Laryngoceles: concepts of diagnosis and management.
A laryngocele is an abnormal dilatation of the laryngeal saccule. It is a rare benign lesion of the larynx. Various modalities of treatment have been advocated for its management. We present our treatment results and outcomes of a series of cases of laryngoceles and discuss the concepts of their management. This study included patients with different laryngocele types. Patients with an internal laryngocele underwent endoscopic C[O.sub.2] laser resection, while those with a combined laryngocele underwent resection via a V-shaped lateral thyrotomy approach. Seven patients had an internal laryngocele, and 4 patients had a combined laryngocele. Hoarseness and neck swelling were the most common symptoms. The mean follow-up period was 8.5 months. None of the patients needed a tracheostomy either preoperatively or postoperatively, or had recurrence of laryngocele. We advocate the lateral thyrotomy approach for combined laryngoceles as it provides safe, precise, and complete resection under direct visualization via a single approach, while we favor the endoscopic laser approach for the internal ones as it allows resection of the entire lesion with minimal laryngeal trauma, less operative time, and a shorter hospital stay.
Laryngocele is an abnormal dilatation or herniation of the laryngeal saccule that extends upward within the false vocal fold in communication with the laryngeal lumen. It is a rare benign lesion of the larynx and has been classified as either internal or combined. The formerly used classifications of internal, external, and combined laryngoceles are being abandoned because a purely external laryngocele cannot exist since laryngoceles originate at the laryngeal saccule. An internal laryngocele is medial to the thyrohyoid membrane, while a combined laryngocele lies both medial and lateral to the thyrohyoid membrane. (1-4)
Laryngoceles are rare lateral neck masses. They are more commonly found in men than women in a 5 to 7:1 ratio and in the fifth or sixth decade of life. Eighty to eighty-five per cent of laryngoceles have been found to be unilateral with no predominance of occurrence on the left or right side. The most common type of laryngocele is the combined type. (5,9)
The simple laryngocele is filled with air. When the neck of the laryngocele is obstructed, it becomes filled with mucus of glandular secretion and is altered to a laryngomucocele. When this lesion becomes infected, a laryngopyocele is formed. (10.11)
There is much controversy regarding the etiology of laryngoceles. Their origin may involve congenital factors, such as when they occur in neonates, and acquired factors that are probably related to an increase in the intralaryngeal pressure, such as chronic cough, straining, blowing into musical instruments, glass blowing, and laryngeal carcinoma. However, many patients do not have any predisposing factor, and most laryngoceles are unilateral. (5,12,13)
Currently, various modalities of treatment have been used for the management of laryngoceles. Both the external approach and the endoscopic approach have been advocated for the resection of a laryngocele. Moreover, a debate remains regarding the management of the combined laryngocele. (3,4,10)
In this study, we present our treatment results and outcomes of a series of cases of laryngoceles and discuss the concepts of their management.
Patients and methods
Patients. This study included 11 male patients with the two different types of laryngoceles. The patients were managed through the Department of Oto-Rhino-Laryngology and Head and Neck Surgery of Zagazig University Hospitals during the period from May 2010 to January 2013.
Diagnosis. The patients underwent the following diagnostic protocol: (1) history with attention to the duration and severity of symptoms (hoarseness, cough, dyspnea, inspiratory stridor, dysphagia, sore throat, and neck mass) and any previous endoscopic or surgical procedure; (2) complete upper airway examination by either fiberoptic flexible nasopharyngoscope or 70[degrees] rigid laryngoscope; (3) computed tomography (CT) scanning of the soft tissues of the neck with and without contrast; (4) rigid endoscopic evaluation under general anesthesia for direct objective assessment of the larynx and ruling out the presence of a neoplasm.
Ethical approval. The Institutional Review Board (IRB) of the Faculty of Medicine, Zagazig University, Egypt, approved the study. Fully informed written consent was obtained from all patients.
Surgery for internal lesions. Patients with an internal laryngocele underwent endoscopic C[O.sub.2], laser resection under general anesthesia after receiving a third-generation cephalosporin. In this procedure, after intubation with a 6-mm endotracheal tube, a wide lumen laryngoscope is positioned with optimum exposure of the false vocal fold ipsilateral to the laryngocele. Moistened cottonoid pledgets are placed on the vocal folds and around the endotracheal tube to protect the vocal folds, subglottis, and endotracheal tube from thermal injury that may be caused by the C[O.sub.2], laser. With the assistance of the operating microscope, the C[O.sub.2], laser is used at a continuous super-pulsed mode and a power of 3 to 5 watts.
The mucosa over the laryngocele is retracted medially with a grasping forceps, an incision is made with the C[O.sub.2], laser into the mucosa of the superior surface of the false vocal fold, and it is deepened laterally to identify the wall of the underlying laryngocele. Once the sac is identified, a portion of the false vocal fold is excised to clearly define the neck of the sac in the ventricle.
Traction is applied to the laryngocele, and the C[O.sub.2], laser is used to open the plane between the sac and surrounding paraglottic tissue. The sac is kept under traction, mobilized, and completely dissected from the surrounding paraglottic tissue. After dissection is completed, the entire sac is resected, and bleeding is controlled by a defocused C[O.sub.2], laser beam and/or suction monopolar electrocautery.
Surgery for combined lesions. Patients with a combined laryngocele underwent resection via an external approach through a V-shaped lateral thyrotomy performed under general anesthesia. Preoperatively, they were given a third-generation cephalosporin. In this procedure, the patient is placed supine with an extended neck and a rotated head to the side opposite the lesion. A horizontal skin-crease incision is made at the thyrohyoid membrane level from the medial border of the sternocleidomastoid muscle to the midline of the neck. The skin flaps are raised in a subplatysmal plane, superiorly 1 cm above the hyoid bone and inferiorly to the lower border of the thyroid cartilage.
The strap muscles on the bulge of the laryngocele are dissected to reach the laryngocele capsule (figure 1). Dissection of the capsule is continued, and the lateral portion of the laryngocele is dissected from the surrounding tissue up to the posterior border of the thyroid cartilage. The sternohyoid, thyrohyoid, and omohyoid muscles are divided along the inferior border of the hyoid bone and reflected downward, while the external thyroid perichondrium is incised along the superior border from the base of the cornu to the thyroid notch, and an inferiorly based thyroid perichondrial flap is created and dissected, exposing the superior half of the lamina (figure 2).
The lateral portion of the laryngocele is dissected toward the thyrohyoid membrane. The internal and external branches of the superior laryngeal nerve are identified, and the thyrohyoid membrane is sectioned from posterior to anterior along the superior border of the thyroid lamina, beginning from where the laryngocele is exteriorized. A V-shaped incision is made at the superior half of the thyroid lamina, creating a triangle with its base at the superior border and the apex at a point midway along the vertical length of the thyroid lamina.
After resection of the triangle of the thyroid lamina, dissection of the laryngocele is continued under direct vision in the paraglottic space down to the ventricle, staying as close as possible to the laryngocele (figure 3). A ligature is placed at the lowest and deepest limit of the laryngocele, and it is totally excised.
The ventricle is closed with interrupted inverted sutures in the mucosa. The external thyroid perichondrial flap is repositioned, and the strap muscles are refixed in their original position. A small Penrose drain is inserted in the deepest portion of the wound, the skin incision is closed in layers, and a compressive dressing is applied to the neck. The drain is kept in place for 24 to 48 hours, and the skin sutures are removed after 1 week.
Postoperative treatment and follow-up. Postoperatively, a third-generation cephalosporin and steroid were given. The patients were routinely followed at 2 weeks, 1 month, and then every 3 months, with laryngeal assessment via either a fiberoptic flexible nasopharyngoscope or a rigid 70[degrees] laryngoscope. CT scanning of the soft tissues of the neck with and without contrast was repeated 3 months postoperatively.
This study included 11 male patients. Their average age was 53.5 years with a range from 36 to 64 years. Seven patients (63.6%) had an internal laryngocele, and 4 patients (36.4%) had a combined laryngocele. Five laryngoceles were on the right side (45.5%), four were on the left side (36.4%), and two were bilateral (18.2%). Hoarseness and neck swelling were the most common symptoms.
The combined laryngocele presented clinically as a swelling in the neck at the level of the hyoid bone anterior to the sternocleidomastoid muscle that increased in size with the Valsalva maneuver; when compressed, the swellingbecame smaller (figure 4). Both the internal and combined laryngoceles appeared on laryngoscopy as a smooth submucosal swelling of the supraglottis within the false vocal folds and with intact mucosa (figure 5). The diagnosis was confirmed by CT scanning of the neck in all the patients (figure 6).
None of the patients had undergone laryngeal surgery previously. Patients undergoing the endoscopic laser approach were hospitalized for 1 to 2 days, while those undergoing the external approach were hospitalized for 3 to 5 days. Patients with bilateral laryngoceles underwent laser surgery on two separate occasions, 8 weeks apart.
In patients undergoing the endoscopic laser approach, minor postoperative edema developed in the aryepiglottic and ventricular folds but resolved within 1 week. None of the patients with the external approach developed any anatomic distortion of the laryngeal framework. All the patients had perfect wound healing and uneventful recovery.
Postoperative histopathologic examination of the surgical specimen was performed for all patients, revealing chronically inflamed laryngeal mucosa with no evidence of a neoplasm. The mean follow-up period was 8.5 months with a range from 6 to 12 months, and none of the patients was lost to follow-up. None of the patients needed a tracheostomy, either preoperatively or postoperatively, or had recurrence of the laryngocele on either laryngoscopy or CT scanning of the neck.
In 1867, Virchow was the first to introduce the term laryngocele, which he considered a dilation of the laryngeal ventricle. The laryngocele consists of a membranous sac located between the false vocal fold and the inner aspect of the thyroid cartilage.
An internal laryngocele is confined within the larynx, extending above the thyroid cartilage without piercing the thyrohyoid membrane. It extends posterosuperiorly into the false vocal fold and the aryepiglottic fold. A combined laryngocele extends upward and protrudes through the opening in the thyrohyoid membrane to the superior laryngeal nerve and vessels to the neck. (2,14,15) In our study, the internal laryngocele was the most common type.
Currently, there are different theories regarding the etiology of laryngoceles. They may occur in individuals with a congenitally large saccule or with congenital weakness of laryngeal tissues. (7,16) Prolonged periods of increased pressure within the laryngeal lumen could result in gradual dilatation of the saccule. Acquired factors such as local laryngeal disease (i.e., carcinoma) could cause increased intraventricular pressure because of a valvular effect restricting the exit of air from the sac. However, many patients do not have any predisposing factors. (9,12,13,17) In our series, we did not find patients' occupations to be an etiologic factor.
The diagnosis of laryngocele is based on clinical findings, endoscopic examination of the larynx, and imaging studies. Symptoms may vary according to the type of laryngocele. The internal laryngoceles may cause hoarseness, snoring, or even upper airway obstruction. Other symptoms include a foreign body sensation, sore throat, dysphagia, and cough. In cases of combined laryngocele, there will be a neck mass with or without associated laryngeal symptoms. (12) In our study, the most common presenting symptoms were hoarseness and neck swelling.
CT scanning of the neck shows the extension, anatomic relationships, and content of both internal and external components of laryngoceles. Furthermore, this imaging is necessary to differentiate laryngoceles from saccular cysts of the larynx and to reveal evidence of an occult laryngeal tumor, because the incidence of laryngocele in laryngeal carcinoma has been estimated to be around 10%. (2,7,8,18)
In cases in which a laryngocele is associated with a laryngeal squamous cell carcinoma, magnetic resonance imaging (MRI) is particularly important to corroborate the diagnosis, evaluate the disease extent in soft tissues, stage the tumor, and provide better surgical planning. (4,19,20) In our study, no evidence of laryngeal neoplasm was encountered on the histologic examination of the surgical specimens.
Management of laryngocele is mainly influenced by the size of the lesion and the experience of the surgeon. (1,3) Several authors have advocated the use of the external approach, while others have favored endoscopic excision of the laryngocele with or without the use of a C[O.sub.2] laser. In cases of combined laryngocele, some authors have suggested a combined external and endoscopic laser approach to ensure complete removal of the laryngocele. (1,9,20-22)
Endoscopic management of laryngoceles has gained popularitybecause of advances in endoscopic techniques and the development and further applications of the laser in surgery. (4,20) However, there are many arguments against the endoscopic approach such as limitations in usage, difficulties with direct laryngoscopy, limited access afforded, the possibility of incomplete resection with the need to perform further procedures, and trauma to the adjacent laryngeal structures, causing excessive scarring. (3)
Currently, a consensus appears to favor the endoscopic resection of internal laryngoceles. (4,10) Therefore, in our study, only patients with internal laryngocele underwent endoscopic C[O.sub.2], laser resection. The operating microscope allowed identification of the capsule of the laryngocele, and the plane of dissection was kept as medial as possible. Bleeding was successfully controlled by the defocused C[O.sub.2], laser beam and/or suction monopolar electrocautery. No complication was encountered, and all the patients were discharged 1 to 2 days after surgery. None of the patients required tracheostomy or had recurrence of laryngocele.
The endoscopic C[O.sub.2], laser approach has reduced operative time, has less incidence of bleeding, and causes minimal damage to the endolarynx, with good recovery of laryngeal functions. However, it requires experience with special instruments and proper selection of patients.
Opinion is divided regarding the use of an endoscopic or combined approach for the management of the combined laryngocele. (1,20) In our study, we favored the external approach as it has the advantages of easy access to the laryngocele and a low recurrence rate. However, the external approach has the disadvantages of creating a scar on the neck, increased operative time, associated morbidity, the possible need for tracheostomy, and a prolonged hospital stay. (3,4,10)
In our study, a V-shaped lateral thyrotomy approach was used for resection of the combined laryngoceles. Thome et al used this approach for resection of all types of laryngoceles, even the internal ones. (3) However, 4 of their patients had tracheostomy, either preoperatively or postoperatively, with successful decannulation after the surgery. This approach provides direct access and superb visibility of the paraglottic space. Therefore, it allows dissection along the plane between the laryngocele and surrounding paraglottic tissue under direct vision, minimizes trauma to the surrounding laryngeal structures, and ensures resection of the entire laryngocele, thereby preventing recurrence. This approach also has low morbidity as the endolarynx is not entered except through the ventricle. Furthermore, the sectioned strap muscles are refixed in their original position, and the laryngeal framework is not deformed as only a V-shaped triangle of the thyroid lamina is resected to gain a wide operative field without any anatomic distortion of the larynx.
In our study, all cases of combined laryngocele were completely resected via the lateral thyrotomy approach alone, and a tracheostomy was not required. None of the patients developed a complication or had recurrence of laryngocele. However, the patients were hospitalized for a longer period.
A laryngocele is a rare disease of the laryngeal ventricle. Despite its being a benign disorder, it is important to rule out any associated malignancy as an etiologic factor. Radiologic studies are essential for the diagnosis and determining the type and extent of laryngocele, as well as for planning management.
With proper selection of patients, the endoscopic C[O.sub.2], laser approach is a reliable method for resection of internal laryngoceles as it allows removal of the entire lesion with an excellent outcome and shorter hospital stay, and it does not necessitate a tracheostomy.
We advocate the V-shaped lateral thyrotomy as a single approach for resection of the combined laryngocele as it provides wide accessibility, good exposure, and safe laryngocele dissection in the paraglottic space and ensures resection of the entire lesion under direct visualization. Despite prolonged hospitalization, this approach has low morbidity because of minimal trauma to the laryngeal structures, and tracheostomy is not a must.
The treatment modality should be individualized based on the size and type of the lesion, the risk of incomplete resection and damage to the structures within the larynx, and the surgeon's experience and results.
Mohammad Kamal Mobashir, PhD, MD; Waleed M. Basha, PhD, MD; Abd ElRaof Said Mohamed, MD; Mostafa Hassaan, MD; Ahmed M. Anany, MD
From the Department of Oto-Rhino-Laryngology and Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt. This study was conducted in Zagazig University Hospitals, a tertiary care hospital and referral center in Zagazig, Al-Sharkia, Egypt.
Corresponding author: Dr. Waleed Mohamed Basha Amin Khamis, Department of Oto-Rhino-Laryngology and Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig 44519, Al-Sharkia, Egypt. Email: email@example.com
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Caption: Figure 1. Photo shows an external approach for resection of a right-sided combined laryngocele.
Caption: Figure 2. Infrahyoid muscles are reflected downward exposing the superior half of the thyroid lamina (black arrow), and an inferiorly based thyroid perichondrial flap is created (white arrow).
Caption: Figure 3. Illustration represents an elevated, inferiorly based thyroid perichondrial flap (A), a resected triangle of the thyroid lamina (B), and a laryngocele completely dissected off the paraglottic space (C).
Caption: Figure 4. In this photo, a right-sided neck swelling (arrow), which is a combined laryngocele, is seen. The swelling increases in size with the Valsalva maneuver.
Caption: Figure 5. endoscopic views show a right-sided internal laryngocele (A) and bilateral internal laryngoceles (B).
Caption: Figure 6. This preoperative axial CT scan of the soft tissues of the neck reveals a right-sided combined laryngocele (arrow).
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Mobashir, Mohammad Kamal; Basha, Waleed M.; Mohamed, Abd ElRaof Said; Hassaan, Mostafa; Anany, Ahmed|
|Publication:||Ear, Nose and Throat Journal|
|Date:||Mar 1, 2017|
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