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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.
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).
Fibrolaryngoscopy showed a supraglottic mass covered with normal mucosa, extending into airways from the right wall of hypopharynx (Fig. (Fig.22).
A computed tomography (CT) scan showed a large mixed internal and external laryngocele without regional lymphadenopathy (Fig. (Fig.33).
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.
The patient remains free from disease.
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 2–5, 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 11–19, unilateral uncommon 2 3 6 11 20, or bilateral rare 1 2 12 15 21.
The main symptoms, at presentation, are: airway obstruction 5 7 9 13 16–18, increasing stridor 4 9 14, hoarseness 4 14–20, sore throat, cough, pain, snoring, globus sensation 4 or a visible or palpable mass in the neck 9 10 15 16 19 20.
There is a rare, but well-documented, association of laryngocele with laryngeal carcinoma 1 11 15 17 20–23. 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.
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.
Options in the management of laryngoceles include observation, endoscopic resection and resection via an external approach 24.
Surgery is the treatment of choice 15.
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.
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.