Endoscopic CO2 laser excision of large or recurrent laryngeal saccular cysts in adults

Strategies for CO2 Laser Use in Laryngeal Microsurgery: A Systematic Review

OBJECTIVE

We aim to systematically review the literature addressing perioperative practices for optimal use of the CO2 laser in laryngeal transoral laser microsurgery (TOLMS), with a focus on safety.

DATA SOURCES

A systematic review of publications indexed in Medline, Embase, and EBM reviews-Cochrane Central Register of Controlled Trials which evaluated perioperative strategies for the use of CO2 laser in laryngeal TOLMS was conducted.

REVIEW METHODS

Records obtained from the search strategy were assessed for eligibility in a 2-step process by 2 independent researchers using the Covidence software.

RESULTS

Among 2143 identified records, 103 were included in this study. The majority of studies (n = 25) focused on the use of the CO2 laser in oncologic resection, while 20 addressed the treatment of vocal cord paralysis, 16 discussed the treatment of pediatric or congenital pathologies, 11 detailed the management of benign lesions, and 31 studies tackled other surgical indications. Strategies for safe CO2 TOLMS were highly heterogeneous across studies and included preoperative measures (ie, related to the environment, staff preparation, patient protection, and ventilation), intraoperative precautions (ie, protection of nontarget structures, technical considerations, topical and systemic medications), and postoperative strategies (ie, related to airway protection, oral intake, vocal rest, hospitalization duration, drug regimen, and consultant follow-up).

CONCLUSION

The results provided in this study can be used as a framework to guide the creation of laser safety protocols across institutions, guide quality improvement initiatives, the development of simulation training activities, and as a tool to facilitate resident teaching and skill assessment.

Clinical Characteristics and Management of Saccular Cysts: A Single Institute Experience

Objectives

A saccular cyst is defined as a dilated saccule of the larynx, filled with mucus, and is located between the false vocal cords and the thyroid cartilage. Although this uncommon laryngeal condition is benign in nature, it could lead to dyspnea, stridor, and airway obstruction, depending on its size and location. Furthermore, some saccular cysts have been associated with laryngeal carcinoma. This study aimed to characterize this rather uncommon laryngeal condition to aid in determining the proper management of this pathology.

Methods

Medical records were retrospectively reviewed of all patients with saccular cysts diagnosed and treated between 2006 and 2017 at a tertiary otolaryngologic care center.

Results

Seven patients with saccular cysts were identified (male:female=2:5; mean age, 34.1 years); two were pediatric patients. Surgical intervention was performed in all patients by laryngo-microsurgery using CO₂ laser. There was no recurrence after the initial surgical treatment.

Conclusion

Saccular cysts can be managed endoscopically using CO₂ laser, without requiring an external approach. Therefore, an endoscopic approach should be actively considered for an optimal treatment outcome.

Laryngeal Cysts in Adults: Simplifying Classification and Management

Objective

Laryngeal cysts may occur at any mucosa-lined location within the larynx and account for 5% to 10% of nonmalignant laryngeal lesions. A number of proposed classifications for laryngeal cysts exist; however, no previously published classification aims to guide management. This review analyzes contemporary laryngeal cyst management and proposes a framework for the terminology and management of cystic lesions in the larynx.

Data Sources

PubMed/Medline.

Review Methods

A primary literature search of the entire Medline database was performed for all titles of publications pertaining to laryngeal cysts and reviewed for relevance. Full manuscripts were reviewed per the relevance of their titles and abstracts, and selection into this review was according to their clinical and scientific relevance.

Conclusion

Laryngeal cysts have been associated with rapid-onset epiglottitis, dyspnea, stridor, and death; therefore, they should not be considered of little significance. Symptoms are varied and nonspecific. Laryngoscopy is the primary initial diagnostic tool. Cross-sectional imaging may be required, and future use of endolaryngeal ultrasound and optical coherence tomography may revolutionize practice. Where possible, cysts should be completely excised, and there is growing evidence that a transoral approach is superior to transcervical excision for nearly all cysts. Histology provides definitive diagnosis, and oncocytic cysts require close follow-up.

Implications for Practice

A new classification system is proposed that increases clarity in terminology, with the aim of better preparing surgeons and authors for future advances in the understanding and management of laryngeal cysts.

Saccular cyst as a complication of medialization laryngoplasty: a case report

We report the case of a 54-year-old woman who presented for evaluation of deterioration in her voice and swallowing function, which had begun after she had undergone a medialization laryngoplasty for unilateral vocal fold paralysis. Findings on examination and imaging revealed that a mass had developed adjacent to the Silastic implant that had been placed during the laryngoplasty. The superior extent of the implant reached above the laryngeal ventricle. Endolaryngeal surgical resection of the mass was accomplished without the need to remove the implant. Pathologic analysis identified the mass as a laryngeal saccular cyst. Although laryngeal saccular cysts are uncommon, medialization laryngoplasties are not. This case represents a rare complication of medialization laryngoplasty in which an implant compressed the laryngeal saccule and led to formation of the cyst.

Saccular cysts: a current review of characteristics and management

OBJECTIVES/HYPOTHESIS

To review a large cohort of adult saccular cyst patients and update current management of saccular cysts.

STUDY DESIGN

Retrospective review of treatment of adult patients with saccular cysts.

METHODS

Medical records were reviewed of all adult patients with saccular cysts identified between July 1, 2005 and August 31, 2009 at a tertiary care voice center.

RESULTS

Sixteen patients were identified. All complained of dysphonia. Saccular cysts were predominantly left-sided (62.5%). The majority were anterior (85.7%); 14.3% were combined anterior/lateral. There were no isolated lateral saccular cysts. Surgical intervention was performed in 13 patients (81%); 100% were endoscopic. No patient required an external approach. Two patients recurred (15%), both within 2 months, and were managed conservatively.

CONCLUSIONS

Saccular cyst is uncommonly encountered but can cause debilitating or even life-threatening symptoms. Over time, management of these lesions has changed dramatically. With current, improved endoscopic techniques, most saccular cysts can be managed endoscopically with great success rates, often without the need for an external approach.

Endoscopic carbon dioxide laser procedure for an endogenous thyroglossal duct cyst

From 1940 to September 2008, 21 cases with TDCs extending into respiratory tract have been reported, often with misdiagnosis. There were only 10 cases by the end of 2006, but the number increased rapidly recently. To evaluate endoscopic carbon dioxide (CO(2)) laser procedure for thyroglossal duct cyst (TDC) extending into respiratory tract, we reported an unusual case and performed a retrospective correlate review. A 3-year-old female patient with a TDC extending into respiratory tract, without any neck lumps, was previously misdiagnosed as an epiglottic cyst. An asymptomatic follow-up visit had been for 10 months after she had received endoscopic CO(2) laser procedure. To our best knowledge, endoscopic CO(2) laser procedure was administered for the first time for TDCs, though it had been a valid management of other benign lesions in respiratory tract. The endoscopic CO(2) laser procedure might be for TDC extending into respiratory tract. In order to increase awareness of this situation, we recommend that the novel concept of endogenous type should be considered to unify these TDCs extending into respiratory tract without projecting neck masses.

Sudden-onset Life-threatening Stridor in an Adult Caused by a Laryngeal Ductal Cyst

Laryngeal cysts are rare in adults; therefore, the majority of previous reports deal primarily with laryngeal cysts in infants and children. Ductal cysts of the larynx arise from the submucous glands when the ducts of these glands are occluded. They are most commonly located in the vallecula. In this report, we present a rare cause of life-threatening stridor in adults, a large ductal cyst of the larynx that was removed via endoscopic CO2 laser resection. On the basis of clinical observations during the postoperative period, we conclude that endoscopic CO2 laser resection is a reliable and safe method for removing cysts of the larynx. It is also a cost-effective procedure that minimizes hospitalization time and the need for tracheotomy.

Current diagnosis and treatment of laryngocele in adults

OBJECTIVE

To evaluate the treatment outcome of a series of laryngoceles and to comment on the current diagnosis and management of laryngoceles.

STUDY DESIGN AND SETTING

A retrospective review of charts, radiological and histopathological notes, videolaryngostroboscopic records, and acoustic voice analyses of patients with laryngocele treated over a 10-year period was undertaken.

RESULTS

Seven patients had internal laryngoceles; one had external; another one had combined laryngocele. Patients with internal laryngocele underwent endoscopic CO2 laser resection, while those with external or combined laryngocele were treated via external approach. Quality of voice was improved and no recurrences were encountered during the follow-up. No evidence of laryngeal cancer was found on the histological examinations.

CONCLUSION

Endoscopic CO2 laser resection of internal laryngocele provides a reliable and cost-effective method that minimizes hospitalization and the need for tracheotomy. We believe that advances in the applications of laser in microlaryngosurgery will alter the traditional management of all type of laryngoceles.

Sudden Death from Saccular Laryngeal Cyst

Laryngeal cysts are benign, uncommon lesions of the larynx that have been reported on rare occasions to cause sudden death in infants and adults by acute airways obstruction. In this report, we document the sudden death of a 36-year-old woman from a previously undiagnosed, asymptomatic laryngeal saccular cyst that presented with acute, and consequent fatal, airway obstruction. Difficulty during intubation, both in theater and in emergency settings, is a frequent presenting problem. This can have significant medicolegal implications in determining possible negligence. The diagnosis, classification, and management of such cysts, and their importance to both the forensic pathologist and clinicians are discussed.

Endolaryngeal cysts presenting with acute respiratory distress

This is a retrospective review of benign cysts of the adult endolarynx that presented as airway emergencies in four teaching hospitals of Dublin, Ireland, over 2 years. During that period nine patients with endolaryngeal cysts necessitating emergency airway intervention were managed. All cases were treated by endoscopic microlaryngeal marsupialization after securing the airway either at the same time or as a staged procedure. Four of these patients required tracheostomies, one performed under local anaesthesia and the others after initial endotracheal intubation. Definitive treatment was carried out in six cases at initial endoscopic diagnosis. Three of the tracheostomized patients had a staged management, two because of their medical status and one for further investigations. On the basis of our findings we suggest that all benign cysts around the endolarynx should simply be called 'endolaryngeal cysts' instead of the current practice of trying to classify them into various histological and morphological types with no prognostic or management differences. Benign cysts of the endolarynx presenting with airway obstruction would appear to be more frequent than is generally maintained in the literature.

Laryngocele resection by combined external and endoscopic laser approach

Options in the management of laryngoceles include observation, endoscopic resection, and resection via an external approach. We introduce a combined endoscopic and external approach that we have employed on several occasions to ensure complete removal of the laryngocele and the saccule from which it originated. A case is presented to help define the technique.