LETTERS TO THE EDITOR.

Dear Dr. Pulec:

The article in the April 2000 ENT Journal by Drs. Isaacson and Sataloff is in error. The title is "Bilateral laryngoceles in a young trumpet player: Case report." This is a case of bilateral pharyngoceles, not laryngoceles. Laryngoceles in general do require surgery, while pharyngoceles are not true pouches and diminish in size if the increases in pharyngeal pressure (playing a musical instrument) are stopped. [1]

Sincerely,

Paul H. Ward, MD

Los Angeles

Reference

(1.) Ward PH, Frederickson J, Strandjord NM, Valvassori GE. Laryngeal and pharyngeal pouches. Surgical approach and the use of cinefluorographic and other radiologic techniques as diagnostic aids. Laryngoscope 1963;73:564-82.

Drs. Isaacson and Sataloff reply:

Dear Dr. Pulec:

As always, Dr. Ward's comments and insights are appreciated. We are familiar with his classic writings on this subject and his 1963 movie Spectacular Problems in Surgery, in which this subject was discussed. We also appreciate the opportunity to discuss a few issues and controversies that were not detailed in our brief case report.

Our selection of figures in the published article did not include any images showing the intralaryngeal component, which we are providing at this time (figure). The new figure depicts one of the images that illustrate why we and our radiologist classified the lesions as laryngoceles. In fact, they are probably most accurately described as combined laryngoceles/pharyngoceles.

Since Dr. Ward's earlier reports on this subject, our understanding of these lesions has changed slightly. Both laryngoceles and pharyngoceles can change size and appearance with variations in internal pressure. While the classical definitions (as described by Dr. Ward, and in our paper) of laryngocele and pharyngocele remain valid, combinations of both can occur. Considering the origins of pharyngeal pouches (as reviewed in Dr. Ward's 1963 paper) and the forces involved, we suspect that most lesions with a laryngeal component originated in the larynx and extended into the neck, rather than vice versa; but it is not always possible to prove origin. Moreover, the distinctions were quite important when we still believed that laryngoceles usually require surgery and pharyngoceles rarely require surgery. However, as arts medicine has evolved, experience has shown that neither lesion requires surgery in most cases. Contrary to our early understanding, the vast majority of laryngoceles are asymptomatic.

We agree with Dr. Ward that terminology should be precise. Air-filled neck masses that arise in the pharynx (commonly in the region of the pyriform sinuses) and lack an intralaryngeal component or origin should be called pharyngoceles. Those that arise in the laryngeal ventricle should be called laryngoceles. It is also important to recognize, however, that the therapeutic implications of the distinction are not as clear-cut as they once were, and that lesions that combine-features of laryngoceles and pharyngoceles occur.

Glenn lsaacson, MD, FACS, FAAP 

Robert Thayer Sataloff, MD, DMA 

Philadelphia