Laryngocele
Description
●Introduction:
• Unlike other neck cysts, this one communicates with the laryngeal lumen and is uncommon, benign, and filled with air or fluid.
• Larrey (1829) described it, and Virchow (1867) gave it a name.
• The annual incidence is about 1 in 2.5 million.
• The M:F ratio is around 5:1.
• Age range of peak: 50–60 years.
● Causes:
➣ Congenital;
• Thyrohyoid membrane weakness during development;
• Laryngeal ventricle/saccule malformation.
➣ Acquired
• ↑ intralaryngeal pressure ↑ wind instrument players, glass blowers, and chronic coughers.
• Saccule orifice obstruction due to:
→ Laryngeal cancer;
→ Scarring, papilloma, and polyps.
● Classification:
➣ External: Protrudes through the thyrohyoid membrane causing lateral neck swelling;
➣ Combined/Mixed: Both components (most common, ~79%);
➣ Internal: Confined within the paraglottic space, inside the thyrohyoid membrane.
● Clinical Characteristics:
➣ The laryngocele inside
• A sense of a foreign body and hoarseness.
Dysphagia.
• Dyspnoea, or blockage of the airway.
➣ Outside laryngocele
• Variable, soft, and compressible swelling in the lateral neck, close to the thyrohyoid membrane.
• Coughing or Valsalva promotes swelling.
➣ Combined
• The above combination.
➣ Issues
Mucus retention when the orifice is occluded is known as laryngomucocele.
• Laryngopyocele: infection of the laryngomucocele resulting in fever and compromised airways.
• Death, acute obstruction, and aspiration pneumonia.
The diagnosis:
Clinical examination: • Swelling of the neck (increases with coughing or Valsalva).
• Direct or indirect laryngoscopy → smooth lump protruding into the fake cord or ventricle.
• CT neck imaging is the gold standard. displays a lesion that is either fluid- or air-filled in respect to the ventricle.
• Soft tissue and malignancy suspicion are defined by MRI.
• USG: solid versus cystic.
• The appearance of a "doughnut sign" on CT Dacryocystography when it is filled with air.
➣ Histopathology:
• Lined by fibrous wall and ciliated columnar or squamous epithelium; excludes laryngeal carcinoma (which may coexist in 5–30% of cases).
● History:
➣ Virchow (1867) defined it after Larrey (1829) first characterised it.
Distribution of types: internal (17%), external (4%), and combined (79%).
➣ Risk of infection: 5–8% => potentially fatal laryngopyocele.
➣Association with cancer: controversial. According to certain research, laryngeal cancer coexists with 5–30% of cases, whereas in others, it does not. Send a specimen for histopathology at all times.
➣ The symptoms include:
• Internal: airway blockage, stridor, dysphagia, and hoarseness.
• Valsalva for external → compressible neck oedema.
•Combined → both plus dyspnoea risk.
➣ The diagnosis is:
• The gold standard is a CT neck scan, which reveals a cystic or air-filled lesion in proximity to the larynx.
•MRI: a useful tool for assessing inflammation, soft tissue extent, and suspected malignancy.
• Laryngoscopy: preliminary examination.
• USG: distinguishes solid from cystic.
➣Management:
• Endoscopic method (CO₂ laser, cold instruments, plasma, robotic) for small internal laryngocele.
• External transcervical excision ± tracheostomy: large internal/external/mixed.
• Tracheostomy is an emergency airway compromise.
• New method: endoscopic low-temperature plasma resection, which is less invasive, doesn't require a tracheotomy, heals more quickly, and leaves no scars.
The patient is a 59-year-old man who has had hoarseness for a year. The case presentation is
➣ Internal Laryngocele. Exam: Expanded right fake vocal fold following laryngoscopy Imaging: CT/MRI shows a right laryngeal cystic dilatation of 1.3 x 0.7 x 1.9 cm.
➣ Management: • Clear fluid drained, capsule root cauterised; • Endoscopic low-temperature plasma radiofrequency excision.
• No tracheostomy is necessary.
• Result: Discharged on day two; 6-month follow-up: normal function, no recurrence.
Protocol
● Therapy:
➣ The final option is surgical excision.
➣ Endoscopic method (small internal lesions):
• Excision using CO₂ laser.
• Excision of cold steel.
• Radiofrequency low-temperature plasma (newer, less invasive, avoids tracheostomy).
• TRO, or transoral robotic excision.
➣ External strategy (external, mixed, or massive lesions):
• Excision of the transcervical region through the thyrohyoid membrane.
• Often requires tracheostomy in airway-compromised patients.
➣ Tracheostomy in the event of airway blockage is an emergency care strategy.
• Laryngopyocele drainage.
● Issues Laryngocele Patients Face:
➣ Cystic masses filled with air or fluid that are connected to the laryngeal saccule can cause a range of symptoms and difficulties for patients with laryngocele.
➣ Common issues include hoarseness, neck swelling that is apparent, discomfort, swelling that becomes worse with time, dysphagia (difficulty swallowing), coughing, stridor, and even acute airway blockage.
➣The swelling may become more noticeable when you cough, do the Valsalva manoeuvre, or engage in physical exercise.
➣Laryngopyocele, which can cause acute airway emergencies such as respiratory distress, dysphagia, aspiration risk, and even sudden death, can be caused by infection in extreme cases.
➣Anxiety and dread related to the possibility of airway blockage and the need for surgery are examples of psychological issues that may arise.
●Clinical Interventions and Nursing
Prior to and following surgical treatment, nursing care and interventions concentrate on both acute management and long-term support.
➣ Preoperative Nursing: Patients need psychological support to reduce their anxiety about the surgical procedure, monitoring for signs of increasing obstruction, and a comprehensive assessment for airway compromise.
• Before surgery, nurses make sure the patient is in NPO status.
• Instruction is given regarding the process and anticipated results.
Vital signs are monitored, with an emphasis on oxygen saturation and respiratory rate.
➣Airway Management: If there is an acute airway blockage during evaluation or therapy, emergency measures like tracheostomy may be necessary.
• Oxygen supply and suction equipment are always available.
• Nurses keep an eye out for cyanosis, stridor, or increased labour of breathing, which are early indicators of airway compromise.
➣ Postoperative care involves keeping an eye out for issues including bleeding, infection, and recurrence, as well as waiting for the ability to swallow and speak to return.
• Using the right analgesics to control pain.
•Assist in mobilising and reintroducing oral intake gradually in accordance with the surgeon's advice (oral diet may resume within 24 hours after certain endoscopic procedures).
• Postoperative psychological care and reassurance are maintained.
•Educating patients on how to care for wounds when external approaches are used, as well as warning signs of complications like abrupt swelling, trouble breathing, or changes in voice.
● Surgical Procedures and Handling
➣ The use of endoscopic low-temperature plasma radiofrequency surgery for tiny internal laryngoceles is described in the study. This procedure enables quick recovery without tracheostomy and minimally invasive excision.
➣ Transcervical external surgical techniques may be necessary for larger or mixed laryngoceles, and tracheostomy may be necessary to secure the airway both during and after the procedure.
➣ Early mobilisation, bleeding or infection surveillance, and airway security are the main goals of intraoperative and postoperative nursing in both kinds.
Notes
For more details 10.3892/etm.2023.12123
