Bilateral laryngoceles in a young trumpet player: Case report.

Abstract

We report the case of a 16-year-old trumpet player who was referred for an otolaryngologic consultation after his band leader noticed that a neck mass would protrude while the boy was playing. X-rays revealed the presence of bilateral laryngoceles, and computed tomography demonstrated bilateral, air-filled outpouchings of the laryngeal saccules during forced expiration. There was no evidence of any other intralaryngeal or cervical pathology. Surgery was deferred while the laryngoceles remained reducible and asymptomatic, and the boy was cleared to continue playing.

Introduction

Laryngoceles are abnormal dilations or herniations of the laryngeal saccule. [1] They communicate with the laryngeal lumen and are generally filled with air. They become clinically apparent when they are distended after air is forced into them or when they are filled with fluid. This report describes our care of a young trumpet player whose career was temporarily halted when he developed a neck mass that appeared only while he was playing his horn.

Case report

A 16-year-old boy was referred for an otolaryngologic consultation after he developed a left neck mass. He had been playing the trumpet since the age of 9, and he was preparing for a brass competition. The mass was first noted by his band leader, who became alarmed and forbade the boy to play the horn until he had undergone a physician's examination and received medical clearance.

On physical examination, no abnormality of the head or neck was apparent at rest. However, with forced expiration against a closed mouth and nasopharynx (trumpet or chipmunk maneuver), an air-filled 6-cm mass inflated in the left neck. The mass rapidly deflated upon relaxation. Although nasopharyngolaryngoscopy during the trumpet maneuver failed to show any intralaryngeal abnormality, neck x-rays revealed the presence of bilateral laryngoceles (figure 1). Computed tomography (CT) demonstrated bilateral, air-filled outpouchings of the laryngeal saccules during forced expiration; these outpouchings disappeared during rest (figure 2). There was no evidence of any other intralaryngeal or cervical pathology.

The decision was made to defer surgery while the laryngoceles remained reducible and asymptomatic, and the boy was cleared to resume playing. At 18-month followup, he had had no enlargement in his laryngoceles, and he had won several regional horn competitions.

Discussion

Laryngoceles limited to the interior of the larynx are called internal, while those that protrude laterally into the neck are called external. Outpouchings of the laryngeal ventricle extend through the openings in the thyrohyoid membrane for the superior laryngeal vessels and nerve, and balloon outward and upward toward the submandibular triangle. [2]

There are several proposed mechanisms for laryngocele formation. In neonates, they are presumed to be remnants of the lateral air sacs seen in other higher primates. In adults, they can represent a congenital enlargement of the saccule or an acquired lesion associated with increased intraluminal pressure. The association of laryngoceles with laryngeal carcinoma and with occupations that involve long periods of forced expiration supports this notion. [3]

Brass and woodwind players are at risk for a variety of head and neck injuries as a result of increased intraluminal pressure during their musical performances. Transient ischemic attacks, temporomandibular joint dysfunction, and dental malocclusion have been reported. Injury to the orbicularis oris in brass players can require surgical repair. [4] Stress velopharyngeal incompetence has been documented in trumpet and bassoon players. Young trumpet players are at greatest risk for injury to oral and cervical tissues when they generate peak respiratory pressures averaging 151 ([pm]19) torr. [5]

Several authors have examined laryngocele formation in woodwind players. Stephani and Tarab obtained plain x-rays on 25 wind instrument players and found laryn-goceles in all of them. [6] Macfie found laryn-goceles in 53 of 94 (56%) woodwind bandsmen. [7]

Certainly, subclinical laryngoceles are common among horn players, and they rarely require surgical intervention. Surgery for laryngoceles in young musicians poses several problems. The literature offers no guidance regarding the timing of surgery, the healing period before playing can be resumed, and the risk of recurrence with continued performance. Furthermore, the cervical approach commonly used for the treatment of external laryngoceles can disrupt the normal function of the strap muscles, which are important for tone generation. [8] The risks of infection and progression of the defect must be balanced against a young performer's desire for musical growth.

From the Department of Otolaryngology--Head and Neck Surgery, Temple University School of Medicine, Philadelphia (Dr. Isaacson), and the Department of Otolaryngology--Head and Neck Surgery, Thomas Jefferson University, Philadelphia, and the Department of Otolaryngology--Head and Neck Surgery, Graduate Hospital, Philadelphia, (Dr. Sataloff).

References

(1.) Holinger LD, Barnes DR, Smid LJ, Holinger PH. Laryngocele and saccular cysts. Ann Otol Rhinol Laryngol 1978; 87: 675-85.

(2.) DeSanto LW. Laryngocele, laryngeal mucocele, large saccules, and laryngeal saccular cysts: A developmental spectrum. Laryn-goscope 1974; 84: 1291-6.

(3.) Norris CW. Pharyngoceles of the hypopharynx. Laryngoseope 1979; 89: 1788-807.

(4.) Papsin BC, Maaske LA, McGrail JS. Orbicularis oris muscle injury in brass players. Laryngoscope 1996; 106: 757-60.

(5.) Fiz JA, Aguilar J, Carreras A, et al. Maximum respiratory pressures in trumpet players. Chest 1993; 104: 1203-4.

(6.) Stephani A, Tarab S. [Obscure ventricular laryngocele]. Schweiz Rundsch Med Prax 1972; 61: 1520-3.

(7.) Macfie DD. Asymptomatic laryngoceles in wind-instrument bandsmen. Arch Otolaryngol 1966; 83: 270-5.

(8.) Backus J. The effect of the player's vocal tract on woodwind instrument tone. J Acoust Soc Am 1985; 78: 17-20.