Laryngoceles,Otolaryngology Grand Rounds Anne Conlin, MD, PGY-4 November 5, 2008,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,The Cases,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,Case #1,PMHx: DCR, otherwise healthy DevtHx: unremarkable L&D, N devt Meds/Allergies: nil,Case #1,Physical Exam Toxic looking, stridorous, distressed patient 10 cm warm, erythematous L/midline/R neck swelling,Case #1,What do you do?,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”,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: Zenkers diverticulum, otherwise healthy Habits: denied EtOH, smoking, musical instruments or glass-blowing,Case #2,Case #2,What do you do?,Laryngoceles & Related Saccular Disorders,Laryngoceles,Historical Context 1st described in 1829 by Napoleons surgeon-in-chief: observed in the man calling the masses to prayer in Egypt,Laryngoceles,Definition Abnormal dilation of the saccule of the laryngeal ventricle Spectrum of disorders characterized by abnormal dilatation of the laryngeal 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,Anatomy of the Saccule,Contains many mucous glands Vestigial air sac Possible function is lubrication of true vocal folds,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 15 mm in 8% pop Burkes defn accepted,Anatomy of the Saccule,A: Normal anatomy,B: Anterior saccular cyst,C: Lateral saccular cyst,D: Laryngocele (external and mixed types),Laryngocele,Saccule filled only with air Orifice remains patent,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,Internal laryngocele,Normal anatomy,External laryngocele,Mixed laryngocele,Saccular Cyst,Saccule filled with glandular secretions & orifice becomes obstructed Symptoms are constant,Laryngopyocele,Contents of a saccular cyst become infected Air & fluid seen on imaging 8-10% of laryngoceles,Etiology: True or False?,Laryngoceles are caused by playing wind instruments, such as the trumpet.,True or False?,Laryngoceles are caused by glass blowing.,Etiology,Uncertain & controversial Commonly felt due to use of the voice in unusually forceful ways & high transglottic pressures Trumpet players Glass blowers,Etiology: Transglottic Pressure,Stell & Maran, J Laryngol Otol, 1975 Reviewed 139 cases Only 1 case associated w/ prolonged & repeated blowing against resistance (trumpet playing),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),Etology: Carcinoma,Theory: Ball-valve obstruction of neck of saccule by tumour Air admitted into saccule However, air cannot escape,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.,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,Carcinoma & Laryngoceles,Canalis et al, J Otol, 1976 131 patients w/ symptomatic laryngoceles Occult ca. 4-15% Inaccuracy of endoscopic evaluation CT mandatory,Etiology: Congenital,Congenital presence of abnormally large saccule Broyles studies on height of saccule: 15 mm in 8% pop,Etiology: Weird & Wonderful,Complication of surgical tracheostomy Complication of laser excision SCCa larynx Voice abuse IV drug user neck injections Amyloidosis Scleroderma,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%),