Laryngoceles - presentations and management

Megaesophagus in an 8-month-old cat secondary to a laryngomucocele

Case summary

An 8-month-old spayed female cat presented with a 7-week history of progressive dyspnoea, dysphagia and regurgitation. Plain radiography revealed megaoesophagus with a large, rounded, soft tissue opacity laryngeal mass. Endoscopic examination revealed a fluid-filled lesion, which was lanced and drained completely. As a result of recurrence of the mass and infection 2 days later, the mass was surgically excised. The mass was diagnosed as a laryngomucocele based on clinical and histopathological findings. Clinical signs resolved immediately after removal of the mass, the megaoesophagus resolved a couple of days postoperatively and no relapse was noted over the following 3 years.

Relevance and novel information

To the author's knowledge, this is the first case of laryngomucocele described in a cat. This cause should be included in the differential diagnosis of respiratory obstruction and acquired megaoesophagus in cats. This report demonstrates that megaoesophagus resulting from a respiratory obstruction resolves spontaneously after removal of the obstruction; therefore, respiratory tract assessment should be recommended in cats with signs of megaoesophagus because the prognosis could be good compared with other causes of megaoesophagus.

Bilateral Combined Laryngocele: Comprehensive Review of the Literature

Laryngocele, an abnormal dilation of the appendix of the laryngeal ventricle filled with air, is a rare condition predominantly presenting unilaterally. However, bilateral occurrences are exceedingly rare. In this article, we present a case of bilateral laryngocele along with a comprehensive literature review. A 57-year-old male presented with dyspnea, stridor, and bilateral neck masses. His medical history included chronic cough and intermittent hoarseness. Over a 3 month period, the neck masses progressively enlarged, resulting in respiratory distress. Interestingly, he denied experiencing weight loss, decreased appetite, or fever. Clinical examination revealed sizable, soft masses on both sides of the neck, obstructing lymph node assessment. Computed tomography (CT) imaging confirmed the presence of a left combined laryngopyocele and a right combined laryngocele. Subsequently, the patient underwent tracheostomy. Benign biopsy results excluded malignancy. Surgical excision of bilateral laryngoceles resulted in an uneventful recovery. The term "laryngocele" was introduced by Virchow in 1867 to describe the abnormal dilation of the saccule associated with Morgagni's ventricle. Diagnosis involves a thorough patient history, physical examination, and radiological imaging, notably CT, to differentiate laryngoceles from other conditions. Typically asymptomatic, they are often incidentally discovered around age 50, although symptoms such as voice changes or breathing difficulties can manifest. A review of the literature identified 77 documented cases, primarily in males, exhibiting various symptoms and treatment modalities. This case underscores the rarity of bilateral combined laryngocele, emphasizing the importance of timely diagnosis and surgical intervention for favorable outcomes. Comprehensive research reveals diverse clinical aspects, highlighting the necessity for continued investigation to enhance management strategies.

Combined Laryngocele and External Approach

Laryngocele, a dilation of the laryngeal saccule, is an uncommon and benign air-filled lesion that expands upwards into the ventricle of Morgagni. A unilateral growth within the larynx that is in communication with the laryngeal lumen typically signals its presence. The exact cause of the disorder remains uncertain, although there are three main theories which suggest congenital reasons, increased pressure in the larynx, or mechanical obstruction of the ventricle of Morgagni. The classification for laryngoceles is based upon their location with respect to the thyrohyoid membrane, and they may be internal, external, or combined. A laryngocele, along with a gradually enlarging submandibular mass, was located in the region from below the hyoid bone to the anterior sternocleidomastoid muscle on the right side of the neck. The diagnosis of a laryngocele may be confirmed through clinical examination, endoscopic investigation and imaging tests. For cases of combined laryngocele, we recommend its removal using an external approach, which not only ensures safety and accuracy but also allows for a complete removal of the laryngocele. Additionally, this approach guarantees that the surgical intervention is carried out with maximum precision and effectiveness, as all procedures will be performed under direct visualization.

Combined Laryngocele and External Approach

Laryngocele, a dilation of the laryngeal saccule, is an uncommon and benign air-filled lesion that expands upwards into the ventricle of Morgagni. A unilateral growth within the larynx that is in communication with the laryngeal lumen typically signals its presence. The exact cause of the disorder remains uncertain, although there are three main theories which suggest congenital reasons, increased pressure in the larynx, or mechanical obstruction of the ventricle of Morgagni. The classification for laryngoceles is based upon their location with respect to the thyrohyoid membrane, and they may be internal, external, or combined. A laryngocele, along with a gradually enlarging submandibular mass, was located in the region from below the hyoid bone to the anterior sternocleidomastoid muscle on the right side of the neck. The diagnosis of a laryngocele may be confirmed through clinical examination, endoscopic investigation and imaging tests. For cases of combined laryngocele, we recommend its removal using an external approach, which not only ensures safety and accuracy but also allows for a complete removal of the laryngocele. Additionally, this approach guarantees that the surgical intervention is carried out with maximum precision and effectiveness, as all procedures will be performed under direct visualization.

Laryngocele: Report of two rare cases and review of the literature

Laryngocele is a rare clinical condition characterized by an abnormal dilation of the laryngeal saccule. The present study focused on two separate cases of diagnosed patients. The first patient suffered from internal laryngocele and complained of hoarseness for almost 1 year. Plasma was used to treat the internal laryngocele and the outcomes were satisfying. The patient did not undergo any tracheostomy due to previous endoscopic surgery. The second patient included in the present study was diagnosed with mixed laryngocele and complained of swelling on the left side of the upper aspect of the neck with considerable pain for >1 month. The patient was prepped for excision by an external transcervical technique under general anesthesia. None of the two patients had any recurrence or other changes during follow-up. The purpose of reporting these two cases of laryngocele was to increase awareness of this condition. Surgery is still the first-line treatment for diagnosed cases, but with the advent of new microscopic techniques, the use of plasma in an inter-pharynx setting has become more common. The results observed after using plasma to treat one internal laryngocele may be relevant to better understanding the application of this method and confirm that it may be a new suitable approach to treat this condition.

A Comprehensive Update of the Incidence and Demographics of Laryngoceles in Adults

OBJECTIVE

To provide updated data on the incidence, types, and demographics of laryngoceles in the adult population.

METHODS

We searched the medical archives of our institute for computed tomography (CT) studies acquired between January 1, 2007 and December 31, 2017 in which the term "laryngocele" appeared in the radiology reports. Two of the authors reviewed relevant images for the presence, type, distribution, and laterality of true laryngoceles. Demographic and clinical data were extracted from medical records and the incidence was calculated.

RESULTS

Laryngoceles were detected in 53 out of the 79 893 patients with relevant CT data, which equates to an incidence of 151 per 2.5 million (0.06:1000) patients per year. The male:female ratio was 3:1, average age was 60 (±18) years, and incidence peaked among patients in the sixth decade of life. Nine patients (17%) had known laryngeal cancer; however, the majority of the cohort did not have follow up clinic visits.

CONCLUSION

Our study demonstrates that the incidence of laryngoceles is much greater than previously reported. In most cases, the diagnosis of a laryngocele was an incidental radiological finding. Male gender predilection and age at presentation are in agreement with previous reports. Association of laryngoceles with laryngeal cancer could not be calculated due to low rates of follow ups.

LEVEL OF EVIDENCE

3.

The role of imaging in the evaluation of hoarseness: A review

Hoarseness is a common symptom indicating an abnormal change in the quality of voice and has a lifetime prevalence of around 30%. There are multiple causes of hoarseness, ranging from acute laryngitis, chronic laryngitis, laryngopharyngeal reflux, functional dysphonia due to vocal overuse or abuse, vocal cord paralysis (VCP), to various pathologies and masses in the larynx. A detailed history and thorough physical examination, and in many cases, laryngoscopy by a clinician are the initial steps in its management. Laryngoscopy should be considered if hoarseness persists for more than 2 weeks without a known benign cause. An Ear Nose and Throat surgeon performs direct visualization by laryngoscopy to rule out VCP or a lesion in the larynx, and it should be performed before ordering any imaging. CT with contrast is the imaging of choice to evaluate the laryngeal tumors and find the etiology of VCP. Typical findings of VCP are ipsilateral dilatation of the pyriform sinus and laryngeal ventricle, thickening and medialization of the ipsilateral aryepiglottic fold, medialization of the arytenoid cartilage and posterior aspect of the true vocal cord (TVC) atrophy of the TVC, and loss of the subglottic arch. The lesions causing the VCP may extend from the medulla, jugular foramen, carotid space, and upper mediastinum. CT neck must cover the aorticopulmonary window when evaluating the left VCP to cover the left recurrent laryngeal nerve's origin.

Thyroid chondroplastic flap for resection of laryngoceles

PURPOSE

Large and combined laryngoceles usually need an external approach. One difficulty in such approach was the dissection at the paraglottic space. To overcome such difficulty, a thyroid chondroplastic flap approach to the paraglottic space was designed.

METHODS

This study is a case series of thirty consecutive patients (24 men and six women with an average age of 45.6 years), having large combined laryngocele resected externally between January 1995 and December 2019) at the department of ORL_HNS Tanta University, Egypt.

RESULTS

This approach allowed for excellent exposure of the paraglottic space, facilitating complete resection. Complications included perichondrial tearing in five patients, obstructing hematoma in two patient and minimal edema in four patients.

CONCLUSIONS

Thyroid chondroplastic flap is an excellent and safe approach for the paraglottic space facilitating complete resection of large laryngoceles.

Left mixed laryngocele in absence of risk factors: A case report and review of literature

Laryngocele is an uncommon benign cystic dilatation of the laryngeal saccule that communicates with the laryngeal lumen and contains air. On the basis of its localization, it can be traditionally classified in internal, external, or mixed. Usually unilateral and rarely bilateral, it may be congenital or acquired. It most often appears later in life without important symptoms except for cervical swelling. Here, together with a review of literature, we report the case of a 72-year-old man, smoker but without other specific risk factors, who presented laryngeal dyspnea for about one year. Neck CT scan performed during a previous hospitalization for respiratory failure revealed a left mixed laryngocele that was later surgically removed with cervicotomic access. The patient was discharged after one week. One month after surgery, we confirmed the absence of disease with video laryngoscopy.

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Laryngocele is a rare benign cystic dilatation of laryngeal saccule.

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Conditions increasing intraluminal laryngeal pressure are the main risk factors.

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The diagnosis of laryngocele is essentially clinic, based on symptoms.

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In some cases it can present with acute respiratory failure as pulmonary pathology.

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Treatment is surgical excision, microlaryngoscopic, external or combined.

Systematic review of laryngocele and pyolaryngocele management in the age of robotic surgery

OBJECTIVE

A laryngocele is a space that develops as a result of pathological dilatation of the laryngeal saccule. However, the reported management of laryngoceles varies. We conducted a systematic review of the literature regarding the surgical management of laryngoceles and pyolaryngoceles, to understand the evolving nature of treatment for this rare condition.

METHODS

We searched for publications in the PubMed, Cochrane Library, JBI Library of Systematic Reviews, and Ovid databases using the terms "laryngocele", "pyolaryngocele", and "laryngopyocele", and reviewed the identified articles.

RESULTS

After removal of repeated studies and filtering for relevance and studies written in English, a total of 227 studies were included in this review. No meta-analyses or randomized controlled trials have been published. The identified studies have been summarized in 14 reviews conducted since 1946. The meta-analysis determined that endoscopy was the preferred approach for internal laryngoceles, while combined laryngoceles benefited from both internal and external surgical approaches.

CONCLUSIONS

Laryngocele management has progressed since its initial description, from open surgery to an endoscopic approach, and more recently to a robotic-assisted surgical approach. The uptake of robotic surgery as a possible treatment modality over the last decade shows much promise for the treatment of these conditions.

Blunt Trauma to the Neck Presenting as Dysphonia and Dysphagia in a Healthy Young Woman; A Rare Case of Traumatic Laryngocele

Laryngocele is not a common clinical entity that presents itself in a trauma setting. In the literature, there are currently two types of laryngocele, internal and mixed. Laryngocele may be congenital or acquired, and most often will present later in life. Traumatic laryngocele has only been reported three times in the literature before. Herein, we report a rare case of a 22-year-old woman who presents with bilateral laryngocele secondary to sustained direct trauma. Neck Ct-scan revealed bilateral laryngocele being responsible for her dysphagia and dysphonia. She was monitored in the hospital for further exacerbation of her symptoms with feared airway occlusion in mind. On hospital day three, her dysphagia had resolved and her dysphonia had significantly improved. A second CT, revealed resolution of left laryngocele with the right decreased in size since the initial presentation. She was followed and had complete resolution of symptoms one week after the injury.

Laryngocele: A Rare Case Report and Review of Literature

Laryngocele is an abnormal cystic dilatation of the saccule of the larynx. It communicates with the laryngeal lumen and contains air. Laryngocele can be classified as internal (within the larynx), external (outside the larynx) and mixed (both). It is a rare entity. Hereby, we are reporting a case of laryngocele, which presented to us with a diagnostic quandary. After confirming the diagnosis by radiology, patient was operated upon by external approach. In the following article, we also discuss the establishment of the diagnosis and review different surgical modalities for the management of various types of laryngocele.

A radiologic review of hoarse voice from anatomic and neurologic perspectives

The differential diagnosis for hoarseness is extensive and includes a multitude of etiologies that span a large geographic area from the brainstem to the mediastinum. Therefore, localizing a causative lesion can be extremely difficult for clinicians and radiologists alike. In this review, we will first discuss the normal anatomy of the larynx and its innervation via the vagus and recurrent laryngeal nerves. We will then proceed with a guided tour of the various infectious/inflammatory, neoplastic, congenital, and traumatic/iatrogenic causes of hoarseness subdivided by anatomic location (brainstem, skull base, carotid sheath, thyroid, larynx, and superior mediastinum). Along the way, we will discuss the various cross-sectional imaging modalities best suited to detect the often subtle signs of recurrent laryngeal nerve injury. With thorough knowledge of these entities, radiologists can impact patient care by suggesting the appropriate imaging test and tailoring their search patterns to detect the subtle findings of laryngeal dysfunction.

Internal Laryngocele: Unusual onset in a 91-year-old female patient

While internal laryngoceles rarely cause major clinical complaints, they may lead to airway obstruction and require emergency intervention on rare occasions. We report a 91-year-old patient who was referred to the Ear, Nose & Throat Clinic of the Policlinico Santa Maria alle Scotte, Siena, Italy, in 2017 due to recurrent episodes of severe dyspnoea. A flexible nasopharyngolaryngoscopic examination revealed an internal laryngocele of approximately 1.5 cm in diameter that moved up and down the glottic plane, occasionally invading the subglottic space during inspiration and impeding airflow. This caused cyanosis and dyspnoea so severe that an emergency tracheotomy was considered. Luckily, after considerable effort, the patient was able to cough, causing the mass to move above the vocal plane and allowing normal breathing. The laryngocele was subsequently removed via laryngomicrosurgery. Although the incidence of internal laryngoceles is quite rare, physicians should consider this potentially life-threatening condition among patients with dyspnoea.

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 CO₂ 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.

Bilateral combined laryngocele

Laryngocele is an uncommon condition that represents a benign dilatation of the laryngeal saccule with air and/or fluid, arising in the region of the laryngeal ventricle. Laryngoceles, or laryngomucocele can be classified as internal, or combined. The aim of presenting this rare case of a bilateral combined laryngocele, are to emphasize the importance of diagnostic laryngoscopy in upper airway pathologies evaluation, increase awareness in the general otolaryngologist community, and to highlight the external surgical method.

A new preserved technique for laryngocele: modified lateral thyrotomy approach

Laryngocele is a benign abnormal dilatation of the laryngeal saccule. We present a 30-year-old male patient who complained with hoarseness since 1 year. Paraglottic laryngocele is detected on medical examination. The patient is operated on successfully with our new thyroid cartilage preserved technique (modified lateral thyrotomy method).

Treatment of Laryngoceles: what is the progress over the last two decades?

OBJECTIVES

To review surgical techniques used in the treatment of laryngoceles over the last two decades and point out developments and trends.

MATERIALS AND METHODS

PubMed, the Cochrane Library, and the JBI Library of Systematic Reviews were searched using the term "laryngocele." Demographic data, type of laryngocele, presence of a laryngopyocele, type of treatment and need for a tracheotomy were assessed.

RESULTS

Overall, data on 86 patients were analyzed, culled from 50 articles, of which 41 were case reports and 9 were case series. No single systematic review or meta-analysis or randomized controlled trial has been published on the topic. Altogether, 71 laryngoceles in 63 patients met the criteria for further analysis focusing on surgical treatment. An external approach was selected in 25/29 (86.2%) cases of combined laryngoceles. Microlaryngoscopic resection using a CO2 laser was performed in three cases and endoscopic robotic surgery in one case. The majority of patients with an internal laryngocele, 31/42 (73.8%), were treated using the microlaryngoscopy approach.

CONCLUSIONS

Microlaryngoscopy involving the use of a CO2 laser has become the main therapeutic procedure for the treatment of internal laryngoceles during the past 20 years. An external approach still remains the main therapeutic approach for the treatment of combined laryngoceles.

Real-time and three-dimensional MRI for diagnosis of pharyngoceles

In the evaluation of patients with local pathologic dilatation inside the upper airway a pressure-related testing seems important for understanding its pathophysiology and for developing a concept of intra-individually adjusted therapy. Commonly used diagnostic techniques like endoscopy or medical imaging including ultrasound, barium swallow or computer-assisted tomography (CT) have shown limitations either in evaluating a dynamic process or assessing the entirety of cervical structures. This article presents a case report of a professional trumpet player with bilateral pharyngoceles, introducing real-time and three-dimensional (3D) MRI as a helpful tool in the diagnosis of pressure dependent pathologies in the upper airway. With the use of MRI the complete sub- and supraglottic airway can be viewed simultaneously, avoiding the distortion which can occur with endoscopy. Thus, it was possible to evaluate the pharyngoceles pressure-related pathophysiology, from which a successful therapy could be conceived which included modifying the musician's blowing technique.

Internal laryngopyocele as a cause of acute airway obstruction: an extremely rare case and review of the literature

The laryngocele is an abnormal cystic dilatation of the saccule or appendix of the laryngeal ventricle, filled with air and communicating with the lumen of the larynx. When the neck of the laryngocele is obstructed, it becomes filled with mucus of the glandular secretion and is changed to a laryngomucocele. When this lesion becomes infected, a laryngopyocele is formed. The laryngocele is fairly rare and laryngopyocele occurs even more rarely. Overall, 39 cases of laryngopyocele have been reported in the world literature. Only in 4 cases was a laryngopyocele reported to have caused acute airway obstruction and only one case of internal laryngopyocele causing acute airway obstruction has been reported until now. This is the first case reported in the literature of an internal laryngopyocele in a female patient in a septic condition, which caused almost 100% obstruction of the airway. An emergency tracheotomy was performed in order to secure the airway. Computed tomography of neck was performed which revealed a cystic 29 mm hypodense mass extending from the right false vocal cord to the level of the epiglottis, narrowing the laryngeal cavity and causing an almost 100% airway obstruction. Laryngopyoceles may present with a rapid and alarming obstruction of the airway and, therefore, an urgent tracheotomy may be inevitable. It is an emergency case, in the field of otolaryngology, and should be included in the differential diagnosis of acute airway obstruction, especially when hoarseness, stridor and fever are present. Diagnosis requires a high index of suspicion for these lesions and scrupulous clinical and radiological evaluation. A computed tomography scan is critical in determining the nature and site of the lesion. The recommended treatment of laryngopyocele is immediate endoscopic drainage. Definitive management of laryngopyoceles is surgical excision which can be performed immediately after endoscopic drainage or some time thereafter.