Laryngoceles

Author Credentials 

Original Author:
Sandra L. Ettema, MD, PhD, CCC-SLP
Division of Otolaryngology Head & Neck Surgery
Southern Illinois University School of Medicine
PO Box 19662
Springfield, IL 62794-9662

Edited by (2017):
Monika Chmielewska, DO
ENT Associates
3455 Regency Park Dr
Grand Blanc, MI 48439
canadabu@yahoo.com

Lee M. Akst, MD
Director, Johns Hopkins Voice Center
601 N. Caroline Street, 6th Floor
Baltimore, MD 21287
lakst1@jhmi.edu

Module Summary

Diagnosis of laryngoceles is based on history and clinical exam. Because of the association of laryngoceles with laryngeal carcinoma, imaging studies and endoscopic-guided biopsies are often included in the evaluation. After excluding the possibility of malignancy, small internal laryngoceles can often be managed with endoscopic excision, while combined laryngoceles generally require an external approach.

Module Learning Objectives 
  1. Review the embryology and anatomy of laryngoceles.
  2. Explain the theories of the pathogenesis of laryngoceles.
  3. Recognize the presenting signs and symptoms of laryngoceles.
  4. Review appropriate diagnostic work-up for laryngoceles.
  5. Describe surgical treatment options for different types of laryngoceles.

Embryology

Learning Objectives 
  1. Understand the development of the saccule (appendix of Morgagni)
    1. The saccule is a small blind sac which develops as an outpouching of the laryngeal cavity.
    2. This occurs during the second intrauterine month.
  2. Understand the saccule is lined with pseudostratified ciliated columnar epithelium with an abundance of mucus glands submucosally.
    1. The saccule empties through an orifice in the anterior part of the ventricle.
    2. This is thought to contribute to true vocal fold lubrication during speech and deglutition.
    3. It may represent a vestigial air sac.
    4. In children, the saccule often displays lymphocytic infiltration.
    5. In adults, lymphoid tissue is typically seen only in conjunction with pathology such as carcinoma.
References 
  1. Delahunty JE, Cherry J. The Laryngeal Saccule. J Laryngol Otol. 1969;83:803-815.
  2. DeSanto LW. Laryngocele, laryngeal mucocele, large saccules, and laryngeal saccular cysts: a developmental spectrum. Laryngoscope. 1974;84:1291-6.
  3. Holinger LD, Barnes DR, Smid LJ, Holinger PH. Laryngocele and saccular cysts. Ann Otol Rhinol Layngol. 1978;87:675-85.
  4. Porter PW, Vilensky JA. The Laryngeal Saccule: Clinical Significance. Clinical Anatomy. 2012;25:647-649.

Anatomy

Learning Objectives 

Understand the anatomy of the laryngeal ventricle and saccule.

  1. The laryngeal ventricle (sinus of Morgagni) is the space between the true vocal fold and the false vocal fold (ventricular fold)
  2. The upward extension of the ventricle is the laryngeal saccule.
    1. The saccule is located in the anterior laryngeal ventricle and extends upward between the false vocal fold (ventricular fold) and the medial aspect of the thyroid cartilage lamina, just posterolateral to the edge of the epiglottis.
  3. The saccule varies in size, with a study of 100 cadaver larynges demonstrating 75% 6-8mm, 17% 10-15mm, and 8% > 15mm.
  4. Saccular cysts are filled with glandular secretions and the orifice is obstructed.
  5. In a laryngocele, the saccule is filled only with air through an orifice that remains patent.
References 
  1. Broyles EN. Anatomical observations concerning the laryngeal appendix. Ann Otol Rhinol Laryngol. 1959;68:461-63.
  2. Cummings Otolaryngology Head and Neck Surgery. Elsevier/Mosby: Bastian: Benign Vocal Fold Mucosal Disorders, Chapter 95 – Saccular Disorders, Fourth Edition, 2005.
  3. Porter PW, Vilensky JA. The Laryngeal Saccule: Clinical Significance. Clinical Anatomy. 2012;25:647-649.

Pathogenesis

Learning Objectives 
  1. Understand the various pathologic conditions in which the saccule becomes dilated
  2. Know that a saccular cyst is a saccule that becomes dilated with mucus.
  3. Know that a laryngocele is a saccule that becomes abnormally dilated with air.
    1. Laryngocele lining, like the saccule, consists of pseudostratified ciliated columnar epithelium.
    2. Laryngoceles can be congenital or acquired expansions of the laryngeal saccule that are filled with air and communicate with the laryngeal lumen.
  4. Know that a laryngopyocele is a laryngocele that becomes infected or filled with fluid.
    1. Recognize that it is estimated that 8% of laryngoceles get infected.
  5. Understand the classification of laryngoceles depends on their association with the thyrohyoid membrane.
  6. Know that internal laryngoceles are confined to the boundaries of the larynx within the vestibular folds.
  7. Know that combined laryngoceles have a clearly defined internal dilation of the vestibular fold within the larynx which coexists with extension through the thyrohyoid membrane external to the larynx. This expansion follows the course of the superior laryngeal neuromuscular bundle.
  8. Know that the traditional classification of internal, external and combined laryngoceles has been abandoned because an external laryngocele cannot exist on its own – by definition, all laryngoceles begin in the laryngeal saccule and therefore have an internal component.
References 
  1. Macfie DD. Asymptomatic laryngoceles in wind-instrument bandsmen. Arch Otolaryngol. 1966;83:270-5.
  2. Holinger LD, Barnes DR, Smid LJ, Holinger PH. Laryngocele and saccular cysts. Ann Otol Rhinol Layngol. 1978;87:675-85.
  3. Cummings Otolaryngology Head and Neck Surgery. Elsevier/Mosby: Bastian: Benign Vocal Fold Mucosal Disorders, Chapter 95 – Saccular Disorders, Fourth Edition, 2005.
  4. Frederickson KL, D’Angelo AJ. Internal Laryngopyocele presenting as acute airway obstruction. Ear Nose Throat J. 2007;86(2):104-106.
  5. Mobashir MK, Basha WM et al. Laryngoceles: Concepts of diagnosis and management. Ear Nose Throat J. 2017;96(3):133-138.

Basic Science

Learning Objectives 
  1. Understand the etiology of laryngoceles
    1. Know that the etiology is uncertain but has been theorized that aging results in laryngeal tissue weakening.
    2. Know other factors regarding the etiology of laryngoceles.
    3. Elevated trans-glottic pressure may lead to development of laryngoceles. Playing a wind instrument, glass blowing, coughing, weight lifting, childbirth, and occupations such as plumbers, etc.
      1. The congenital presence of an abnormally large saccule.
      2. Partial obstruction of the saccule secondary to inflammation or laryngeal carcinoma.
  2. Know that laryngeal carcinoma has a relationship with the development of laryngoceles. The literature cites a 2% incidence of laryngoceles amongst 360 control cadaver larynges, compared with an 18% incidence of laryngoceles amongst 546 laryngeal tumor-associated (total laryngectomy) specimens.
  3. Know that although rare, laryngeal amyloidosis has been reported to cause mechanical obstruction of the saccule, thus causing a laryngocele.
References 
  1. Micheau C, Luboinski B, Lanchi P, Cachin Y. Relationship between laryngoceles and laryngeal carcinomas. Laryngoscope. 1978;88:680-8.
  2. Close LG, Merkel M, Burns DK, Deaton CW Jr., Schaefer SD. Asymptomatic laryngocele: incidence and association with laryngeal cancer. Ann Otol Rhinol Laryngol. 1987;96:393-9.
  3. Cavo JW Jr, Lee JC. Laryngocele after childbirth. Otolaryngol Head Neck Surg. 1993;109:766-8.
  4. Isaacson G, Sataloff RT. Bilateral laryngoceles in a young trumpet player: case report. Ear Nose Throat J. 2000;79:272-4.
  5. Mitroi M, Capitanescu A, Popescu FC. Laryngocele associated with laryngeal carcinoma. Rom J Morphol Embryol. 2011;52(1):183-185.
  6. Ramalingam WVBS, Nair S et al. Combined Laryngocele Secondary to Localized Laryngeal Amyloidosis. Indian J Otolaryngol Head Neck Surg. 2012;64(2):193-196.

Incidence

Learning Objectives 
  1. Understand that symptomatic laryngoceles are rare and exact incidence is unknown.
  2. Understand that the incidence of asymptomatic laryngoceles ranges from 2.0% to 8.6% which is based on imaging and cadaver studies.
  3. Understand that laryngoceles present more so in white males in their fifth to sixth decade of life.
  4. Know that most laryngoceles are unilateral and of the combined variety.
References 

 

  1. Close LG, Merkel M, Burns DK, Deaton CW Jr., Schaefer SD. Asymptomatic laryngocele: incidence and association with laryngeal cancer. Ann Otol Rhinol Laryngol. 1987;96:393-9.
  2. Zelenik K, Stanikova L et al. Treatment of Laryngoceles: What Is the Progress over the Last Two Decades? BioMed Research International. 2014;Article ID 819453:1-6.

Patient Evaluation

Learning Objectives 
  1. Know to obtain the following during elicitation of the history:
    1. Risk factors for development of a laryngocele
      1. Factors associated with laryngeal carcinoma.
      2. Occupational or social activities which may raise transglottic pressure. (e.g., glass blowing, playing wind instrument, weight lifting, etc.)
      3. Comorbidities such as COPD resulting in chronic cough.
    2. Internal laryngoceles may interfere with phonation or the airway
      1. May present with hoarseness, stridor, foreign body sensation, cough, sore throat, dysphagia, or snoring.
      2. 10% of laryngoceles present as emergencies and may require tracheostomy.
    3. Patients presenting with combined laryngoceles may complain of fullness in the neck
      1. Puffing, straining (Valsalva maneuver) may lead to increase in size of laryngocele
    4. Congenital saccular cysts usually present in the supraglottis of the newborn
      1. Symptoms include inspiratory stridor, weak cry, dysphagia, and varying degrees of airway obstruction.
  2. Know the following to document during the physical exam:
    1. Visible on indirect laryngoscopy, fiberoptic, rigid telescopic, or direct laryngoscopic examination of the larynx – a cystic swelling of the false vocal fold or the aryepiglottic fold.
    2. If the laryngocele is combined, the laryngeal exam may be similar to that of the internal laryngocele with the possibility of an external neck mass (as described below).
    3. Neck exam for a combined laryngocele may demonstrate the following:
      1. A fullness overlying the thyrohyoid membrane, anterior to the SCM and/or lateral to the thyroid cartilage.
      2. The mass may be compressible and enlarges with increased intralaryngeal pressure (e.g. may ask the patient to bear down).
References 
  1. Holinger LD, Barnes DR, Smid LJ, Holinger PH. Laryngocele and saccular cysts. Ann Otol Rhinol Laryngol. 1978 Sep-Oct;87(5 Pt 1):675-85.
  2. Cummings Otolaryngology Head and Neck Surgery, Elsevier/Mosby: Bastian: Benign Vocal Fold Mucosal Disorders, Chapter 95 – Saccular Disorders, Fourth Edition, 2005.
  3. Zelenik K, Stanikova L et al. Treatment of Laryngoceles: What Is the Progress over the Last Two Decades? BioMed Research International. 2014; Article ID 819453:1-6.
  4. Raine JI, Allin D, Golding-Wood D. Laryngopyocele presenting with acute airway obstruction. BMJ. 2014 Jul 15;2014.

Measurement of Functional Status

Learning Objectives 

Understand that establishing a secure airway is of primary concern

  1. Infants with congenital saccular cysts with a weak cry, stridor, and/or cyanosis may need to be intubated followed by aspiration or cyst contents.
  2. Make note of above history and physical examination signs and symptoms with adults.
References 
  1. Cummings Otolaryngology Head and Neck Surgery, Elsevier/Mosby: Bastian: Benign Vocal Fold Mucosal Disorders, Chapter 95 – Saccular Disorders, Fourth Edition, 2005.

Imaging

Learning Objectives 
  1. Know that flexible fiberoptic or rigid endoscopy is recommended in identification of laryngoceles to document the pathology causing the signs and symptoms of the patient.
  2. Know that CT (or MRI) is the most common radiographic method of choice to confirm an air-filled sac indicative of a laryngocele or fluid-filled sac indicative of a saccular cyst or laryngopyocele.
    1. CT gives more information about the pathology whether it is fluid or air-filled as well as its anatomic extent.
    2. MRI has also been demonstrated to be a useful adjunct in demonstrating tumor within a laryngocele when CT could not differentiate the tumor from mucus.
References 
  1. Harvey RT, Ibrahim H, Yousem DM, Weinstein GS. Radiologic findings in a carcinoma-associated laryngocele. Ann Otol Rhinol Laryngol. 1996;105:405-8.
  2. Ettema SL, Carothers DG, Hoffman HT. Laryngocele resection by combined external and endoscopic laser approach. Ann Otol Rhinol Laryngol. 2003;112:361-4.
  3. Cummings Otolaryngology Head and Neck Surgery, Elsevier/Mosby: Bastian: Benign Vocal Fold Mucosal Disorders, Chapter 95 – Saccular Disorders, Fourth Edition, 2005.
  4. Vasileiadis I, Kapetanakis S, Petousis A. Internal laryngopyocele as a cause of acute airway obstruction: an extremely rare case and review of the literature. Acta Otorhinolaryngologica Italica. 2012;32:58-62.

Pathology

Learning Objectives 
  1. Know that the lining helps to differentiate cysts into a variety of subtypes.
  2. Know that without clinical information or any contents within the lumen a distinction cannot be made between a laryngocele and a laryngeal cyst on histology alone.
  3. Know that saccular cysts and laryngoceles are lined with normal respiratory epithelium specifically with pseudostratified ciliated columnar epithelium.
  4. Know that after surgical excision, it is important to exclude the possibility of carcinoma.
    1. Understand, however, that laryngoceles are generally discovered during staging of a known cancer and are rarely the presenting symptom of a carcinoma.
References 
  1. Head and Neck Pathology With Clinical Correlations, Churchill Livingstone: Thompson: Chapter 8, Part III - Pathology of the larynx, hypopharynx, and trachea; 2001.

Treatment

Learning Objectives 

Know that treatment of laryngoceles is surgical.

Surgical Therapies

Learning Objectives 
  1. Know that endoscopic exam with biopsies to rule out cancer in the laryngeal ventricle is an important step before definitive laryngocele management.
  2. Know that definitive management options include primary endoscopic excision versus resection via an external approach.
  3. Understand that for small internal laryngoceles, endoscopic microsurgical excision is an ideal approach.
    1. Some have reported an approach through laryngofissure techniques.
    2. The laryngocele may be excised with micro-phonosurgical instruments such as a cup forceps and endolaryngeal scissors or with the CO2 laser.
    3. The involved section of the false vocal fold, including the origin at the anterior ventricle should be excised with the laryngocele.
    4. Advantages of an endoscopic approach include avoidance of a neck scar, potential avoidance of a temporary tracheostomy, and decreased hospital stay and cost.
    5. Disadvantages include limited access which may lead to incomplete resection and the potential trauma to surrounding laryngeal structures/mucosa that could lead to scarring.
  4. Understand if the laryngocele extends beyond the confines of the larynx, an external approach is generally warranted for definitive removal in adults.
    1. This approach includes a temporary tracheostomy for airway protection.
    2. A lateral external approach is preferred and starts with a lateral neck incision with identification and medial retraction of the strap muscles.
    3. The laryngocele is then identified and the external portion of the sac tracked through the thyrohyoid membrane to the endolarynx.
    4. The superior laryngeal nerve (SLN) must be identified and preserved at the thyrohyoid membrane.
    5. The SLN typically runs through the membrane adjacent to the external component of the laryngocele.
    6. The laryngocele sac is then transected as closely as possible to the orifice of the saccule.
    7. Segmental excision of the upper portion of the thyroid cartilage may be necessary for adequate exposure and easier access to the endolarynx.
    8. Advantages of the external approach include direct access to the paraglottic space.
    9. This aids in minimizing trauma to the surrounding structures and assures complete excision.
    10. Disadvantages include the need for a temporary tracheostomy, creation of an external neck scar, and increased hospitalization periods and cost.
  5. Understand that many studies have reported a combined external and endoscopic laser approach to laryngocele resection.
  6. Know that transoral robotic surgery has been used to manage internal and combined laryngoceles successfully.
References 
  1. Frederick FJ. Endoscopic microsurgical excision of internal laryngocele. J Otolaryngol. 1985;14:1163-166.
  2. Komisar A. Laser laryngoscopic management of internal laryngocele. Laryngoscope. 1987;97:368-369.
  3. Myssiorek D, Persky M. Laser endoscopic treatment of laryngoceles and laryngeal cysts. Otolaryngol Head Neck Surg. 1989;100:538-41.
  4. Hogikyan ND, Bastian RW. Endoscopic CO2 laser excision of large or recurrent laryngeal saccular cysts in adults. Laryngoscope. 1997;107:260-5.
  5. Szware BJ, Kashima HK. Endoscopic management of a combined laryngocele. Ann Otol Rhinol Layngol. 1997;106:556-9.
  6. Thome R, Thome DC, De La Cortina RA. Lateral thyrotomy approach on paraglottic space for laryngocele resection. Laryngoscope. 2000;110:447-450.
  7. Ettema SL, Carothers DG, Hoffman HT. Laryngocele resection by combined external and endoscopic laser approach. Ann Otol Rhinol Laryngol2003. 2003 Apr;112(4):361-4.
  8. Cummings Otolaryngology Head and Neck Surgery, Elsevier/Mosby: Bastian: Benign Vocal Fold Mucosal Disorders, Chapter 95 – Saccular Disorders, Fourth Edition, 2005.
  9. Zelenik K, Stanikova L et al. Treatment of Laryngoceles: What Is the Progress over the Last Two Decades? BioMed Research International. 2014;Article ID 819453:1-6.
  10. Villeneuve A, Vergez S et al. Management of laryngoceles by transoral robotic surgery. Eur Arch Otorhinolaryngol. 2016;273:3813-3817.

Rehabilitation

Learning Objectives 
  1. Know that if excision was completed via endoscopic approach then healing by secondary intention is completed.
  2. Know that if excision was completed via an external approach with temporary tracheostomy then a time period to allow for secondary intention as well as healing of the defect in the supraglottic larynx must be completed.
    1. It is theoretically possible for air to be forced into the neck through the supraglottic defect with vigorous coughing or sneezing.
    2. Have patients sneeze with mouth open, refrain from vigorous coughing (may consider cough suppressants), eliminate activities involving valsalva maneuvers or increased subglottic pressures. (i.e., no bending over, lifting, or straining)
  3. Temporary tracheostomy for approximately 10 days to allow for this healing and eliminate increase in subglottic pressures
References 
  1. Ettema SL, Carothers DG, Hoffman HT. Laryngocele resection by combined external and endoscopic laser approach. Ann Otol Rhinol Laryngol. 2003;112:361-4.

Case Studies

  1. A 55 year old man presents with a left sided neck mass for the past 4 months as well as dysphonia. He has noted that the neck mass is compressible. He has an extensive history of smoking. On exam he has fullness on the left side of his neck at the level of the thyrohyoid membrane. On laryngoscopy fullness is noted of the left false vocal fold. How would you further work up this scenario? How does his history of smoking affect your treatment protocol? What surgical technique would you consider in this scenario?
  2. A 49 year old woman describes progressive onset of dyspnea for the last week. She has also noted a right sided neck mass which fluctuates in size. She is stridulous at presentation. Imaging reveals a laryngopyocele of the right neck. How would you proceed in stabilizing this patient’s airway?

Complications

Learning Objectives 

Know that the primary complication would be airway compromise, which would be eliminated with a temporary tracheostomy. Others would include bleeding, infection, hematoma, crepitus and damage to the superior laryngeal nerve.

Review

Review Questions 
  1. What is the site of origin of laryngoceles?
    -the saccule
  2. What other pathologic lesions originate from this site?
    -saccular cyst, laryngopyocele (a fluid-filled or an infected laryngocele)
  3. What symptoms does a large internal laryngocele often produce?
    -hoarseness, stridor, foreign body sensation, cough, sore throat, dysphagia
  4. What neck findings may a patient with a large combined laryngocele demonstrate?
    -a compressible mass overlying the thyrohyoid membrane, anterior to the sternocleidomastoid muscle and lateral to the thyroid cartilage
  5. What type of evaluation should be considered prior to the definitive management of a laryngocele?
    -imaging (CT/ MRI) and endoscopy with biopsies to rule out malignancy
  6. What membrane must be traversed in resection of a combined laryngocele using an external approach? Which nerve is at risk in this area?
    -thyrohyoid membrane; superior laryngeal nerve