1. Laryngoceles Otolaryngology Grand Rounds Anne Conlin, MD, PGY-4 November 5, 2008

2. Objectives • To discuss 2 case presentations of laryngocele • To understand the anatomy and etiology of laryngoceles & related saccular disorders • To discuss work-up and management options for laryngoceles & related saccular disorders

3. TheCases

4. Case #1 • ID: 2 y.o. male in-patient • RFC: stridor & neck swelling • HPI: • 1 wk Hx URTI Sx (fever, rhinorrhea) • 1 d Hx acute stridor, rapid neck swelling x10 cm w/ erythema, dysphagia, and inability to lie flat d/t air hunger • Admitted to ICU

5. Case #1 • PMHx: DCR, otherwise healthy • DevtHx: unremarkable L&D, N dev’t • Meds/Allergies: nil

6. Case #1 • Physical Exam • Toxic looking, stridorous, distressed patient • 10 cm warm, erythematous L/midline/R neck swelling

8. Case #1 • What do you do?

9. Case #2 • ID: 68 y.o. male out-patient • CC: “When I cough, something pops up into the back of my throat, and I have to push it down with my fingers”

10. Case #2 • HPI: • CC ongoing several times per day for 2 months • Transient dysphonia, resolved with digital displacement of mass in his mouth • No dyspnea or stridor • PMHx: Zenker’s diverticulum, otherwise healthy • Habits: denied EtOH, smoking, musical instruments or glass-blowing

11. Case #2

15. Case #2 • What do you do?

16. Laryngoceles & Related Saccular Disorders

17. Laryngoceles • Historical Context • 1st described in 1829 by Napoleon’s surgeon-in-chief: observed in the man calling the masses to prayer in Egypt

18. Laryngoceles • Definition • Abnormal dilation of the saccule of the laryngeal ventricle • Spectrum of disorders characterized by abnormal dilatation of the laryngeal saccule

19. Anatomy of the Saccule • Saccule: aka laryngeal appendix • The normal out-pouching at the anterior end of the laryngeal ventricle • A blind sac that extends upwards between the false VCs and the thyroid cartilage

20. Anatomy of the Saccule • Contains many mucous glands • Vestigial air sac • Possible function is lubrication of true vocal folds

21. Anatomy of the Saccule • Burke & Golden: • Laryngocele is a saccule which extends beyond the superior border of the thyroid cartilage • Broyles: height of “normal” saccule • <8 mm in 75% pop • 10-15 mm in 17% pop • >15 mm in 8% pop • Burke’s def’n accepted

26. A: Normal anatomy B: Anterior saccular cyst C: Lateral saccular cyst D: Laryngocele (external and mixed types)

27. Laryngocele • Saccule filled only with air • Orifice remains patent

28. Classification of Laryngoceles • Classification • Internal (40%): lies within the confines of the larynx beneath the mucosa of the false cords & AEFs • External (25%): extends beyond thyroid cartilage & protrudes through thyrohyoid membrane at point of insertion of SLN • Mixed (45%): abnormal dilatation of saccule on both sides of the thyrohyoid membrane

29. Normal anatomy Internal laryngocele External laryngocele Mixed laryngocele

30. Saccular Cyst • Saccule filled with glandular secretions & orifice becomes obstructed • Symptoms are constant

31. Laryngopyocele • Contents of a saccular cyst become infected • Air & fluid seen on imaging • 8-10% of laryngoceles

32. Etiology: True or False? • Laryngoceles are caused by playing wind instruments, such as the trumpet.

33. True or False? • Laryngoceles are caused by glass blowing.

34. Etiology • Uncertain & controversial • Commonly felt due to use of the voice in unusually forceful ways & high transglottic pressures • Trumpet players • Glass blowers

35. Etiology: Transglottic Pressure • Stell & Maran, J Laryngol Otol, 1975 • Reviewed 139 cases • Only 1 case associated w/ prolonged & repeated blowing against resistance (trumpet playing)

36. Etiology: Carcinoma • Celin et al, Laryngoscope, 1991 • Pathology specimens: • Laryngeal carcinoma: 19% w/ laryngocele • Pharyngeal carcinoma: 2% w/ laryngocele • CT findings: • Laryngeal carcinoma: 29% w/ laryngocele • Normal larynx: 9% w/ laryngocele • (Laryngocele defined as saccule detectable 10 mm above superior aspect of thyroid cartilage; comparable to Broyles’ descriptions of the saccule)

37. Etology: Carcinoma • Theory: • Ball-valve obstruction of neck of saccule by tumour • Air admitted into saccule • However, air cannot escape

38. Etology: Carcinoma • Limitations to the Theory: • Half of laryngoceles are ipsilateral to laryngeal carcinoma; half are contralateral • Alternative theory: • Abnormal intralaryngeal pressures d/t coughing, altered phonation, etc.

39. Carcinoma & Laryngoceles • Micheau et al, 1976, Cancer • Laryngocele present in 22 of 120 cases • Thyroid cartilage invasion in 50% & cricoid invasion in 10% • Upward spread • Very invasive

40. Carcinoma & Laryngoceles • Canalis et al, J Otol, 1976 • 131 patients w/ symptomatic laryngoceles • Occult ca. 4-15% • Inaccuracy of endoscopic evaluation • CT mandatory

41. Etiology: Congenital • Congenital presence of abnormally large saccule • Broyles studies on height of saccule: • <8 mm in 75% pop • 10-15 mm in 17% pop • >15 mm in 8% pop

42. Etiology: Weird & Wonderful • Complication of surgical tracheostomy • Complication of laser excision SCCa larynx • Voice abuse • IV drug user neck injections • Amyloidosis • Scleroderma

43. Clinical Presentation • Epidemiology • Incidence: 1 per 2.5 million people per year • Male:female = 5:1 (between 2 and 7:1) • Most commonly affects Caucasian men in their 50s • Pattern • Unilateral (75%) • Mixed (45%)

44. Symptoms • Symptoms intermittent for laryngoceles • Depend whether the laryngocele is internal, external, or combined • Hoarseness • Neck swelling • Stridor • Dysphagia • Sore throat • Snoring • Cough • Globus

45. Symptoms • Congenital & Pediatric Cases: • Airway obstruction • Feeding difficulties • Weak cry

46. Signs • Swelling of the false VCs & aryepiglottic folds • Palpable mass in lateral neck which increases w/ Valsalva maneuver (external type) • Bryce sign: gurgling or hissing sound on compression of the neck mass

47. Investigations • CT scan • Traditionally, the primary imaging study • Fluid- or air-filled, sharply defined sac

48. Investigations • CT scan • Definitive dx: connection btwn air sac & airway • Useful for mapping & surgical planning

49. Investigations • MRI • Useful, especially to distinguish btwn mucus/inflammation and malignancy • Visualization of thyrohyoid membrane, paralaryngeal space, true cord, false cords

50. T1W MRI w/ gad Thin rim of enhancing mucosa T2W MRI Hyperintense cyst contents (fluid) Investigations