A laryngocoele is an abnormal enlargement of the saccule of a laryngeal ventricle. Laryngocoeles are generally filled with air, and are termed internal when limited to the interior of the larynx and external when they protrude laterally into the neck.1
Three types of laryngocoeles have been described: internal, external and combined. The internal laryngocoele remains within the larynx, whereas the external type extends through the thyrohyoid membrane. Combined laryngocoeles, which consist of both internal and external elements, are the most common of the three types.2
Dental disorders are the most frequent causes of secondary otalgia presenting to the ENT clinic, and may account for up to 50% of referred otalgia. TMJ dysfunction syndrome is the most common dental cause of referred otalgia,3
is twice as common among women than among men and has environmental, physiological and behavioural causes.4
In a study of 123 patients with ear pain, the most frequent cause of referred otalgia in one group (n=72) was TMJ dysfunction (46%), while the most common cervical spine finding in a second group (n=51) was cervical spine degenerative disease (88%).5
The cause of laryngocoeles is felt to be either a congenital enlargement of the saccule or acquired enlargement caused by increased, sustained intralaryngeal pressure (eg, in a trumpet player).Wind and brass players are at increased risk for laryngocoeles; one report showed laryngocoeles in 52 (56%) of 93 band members studied.1
The incidence of carcinoma in patients presenting with a laryngocoele is 2–18%. Flexible nasoendoscopy is probably the gold standard for visualisation of the pharynx and larynx in the clinical setting. This case shows that it could miss supraglottic pathology. The patient initially underwent nasoendoscopy by an ENT registrar and then later by a consultant (before her laryngoscopy under general anaesthesia).
A laryngocoele is gravity dependant, and as flexible laryngoscopy was carried out with the patient in a sitting position, the laryngocoele was not seen when this investigation was first carried out. However, when a rigid laryngoscopy was carried out with the patient in a supine position the laryngocoele fell into the field of view and was seen ().
Internal laryngocoele before operation.
A CT scan with contrast media would have been the first choice of investigation with a working diagnosis of laryngocoele. However, ear pain may also be the first sign of a head and neck malignancy.6
In view of the patient being a chronic smoker, a soft tissue malignancy had to be ruled out as soon as possible, and so we requested an MRI scan instead of a CT scan ().
- Identifying the cause of referred otalgia is challenging.
- Clinical examination may be normal.
- Multiple repeat nasoendoscopies may be negative, and so imaging may be required.
- Laryngocoele should be included as one of the possible causes of referred otalgia.