|Year : 2011 | Volume
| Issue : 1 | Page : 33-35
Endoscopic CO 2 laser excision of combined laryngocoele
Inita Matta, Sunita Chhapola, Prabodh Karnik
Department of ENT, Mumbai Port Trust Hospital, Wadala, Mumbai, Maharashtra, India
|Date of Web Publication||7-Feb-2011|
Flat no. 4, Dhanvantari, Mumbai Port Trust Hospital campus, Wadala (E), Mumbai - 400037, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Virchow described a laryngocoele as a saccule extending above the thyrohyoid membrane. Total excision and marsupialisation are established surgical techniques for external and internal laryngocoeles. The external cervical approach is advocated for external and combined laryngocoeles. We describe here a case of combined laryngocoele that was treated endoscopically, using a CO 2 laser. Both the internal and external components of the laryngocoele were excised completely; its internal supraglottic component was excised followed by the external component into the neck. The CO 2 laser with its property of minimal trauma to adjacent tissues, quick tissue recovery, reduced hospital stay and avoidance of tracheostomy makes it useful for treatment of laryngocoele. Endoscopic CO 2 laser excision also avoids the necessity of an external approach.
Keywords: CO 2 laser, Endoscopy, Laryngocoele
|How to cite this article:|
Matta I, Chhapola S, Karnik P. Endoscopic CO 2 laser excision of combined laryngocoele. J Laryngol Voice 2011;1:33-5
| Introduction|| |
A laryngocoele is an abnormal saccular dilatation, filled with air when its orifice is patent. Male to female ratio is 5:1 and peak age of incidence is 50-60 years. It is internal (arises from laryngeal ventricle and presents in the vallecula) in 20% of cases, external (sac arises from the laryngeal ventricle and expands into the neck through the thyrohyoid membrane) in 30% of cases or in combination in 50% of cases.  The most common presenting symptoms are hoarseness and a neck lump. Large saccular size is common and may be a likely underlying factor, though not a determinant one. Laryngocoeles are lined by columnar ciliated epithelium. About 10% of laryngocoele are infected and present as pyoceles.
An external laryngocoele requires total excision, conventionally, by a cervical incision. Endoscopic marsupialisation was suggested by Holinger et al.  Simple de-roofing with biting forceps may imply incomplete excision. Van de Water recommended a more complete excision, with stripping of the cyst lining from its bed. The CO 2 laser would be of use here. It has advantages of minimal postoperative oedema and least collagen formation in the wound. The patient therefore recovers aerodigestive functions faster and a tracheostomy may be avoided.
The present case highlights an instance in which CO 2 laser has been used successfully to treat a case of combined laryngocoele.
| Case Report|| |
The patient was an 80-year-old housewife who presented with right-sided neck swelling, cough, hoarseness, and dysphagia of 3-4 months duration. On examination, she had a 2.5 × 2.5 cm non-fluctuant, nonpulsatile compressible swelling in the right anterior triangle of the neck. The swelling increased on Valsalva manoeuvre. Flexible fibreoptic laryngoscopy showed a diffuse swelling overlying the right supraglottis. Plain X-rays of the neck demonstrated an air-filled sac in the neck, consistent with the diagnosis of a combined laryngocoele [[Figure 1]a and b]. Barium swallow showed a cystic swelling in the right pyriform fossa and adjacent area. A Computed Tomography (CT) scan revealed a cystic mass herniating through the thyrohyoid membrane without any laryngeal growth. Prior consent was taken from the patient for a neck approach if the endoscopic excision was to be abandoned at any stage.
Under general anaesthesia, a direct micro-laryngoscopic examination was done to rule out laryngeal ventricular growth. The supraglottic sac was de-roofed by CO 2 laser and the sac lining then stripped from its bed. A power 6 W and spot size of 0.4 mm was used in the super pulse mode. A bipolar cautery along with the laser was employed to achieve haemostasis. Dissection was carried towards the thyrohyoid membrane to the neck of sac. The sac wall was identified carefully and the external component of the sac was separated from the surrounding soft tissues. A complete excision was thus possible. Flexible laryngoscopy just prior to extubation showed minimal oedema and patient was extubated the following morning. The postoperative recovery was uneventful. She could swallow liquids on the second day and semisolids by the third postoperative day. She was discharged on the fourth postoperative day. A week later, she had some hoarseness and dysphagia. At three weeks postoperation, there was no external neck swelling and minimal raw area in the supraglottis. At one month postoperation, she had no hoarseness, no neck swelling, or dysphagia. An indirect laryngoscopy showed a normal-appearing larynx. A follow-up 3 years later showed no evidence of the laryngocoele.
| Discussion|| |
Most textbooks suggest laryngocoeles to be atavistic remnants from the higher apes. The term laryngocoele was introduced by Virchow in 1867 to describe abnormal dilatation of the saccule or ventricle.  These were defined by Holinger as laryngeal saccules, which were radiologically found to extend above the superior margin of the thyroid cartilage. 
The aetiology of laryngocoeles has not been fully established and multiple hypotheses have been proposed. The laryngocoeles seen in newborns are congenital, while an example of an acquired factor might be increased intralaryngeal pressure, eg, in trumpet and other wind instrument players. Surprisingly, since most laryngocoeles are unilateral, and even rarely seen in predisposed population, other factors might be important. Moreover, they do not seem to recur after simple removal.  Large bilateral laryngeal saccules are common per se and are a predisposing factor in laryngocoele formation, but there probably is a local mechanical obstruction for them to grow into laryngocoeles. Laryngeal malignancy is probably one such condition, and there is a high incidence of accompanying laryngocoeles in these cancers. The mechanism is likely to be an increased laryngeal pressure from airway obstruction, increased phonatory effort and/or excessive coughing and local mechanical conditions. There is a 5-18% incidence of laryngocoele in the presence of laryngeal carcinoma, and a 0.2-2% incidence in the normal larynx.  Thus, a thorough search for an obstructing lesion must be made on CT, Magnetic Resonance Imaging (MRI), and at the time of surgery. A CT is the method of choice for assessment of a laryngocoele. CT scan has the advantage that it can show a combined laryngocoele when only one component is clinically suspected.  Complications of a laryngocoele include infection, pyocele formation, aspiration and subsequent bronchitis or pneumonia, airway obstruction, and rarely para-pharyngeal space infection in case of rupture. Because of its potential for stridor, a laryngocoele necessitates treatment by external excision, marsupialisation, or a combination of both.
The CO 2 laser is of proven benefit in the larynx. , Laser application in otolaryngology began in the late 1960s by Strong, Jaks, Vaugh, and Andrews, and was popularised in Boston at the same time. The CO 2 laser with a wavelength of 10.6 μ is precise and involves less tissue manipulation. The disadvantages are related to the thermal damage it may cause to the tube or adjacent laryngeal tissue. This can be minimised by paying attention to the concepts of radiant exposure and lateral thermal energy spread. A power setting of 4-6 W and a spot size of 0.4-0.8 mm are recommended for laryngeal work. Super pulse mode further decreases tissue damage. There is minimal postoperative oedema, few myofibroblasts, and little collagen formation in the healing wound. This translates into quick tissue healing and reduced hospital stay.
The internal component of the sac is easily dealt with endoscopically by the CO 2 laser. Once the neck of the sac is reached near the thyrohyoid membrane, careful stripping of the sac wall and its separation from the adjacent neck structures must be done. The major neurovascular bundles of the neck are at risk at this stage and thorough dissection is needed. Meticulous unhurried haemostasis is easily achieved by application of the CO 2 laser and a bipolar cautery. The cyst wall can be endoscopically excised up to the neck. Postoperative tracheostomy avoidance and early aerodigestive tract recovery are significant factors.  Even though these patients are rare, the avoidance of a neck incision with a downfracture of the thyroid cartilage, combined with the advances in endolaryngeal surgery and now the superior illumination afforded by the use of the endoscope would seem to be an adequate stimulus to further work in this area.
CO 2 laser-assisted endoscopic excision of a laryngocoele is a quick, precise, and safe alternative to an external approach excision, which results in faster rehabilitation of both the patient and his/her voice. However, risk to great vessels and major nerves in the neck and makes the procedure technically challenging.
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