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Acta Otorhinolaryngol Ital. 2007 October; 27(5): 255–257.
PMCID: PMC2640037

Mixed laryngocele: a case report and review of the literature

Summary

Laryngocele is a rare, benign dilatation of the laryngeal saccule that may extend internally into the airway or externally through the thyrohyoid membrane. Many laryngoceles are asymptomatic; sometimes they may cause a cough, hoarseness, stridor, sore throat and may present as a swelling on one or both sides of the neck. Laryngocele may be associated with supraglottic squamous cell carcinoma. Computed tomography scan is the most effective imaging method for diagnosis. Surgery is the treatment of choice. A case of large mixed laryngocele in a 75-year-old male is described together with surgical management and follow-up. A review of the literature is also presented.

Keywords: Larynx, Laryngocele, Professional diseases, Surgical treatment

Case report

The patient B.D.G., a 75-year-old male had been suffering from hoarseness for approximately 5 years. Over the last month, he had been suffering from dyspnoea on exertion and, in the last few days even when at rest.

The patient also suffered from hypertension, chronic atrial fibrillation, emphysema and chronical bronchitis; despite these problems, he managed a mixed farm with crops and livestock.

On examination, he was found to have a painless soft mass at the right side of the neck, about 5 cm in size, conducting vibration during speech, manually reducible, covered with normal skin (Fig. (Fig.11).

Fig. 1
Patient with soft swelling approximately 5 cm in diameter located in latero-cervical area, decreasing upon palpation.

Fibrolaryngoscopy showed a supraglottic mass covered with normal mucosa, extending into airways from the right wall of hypopharynx (Fig. (Fig.22).

Fig. 2
Flexible pre- and post-operative fibro-endoscopic assessment.

A computed tomography (CT) scan showed a large mixed internal and external laryngocele without regional lymphadenopathy (Fig. (Fig.33).

Fig. 3
Computed tomography image of patient’s neck: extended gaseous right laryngocele located on soft parts of neck.

The patient had a CT scan about five years before. Surgical resection of the laryngocele had previously been deferred at the request of the patient who now agreed to undergo surgery in our Department and resection of the laryngocele was performed by the external lateral cervical approach. Post-operative recovery was uneventful.

The patient was discharged from hospital 7 days after surgery in good health.

Swallowing of semisolid food was normal.

The final histological diagnosis of the specimen was laryngocele.

Post-operative CT 4 months after surgery, showed complete removal of the laryngocele (Fig. (Fig.4).4). The larynx and the other neck structures were normal.

Fig. 4
Post-operative CT revealing disappearance of gaseous laryngeal mass.

The patient remains free from disease.

Review of the literature

Laryngocele, an abnormal cystic dilatation of the laryngeal saccule 15, is uncommon 2 46, usually benign 7 and may occur in up to 5% of benign laryngeal lesions 4.

The aetiology is unknown and unclear 3, but there is an inter-relation between a congenital predisposition – represented by a large ventricular appendix 8, for example, a congenital laryngocele which causes respiratory distress in a newborn 9 – and other post-natal acquired factors, for instance, laryngeal papillomatosis in a child 8.

An acquired laryngocele may develop when the laryngeal ventricle becomes functionally obstructed as a result of an increase in intra-glottic pressure, such as that caused by excessive coughing, playing a wind instrument, glass blowing 25, after performing Valsalva manoeuvre 10 or using ventricular phonation during speech 2.

Laryngoceles may extend internally into the airway or externally through the thyrohyoid membrane 2, so they may present as internal, external or combined mixed internal and external laryngocele 1119, unilateral uncommon 2 3 6 11 20, or bilateral rare 1 2 12 15 21.

Laryngocele may be asymptomatic and incidentally discovered through radiographic studies for unrelated symptoms 1 4 5.

The main symptoms, at presentation, are: airway obstruction 5 7 9 13 1618, increasing stridor 4 9 14, hoarseness 4 1420, sore throat, cough, pain, snoring, globus sensation 4 or a visible or palpable mass in the neck 9 10 15 16 19 20.

Serious forms of clinical emergency requiring tracheotomy may occur 5 7 12 16.

There is a rare, but well-documented, association of laryngocele with laryngeal carcinoma 1 11 15 17 2023. Therefore, if a laryngocele is detected clinically or radiologically, a carcinoma must be taken into consideration and appropriate tests be performed 12 22 23.

Supraglottic carcinoma is the most common laryngeal tumour 17.

Fewer reports have appeared concerning the coexistence with other laryngeal diseases, for example, papillomatosis in children 8, amyloidosis 6, rheumatoid arthritis 3, oncocytic cysts 21.

CT scan has proved to be the most accurate imaging method in defining the spatial relationship between the laryngocele and the laryngeal structures and extra-laryngeal soft tissues, in differentiating the laryngocele from other cystic formations and in identifying the coexistence of a laryngeal cancer 1 6 9 14 15 17 23.

Magnetic resonance imaging may be also useful 6 14 20.

Options in the management of laryngoceles include observation, endoscopic resection and resection via an external approach 24.

Surgery is the treatment of choice 15.

Endoscopic marsupialization with CO2 laser is frequently used to remove small internal laryngoceles 7 1517 19.

According to some Authors, the external cervical approach, without tracheotomy, allows good exposure of the lesion with minimal functional disability 15 17 18. It is recommended for the mixed and external laryngoceles 12 13 17.

Careful dissection of the neck, in the case of an external laryngocele sac, is important to prevent damage to the neurovascular bundle which penetrates the thyrohyoid membrane at the site of penetration of the external laryngocele 13.

Conclusion

Laryngocele is a rare benign laryngeal disease which is often asymptomatic.

The diagnosis may be incidentally discovered when the patient undergoes a CT scan for a nagging cough or persistent hoarseness.

In our opinion, the present case is of particular interest since the patient was affected by a large laryngocele unrelated to his profession.

It is mandatory, in any patient presenting with a soft cervical mass, even if not a wind instrument player or a glass blower, to exclude the possibility of a laryngocele.

In fact, the patient described had no predisposing factors for laryngocele although he presented increased intra-glottic pressure due to chronic bronchitis and emphysema.

In the present case, laryngocele was not associated with laryngeal cancer, but it is most important to remember and to consider the possibility of this association.

An external cervical approach to laryngocele gave adequate exposure of the lesion; post-operative recovery was free from complications.

In our opinion, endoscopic laser treatment would not have permitted complete excision of this large and mixed (external and internal) lesion.

References

1. Akbas Y, Unal M, Pata YS. Asymptomatic bilateral mixed-type laryngocele and laryngeal carcinoma. Eur Arch Otorhinolaryngol 2004;261:307-9. [PubMed]
2. Dray TG, Waugh PF, Hillel AD. The association of laryngoceles with ventricular phonation. J Voice 2000;14:278-81. [PubMed]
3. Erdogmus B, Yazici B, Ozturk O, Ataoglu S, Yazici S. Laryngocele in association with ankylosing spondylitis. Wien Klin Wochenschr 2005;117:718-20. [PubMed]
4. Gallivan KH, Gallivan GJ. Bilateral mixed laryngoceles: simultaneous strobovideolaryngoscopy and external video examination. J Voice 2002;16:258-66. [PubMed]
5. Pennings RJ, van den Hoogen FJ, Marres HA. Giant laryngoceles: a cause of upper airway obstruction. Eur Arch Otorhinolaryngol 2001;258:137-40. [PubMed]
6. Aydin O, Ustundag E, Iseri M, Ozkarakas H, Oguz A. Laryngeal amyloidosis with laryngocele. J Laryngol Otol 1999;113:361-3. [PubMed]
7. Detsouli M, Chelly H, Essaadi M, Mokrim B, Touhami M, Benchekroun Y. Laryngocele as an etiology of respiratory distress. Ann Otolaryngol Chir Cervicofac 1994;111:476-8. [PubMed]
8. Altamar-Rios J, Morales Rozo O. Laryngocele and pyolaryngocele. An Otorinolaringol Ibero Am 1992;19:393-9. [PubMed]
9. Zelman WH, Burke LI. External laryngocele: an unusual cause of respiratory distress in a newborn. Ear Nose Throat J 1994;73:19-22. [PubMed]
10. Drozd M, Szuber K, Szuber D. The significance of the valve mechanism in pathology of laryngocele. Otolaryngol Pol 1996;50:17-20. [PubMed]
11. Gierek T, Majzel K, Slaska-Kaspera A. Laryngocele. Otolaryngol Pol 1997;51:550-4. [PubMed]
12. Gil Tutor E. Laryngoceles. Clinical and therapeutic study. An Otorrinolaringol Ibero Am 1991;18:451-64. [PubMed]
13. Ingrams D, Hein D, Marks N. Laryngocele: an anatomical variant. J Laryngol Otol 1999;113:675-7. [PubMed]
14. Larsen JL, Lind O. Laryngocele. Tidsskr Nor Laegeforen 1991;111:1488-9. [PubMed]
15. Luzzago F, Nicolai P, Tomenzoli D, Maroldi R, Antonelli AR. Laryngocele: analysis of 18 cases and review of the literature. Acta Otorhinolaryngologica Italica 1990;10:399-412. [PubMed]
16. Martinez Devesa P, Ghufoor K, Lloyd S, Howard D. Endoscopic CO2laser management of laryngocele. Laryngoscope 2002;112:1426-30. [PubMed]
17. Matino Soler E, Martinez Vecina V, Leon Vintro X, Quer Agusti M, Burgues Vila J, de Juan M. Laryngocele: clinical and therapeutic study of 60 cases. Acta Otorrinolaringol Esp 1995;46:279-86. [PubMed]
18. Myssiorek D, Madnani D, Delacure MD. The external approach for submucosal lesions of the larynx. Otolaryngol Head Neck Surg 2001;125:370-3. [PubMed]
19. Szwarc BJ, Kashima HK. Endoscopic management of a combined laryngocele. Ann Otol Rhinol Laryngol 1997;106:556-9. [PubMed]
20. Brugel FJ, Grevers G, Vogl TJ. Coincidental appearance of laryngocele and laryngeal carcinoma. Laryngorhinootologie 1991;70:511-4. [PubMed]
21. McDonald SE, Pinder DK, Sen C, Birchall MA. Oncocytic cyst presenting as laryngocele with surgical emphysema. Eur Arch Otorhinolaryngol 2006;263:237-40. [PubMed]
22. Harney M, Patil N, Walsh R, Brennan P, Walsh M. Laryngocele and squamous cell carcinoma of the larynx. J Laryngol Otol 2001;115:590-2. [PubMed]
23. Uguz MZ, Onal K, Karagoz S, Gokce AH, Firat U. Coexistence of laryngeal cancer and laryngocele: a radiologic and pathologic evaluation. Kulak Burun Bogaz Ihtis Derg 2002;9:46-52. [PubMed]
24. Ettema SL, Carothers DG, Hoffman HT. Laryngocele resection by combined external and endoscopic laser approach. Ann Otol Rhinol Laryngol 2003;112:361-4. [PubMed]

Articles from Acta Otorhinolaryngologica Italica are provided here courtesy of Pacini Editore