|Year : 2013 | Volume
| Issue : 2 | Page : 67-69
External laryngocele: Points to remember
J Jishana, Jayita Das Poduval
Department of ENT, Pondicherry Institute of Medical Sciences, Puducherry, India
|Date of Web Publication||7-May-2014|
Jayita Das Poduval
D-2-7, JIPMER Campus, Dhanvantari Nagar, Puducherry - 605 006D-2-7, JIPMER Campus, Dhanvantari Nagar, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Laryngocele is a rare cystic swelling arising from the saccule of larynx. It is seen mostly among trumpeters and glassblowers. In others, it is often associated with underlying malignancy. Here we report a case of external laryngocele in a young farmer who did not have any of the above mentioned associations.
Keywords: Laryngocele, malignancy, Neck swelling, resection
|How to cite this article:|
Jishana J, Poduval JD. External laryngocele: Points to remember
. J Laryngol Voice 2013;3:67-9
| Introduction|| |
Laryngocele is a cystic dilatation of the saccule of the larynx and it is generally filled with air. If communication between the cyst and the laryngeal lumen is occluded, fluid may accumulate within the sac. A mucous retention cyst may also arise from the mucus gland of the saccule of the larynx, in which case it is filled only with mucus and not air and is called a saccular cyst.  The incidence of laryngocele is 1 in 2.5 million population, hence it is rare. Usually, males between 50 and 60 years of age are affected. Other laryngeal cysts, such as congenital saccular cysts and vallecular cysts, may be seen in younger patients too. Since a laryngocele is mainly seen among glass blowers and trumpet players, an increase in intraluminal laryngeal pressure has been postulated as a possible mechanism. However, in the elderly, an underlying laryngeal carcinoma needs to be excluded. This case is unique in that the patient was neither a glass blower nor a trumpet player. Besides, the excised specimen showed no evidence of malignancy.
| Case Report|| |
This was a case report of a 25-year-old male patient who presented with the complaints of painless swelling in the upper right side of the neck for the past 3 years. It used to increase in size during coughing and straining.
Examination revealed a compressible swelling measuring 3 × 4 cm in the right anterior triangle of neck with normal overlying skin. It was non-tender, soft, cystic, fluctuant and mobile. The swelling increased in size on coughing and on Valsalva maneuver. Indirect laryngoscopy was normal [Figure 1].
Soft-tissue radiograph of neck (antero-posterior view) revealed an air-filled sac suggestive of external laryngocele [Figure 2].
Ultrasonogram of neck confirmed the diagnosis following which the patient was taken up for excision of laryngocele.
Under general anesthesia with endotracheal intubation and aseptic precautions, a horizontal skin crease incision was made over the swelling. After raising skin flaps and dissecting soft-tissues, the laryngocele was identified, separated from surrounding tissues and mobilized up to its neck as far as the thyrohyoid membrane. The neck (or fundus) was transected after securing it with a transfixation suture to reduce the risk of recurrence. The skin was closed in layers after placing a drain. The post-operative period was uneventful and sutures were removed after 7 days. Histopathologic examination of the specimen confirmed laryngocele and excluded malignancy [Figure 3] and [Figure 4].
| Discussion|| |
Laryngocele is an abnormal cystic dilatation of the saccule of larynx. Etiology remains unclear. A congenital laryngocele, which causes respiratory distress in new borns, may be the result of a large ventricular appendix. An acquired laryngocele may develop as a result of an increase in intra-glottic pressure, such as that caused by excessive coughing, playing a wind instrument, glass blowing and after performing Valsalva maneuver,  or using ventricular phonation during speech. 
Laryngoceles may extend internally into the airway or externally through the thyrohyoid membrane  and they are termed internal if medial to the thyroid cartilage, or external if lateral to it.  As the laryngocele expands and escapes laterally across the thyroid cartilage, the air-filled communication may become tenuous, even though pressure changes may still be transmitted through it; this accounts for the presence of a cough impulse and also increase in size with Valsalva maneuver. Depending on the size and duration, the swelling may present as internal, external or combined (mixed) internal and external laryngocele. 
The common presenting symptoms of internal or mixed laryngoceles are globus sensation, sore throat, cough, pain, snoring, increasing stridor, hoarseness, airway obstruction if the lesion is large,  or in case of external laryngoceles, a visible or palpable mass in the neck. Laryngoscopic examination may reveal a globular swelling in the laryngeal lumen or a submucosal fullness, but may miss the internal component of a mixed laryngocele if it is small and also due to rapid deflation and inflation.
There is a well-documented association of laryngocele with laryngeal carcinoma,  supraglottic carcinoma being the most common. Furthermore, malignancy must be suspected in the case of an acquired saccular cyst, in which case the mouth of the mucous gland of the saccule is obstructed by tumor.  Therefore, if a laryngocele is detected clinically or radiologically, a carcinoma must be excluded.
While it is often difficult to establish if a laryngeal cyst is congenital or acquired,  a laryngocele must be differentiated from other laryngeal cysts, of which the true cysts may be classified as epithelial, oncocytic and tonsillar.  Epithelial cysts are the most common and include saccular cysts, whereas tonsillar cysts are mostly found in the region of the vallecula, epiglottis or pyriform sinus and bear resemblance to lympho-epithelial cysts of the oral cavity.  Oncocytic cysts are more common in the ventricle, are seen predominantly in the elderly, may be multiple in number, have higher rates of recurrence and generally behave like benign neoplasms, though the jury is still out on whether the oncocytic cells containing hypertrophied deeply eosinophilic mitochondria are the result of degeneration or neoplastic change. ,
Laryngeal pseudocyst is another entity and has been described as a discrete, unilateral, localized area of Reinke's edema, usually occurring at the mid-portion of the free-edge striking zone. 
A laryngocele may coexist with other laryngeal diseases like recurrent respiratory papillomatosis, amyloidosis, rheumatoid arthritis, etc., and must not only be differentiated from, but may also be co-existent with, oncocytic cysts. 
Computed tomography scan is the most accurate imaging method in defining spatial relationships between the laryngocele and laryngeal structures and extra-laryngeal soft-tissues, in differentiating the laryngocele from other cystic formations and in identifying the coexistence of a laryngeal malignancy.  Management includes observation, endoscopic resection,  or resection through an external approach.
Marsupialization using CO 2 laser,  may be done trhough an endolaryngeal, endoscopic or microscopic approach for internal or mixed laryngoceles.
The external cervical approach, with or without tracheotomy, may be employed for mixed and external laryngoceles. The neck, in case of an external laryngocele sac, should be dissected carefully in order to prevent damage to the neurovascular bundle which penetrates the thyrohyoid membrane at the site of exit of the external laryngocele. 
Though rare, laryngocele should be considered in any patient presenting with a compressible neck swelling, even in the absence of known risk factors or associations. Repeated and thorough laryngoscopic examination must be carried out to determine whether the laryngocele is internal, external or mixed so that appropriate treatment can be instituted.
| Acknowledgment|| |
The authors would like to thank Head of Department Dr. Balasundaram D for support and encouragement.
| References|| |
|1.||Michael M, Parikh S. Benign laryngeal lesions. Ballenger's Otorhinolaryngology, Head and Neck Surgery. 17 th ed. CBS Publishers & Distributors Pvt. Ltd.; 2009. p. 880. |
|2.||Drozd M, Szuber K, Szuber D. The significance of the valve mechanism in pathology of laryngocele. Otolaryngol Pol 1996;50:17-20. |
|3.||Dray TG, Waugh PF, Hillel AD. The association of laryngoceles with ventricular phonation. J Voice 2000;14:278-81. |
|4.||Gallivan KH, Gallivan GJ. Bilateral mixed laryngoceles: Simultaneous strobovideolaryngoscopy and external video examination. J Voice 2002;16:258-66. |
|5.||Pennings RJ, van den Hoogen FJ, Marres HA. Giant laryngoceles: A cause of upper airway obstruction. Eur Arch Otorhinolaryngol 2001;258:137-40. |
|6.||Akbas Y, Unal M, Pata YS. Asymptomatic bilateral mixed-type laryngocele and laryngeal carcinoma. Eur Arch Otorhinolaryngol 2004;261:307-9. |
|7.||Zawadzka-Glos L, Frackiewicz M, Brzewski M, Biejat A, Chmielik M. Difficulties in diagnosis of laryngeal cysts in children. Int J Pediatr Otorhinolaryngol 2009;73:1729-31. |
|8.||Ramesar K, Albizzati C. Laryngeal cysts: Clinical relevance of a modified working classification. J Laryngol Otol 1988;102:923-5. |
|9.||Salerno G, Mignogna C, Cavaliere M, D'Angelo L, Galli V. Oncocytic cyst of the larynx: An unusual occurrence. Acta Otorhinolaryngol Ital 2007;27:212-5. |
|10.||Oliveira CA, Roth JA, Adams GL. Oncocytic lesions of the larynx. Laryngoscope 1977;87:1718-25. |
|11.||Koufman JA, Belafsky PC. Unilateral or localized Reinke's edema (pseudocyst) as a manifestation of vocal fold paresis: The paresis podule. Laryngoscope 2001;111:576-80. |
|12.||McDonald SE, Pinder DK, Sen C, Birchall MA. Oncocytic cyst presenting as laryngocele with surgical emphysema. Eur Arch Otorhinolaryngol 2006;263:237-40. |
|13.||Uðuz MZ, Onal K, Karagöz S, Gökçe AH, Firat U. Coexistence of laryngeal cancer and laryngocele: A radiologic and pathologic evaluation. Kulak Burun Bogaz Ihtis Derg 2002;9:46-52. |
|14.||Ettema SL, Carothers DG, Hoffman HT. Laryngocele resection by combined external and endoscopic laser approach. Ann Otol Rhinol Laryngol 2003;112:361-4. |
|15.||Martinez Devesa P, Ghufoor K, Lloyd S, Howard D. Endoscopic CO2 laser management of laryngocele. Laryngoscope 2002;112:1426-30. |
|16.||Ingrams D, Hein D, Marks N. Laryngocele: An anatomical variant. J Laryngol Otol 1999;113:675-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]