Excision of Laryngocele

Introduction

The ventricle ends in a blind pouch anteriorly called the sacculus or saccule, which is variously known as the appendix ventriculi larynges or Hilton’s sac. Laryngocele refers to a pathologic cystic dilation and enlargement of the saccule of the laryngeal ventricle. It is a rare and benign lesion of the larynx that may present with hoarseness, dyspnea, or dysphagia, depending on its size.

Laryngoceles are classified into three groups: the internal, external, and mixed type. In the internal type, the swelling is confined within the larynx. This may be seen as a swelling of the ventricle, hiding the true cord of the same side, and even extending across the midline to compromise the airway. The internal type may extend to the aryepiglottic fold and even to the base of the tongue, completely filling one vallecula.

The external type appears as a swelling in the neck, usually at about the level of the hyoid bone and just anterior to the sternocleidomastoid muscle, but can be found almost anywhere in the neck. The sacculus extends and perforates the thyrohyoid membrane where the superior laryngeal neurovascular bundle passes. This seems to be the weakest point of the membrane. In the mixed or combined type, the internal and external portions are joined by an isthmus that gives an hourglass appearance.

DeSanto classified benign cystic lesions derived from the saccule into laryngocele, laryngeal mucocele, large saccules, and laryngeal saccular cyst, depending on the size of the saccule, the presence of a communication between the saccule and the laryngeal lumen, the presence of inflammation, and the presence of symptom. They concluded that these lesions have a common pathology but show different manifestations in a developmental spectrum.

Surgical excision is indicated when the patient has apparent symptoms and a differential diagnosis is needed. A key issue is whether complete excision can be achieved without complications.

The author describes various approaches for safe surgical excision of laryngoceles.

Key Operative Learning Points

• Diagnosis and differential diagnosis are critical.

• Identification of coexisting pathology is necessary.

• Airway compromise should be avoided.

• Temporary tracheostomy may be needed to prevent postoperative airway compromise.

• Care should be taken to prevent injury to the superior laryngeal neurovascular bundle.

• Careful selection of patients is important, as the surgical approach can vary according to the size and location of the laryngocele.

Preoperative Period

It is important to know that not all laryngoceles induce symptoms and not all laryngoceles should be surgically removed. Most laryngoceles are asymptomatic at onset and do not produce symptoms until they are quite large. The most common symptom is hoarseness, but the patients may also present with dyspnea or dysphagia, depending on the size of the laryngocele, or may present with a mass in the neck depending upon the location of the external laryngocele.

An asymptomatic laryngocele incidentally found on radiographic studies is not an indication for surgical treatment. Office laryngoscopy is necessary to reveal a unilateral or bilateral bulge of the false vocal fold and/or aryepiglottic fold ( Fig. 7.1 ). Examination of the ventricle is also necessary to identify synchronous pathologies that might have caused the laryngocele, but this is almost impossible to do in an office visit because the ventricular cavity is obscured by the laryngocele.

Several imaging techniques can be used to diagnose a laryngocele. Computed tomography (CT) is the gold standard, as it allows the visualization of the air-filled saccule and its anatomic relations ( Fig. 7.2 ). CT scan has proven to be the most accurate imaging method in defining the spatial relationship between the laryngocele and the laryngeal structures and extralaryngeal soft tissues, in differentiating the laryngocele from other cystic formations, and in identifying the coexistence of a laryngeal cancer.