AD. The association of laryngoceles with ventricular
phonation. J Voice 2000;14:278-81.
4. Gallivan KH, Gallivan GJ. Bilateral mixed laryngoceles: Simultaneous
strobovideolaryngoscopy and external video examination. J Voice 2002;16:258-66.
5. Pennings RJ, van den Hoogen FJ, Marres HA. Giant laryngoceles: A cause of upper
airway obstruction. Eur Arch Otorhinolaryngol 2001;258:137-40.
6. Akbas Y, Unal M, Pata YS. Asymptomatic bilateral mixed-type laryngocele and
laryngeal carcinoma. Eur Arch Otorhinolaryngol 2004;261:307-9.
7. Zawadzka-Glos L, Frackiewicz M, Brzewski M, Biejat A, Chmielik M. Difficulties in
diagnosis of laryngeal cysts in children. Int J Pediatr Otorhinolaryngol 2009;73:1729-
31.
8. Ramesar K, Albizzati C. Laryngeal cysts: Clinical relevance of a modified working
classification. J Laryngol Otol 1988;102:923-5. Salerno G, Mignogna C, Cavaliere M,
DAngelo L, Galli V. Oncocytic cyst of the larynx: An unusual occurrence. Acta
Otorhinolaryngol Ital 2007;27:212-5.
References
9. Oliveira CA, Roth JA, Adams GL. Oncocytic lesions of the larynx. Laryngoscope
1977;87:1718-25.
10. Koufman JA, Belafsky PC. Unilateral or localized Reinkes edema (pseudocyst) as a
manifestation of vocal fold paresis: The paresis podule. Laryngoscope
2001;111:576-80. McDonald SE, Pinder DK, Sen C, Birchall MA. Oncocytic cyst
presenting as laryngocele with surgical emphysema. Eur Arch Otorhinolaryngol
2006;263:237-40.
11. Uguz MZ, Onal K, Karagz S, Gke AH, Firat U. Coexistence of laryngeal cancer
and laryngocele: A radiologic and pathologic evaluation. Kulak Burun Bogaz Ihtis
Derg 2002;9:46-52.
12. Ettema SL, Carothers DG, Hoffman HT. Laryngocele resection by combined external
and endoscopic laser approach. Ann Otol Rhinol Laryngol 2003;112:361-4.
13. Martinez Devesa P, Ghufoor K, Lloyd S, Howard D. Endoscopic CO2 laser
management of laryngocele. Laryngoscope 2002;112:1426-30.
14. Ingrams D, Hein D, Marks N. Laryngocele: An anatomical variant. J Laryngol Otol
1999;113:675-7.
Thankyou