Case Report

Internal Laryngocele Managed with LASER-Assisted Microlaryngoscopic Excision

Pankaj Goyal¹*, Kishan Kumawat¹, Chandrani Chatterjee², GN Gupta³ and Nidhi P Chanchalani³

¹Apollo ENT Hospital, India

²Department of ENT, AIIMS, India

³Reliable Diagnostic Centre, India

Submission: June 28, 2024; Published:July 15, 2024

*Corresponding author: Pankaj Goyal, Apollo E.N.T. Hospital, pal road, Jodhpur, Rajasthan, India

How to cite this article: Pankaj G, Kishan K, Chandrani C, GN G, Nidhi P Chanchalani. Internal Laryngocele Managed with LASER-Assisted Microlaryngoscopic Excision. Glob J Oto, 2024; 26 (4): 556199. DOI: 10.19080/GJO.2024.26.556199

Abstract

Laryngoceles are rare benign lesions characterized by abnormal dilatation of the laryngeal saccule. Internal laryngoceles are even rarer and pose diagnostic and therapeutic challenges due to their atypical presentation. We present a case of a 45-year-old male who presented with progressive dysphonia and intermittent dyspnoea. Direct laryngoscopy revealed an internal laryngocele. The patient underwent CO₂ LASER-assisted microlaryngoscopic excision, resulting in symptomatic relief and restoration of normal laryngeal function. This case highlights the efficacy of this minimally invasive surgical approach in the management of internal laryngoceles.

2. Keywords: Laryngocele; Internal laryngocele; Dysphonia; CO₂ LASER; Microlaryngoscopic excision

Introduction

Laryngoceles are uncommon benign lesions that are distinguished by an atypical dilatation of the laryngeal saccule, which is filled with air, extends upward within the false vocal fold, and communicates with the laryngeal lumen [1,2]. The laryngeal ventricle was initially mentioned by Galen [3] in the 2nd century, but it was not until 1741 that Morgagni [4] delineated its physical borders, giving it his name (ventriculus laryngis Morgagni). In 1829, Larrey [5], a surgeon in Napoleon's Egyptian army, reported air-filled "tumors" in the necks of muezzins, who summon Muslims to prayer. In 1837, Hilton [6] identified the ventricular appendix or saccule located in the anterior portion of the laryngeal ventricular chamber. The word "laryngocele" was first used by Virchow in 1867. He defined it as a dilatation of the laryngeal ventricle [7]. The ciliated glandular epithelium lining the ventricle's walls held air within. There have been a few reports of laryngoceles in the literature, but most of the reports seem to have come from the treatment of this ailment in the last few years.

These infrequent laryngeal lesions fall into one of two categories: internal or mixed. Whereas combined laryngoceles are positioned both medially and laterally to the thyroid hyoid membrane, internal laryngoceles grow medially to it [8]. Men over 50 years old typically develop laryngoceles, with the majority being unilateral and mixed in nature [8,9]. Laryngoceles normally contain air, but if the neck gets occluded due to inflammation or a mechanical blockage, they might additionally contain mucus. Additionally, an infection of the dilated saccule may result in a laryngopyocele, which may lead to substantial laryngeal supraglottic edema and mechanical obstruction. Acute airway crises can occasionally be the presentation of laryngopyoceles [10]. Despite their rarity, internal laryngoceles can be difficult to diagnose and treat because of their unusual appearance and risk of airway impairment. Diverse approaches are documented for treating laryngoceles [11,12].

The majority of the time, surgical excision is the course of treatment; several approaches are covered in the literature [13-19]. Some writers continue to support the conventional therapy, which is an external approach [13,14]. However, with the development of CO₂ lasers and microlaryngoscopic surgery throughout the past 20 years, endoscopic care of laryngoceles has become more common [15,18,19]. Here, we describe a successful case in point of microlaryngoscopic excision with LASER assistance for internal laryngocele.

Case Presentation

After experiencing increasing changes in his voice for the previous six months, a 45-year-old man came to our clinic. The patient disclosed a past medical history of sporadic dysphagia and a sore throat feeling. He denied having ever experienced any recent neck injuries or upper respiratory tract illnesses. His voice had always been strained. Individuals occasionally drank alcohol. There was no prior history of dyspnoea. A swelling at the false vocal fold on the right side obscured the true vocal cord during direct laryngoscopy. The swelling had a cystic appearance and mucosal alterations that suggested persistent inflammation. Following an extensive preoperative assessment and informed consent, the patient was placed under general anaesthesia and had LASER-assisted microlaryngoscopic excision of the laryngocele.

A CO₂ LASER system with microlaryngoscopic tools was used to execute the surgery (Figure:1). The laryngocele was seen intraoperatively as a cystic enlargement that extended into the supraglottic area and emerged from the saccule. The surrounding laryngeal tissues were preserved throughout the meticulous dissection and excision of the laryngocele (Figure 2-4). After full excision of the laryngocele, the surgical specimen was submitted for histopathology (Figure 5). Histologic reported the cyst lining is made up of a ciliated pseudostratified columnar epithelium with no atypia. The lumen showed no evidence of mucus buildup, confirmed the diagnosis of a laryngocele (Figure 6A & 6B).

Outcome

Following surgery, the patient recovered without incident and his voice quality started to improve right away. He stated that the sore throat feeling had subsided. When direct laryngoscopy was done one week and three months after surgery, the laryngocele was completely resolved and there was no sign of a recurrence. During follow-up visits, the patient reported no further incidents of throat pain, and his voice remained normal.

Discussion

Laryngoceles are herniations of the laryngeal ventricle that connect with the larynx [20]. The ventricle is a fusiform dilatation of the larynx that extends from the thyroid notch to the arytenoids, situated between the true and false vocal cords [20]. The anterior portion is in contact with the saccule, a pouch where the laryngocele develops [9,20]. Its histological structure is made up of a thin basal membrane surrounded by ciliated pseudo-stratified cylindrical epithelium that contains a variable number of goblet cells within a membranous sac [20]. According to estimates, there is one case of laryngocele for every 2.5 million people annually [21]. According to reports, males are five times more likely to suffer laryngoceles, which peak in prevalence in the sixth decade of life [22,23]. There are three basic theories for the cause of laryngoceles: congenital causes, increased laryngeal pressure, and mechanical blockage [22,24]. Long durations of high laryngeal pressure, such as those experienced by glass blowers and wind instrument players, may cause progressive saccule dilatation [25].

The same outcome may occur if a laryngeal mask is used during general anaesthesia [26]. Moreover, increased intraventricular pressure and saccule dilatation might be facilitated by mechanical blockage of the ventricle resulting from acquired laryngeal diseases (amyloidosis, chondroma, carcinoma, and others) [22,27-30]. Diagnosing internal laryngoceles might be difficult since they are uncommon entities with vague symptoms. The laryngoceles subtype affects the symptoms. The size of an external laryngoceles often changes according to the amount of air within the saccule at any one moment. They manifest as a neck lump. Internal laryngoceles manifest as aching throats, hoarse voices, and a feeling of a foreign body in the throat. Only around 50 instances have been documented in the literature so far about laryngoceles becoming infected and developing into laryngopyocoeles [31,32].

Flexible or direct laryngoscopy is the initial diagnostic modality, although CT or magnetic resonance imaging (MRI) may be necessary for further characterization and surgical planning. With cross-sectional imaging and contrast resolution better than conventional radiography, computed tomography scanning offers a conclusive diagnosis of laryngocele [33]. The limits of the air-filled sac and its relationship to the thyrohyoid membrane may be clearly seen on magnetic resonance imaging, which enables great clarity of soft tissues. This information helps differentiate the internal from the exterior or mixed components of this cyst [34]. A mucus-filled cyst or an abscess (also known as a laryngopyocele or laryngomucocele) may occasionally develop in the cyst [35]. Surgical excision is usually the first step in the management of internal laryngoceles in order to alleviate symptoms and avoid potential problems like airway obstruction or recurring infections.

Laryngocele is an uncommon ailment that poses a surgical conundrum. As a result, several surgical techniques have been employed to treat it. Traditionally, an external method was used to excise both internal and mixed kinds [36]. For the excision of laryngoceles, a variety of surgical procedures have been reported; they include endoscopic techniques like microlaryngoscopic excision and exterior approaches like thyrotomy or transcervical approaches. The size, location, and experience of the surgeon all play a role in the procedure selection for laryngocele surgery. In the past twenty years, the endolaryngeal approach has gained popularity due to the introduction of microlaryngoscopic surgery and the CO₂ laser. As a result, several of the reviewed authors have started using this technique to treat internal laryngoceles [18,19]. In addition, several writers have started treating combined laryngoceles with a microlaryngoscopy approach [19]. Nevertheless, some writers continue to support the external approach [13,14]. An endolaryngeal CO₂ laser approach is the usual method used to treat internal laryngoceles.

According to the current analysis, the majority of patients had CO₂ laser treatment. The ideal method for resection is the CO₂ laser approach since it is safer, more accurate, and more efficient than an open procedure [17]. Additionally, speaking, and swallowing recovery happens more quickly [36]. The endolaryngeal method for treating internal laryngoceles has a number of drawbacks, including scarring, insufficient resection, restricted exposure, and the requirement for specific tools. However, with just nine instances recorded since 1952, internal laryngoceles were seldom treated using an open approach. These were all published before 1990 and came before the widespread usage of endoscopic procedures. The transcervical incision or approach through a laryngofissure were two of the open surgical techniques utilized to treat internal laryngoceles [37]. The literature indicates that there has been a shift toward endoscopic management of this condition, particularly for excision of the internal component of the laryngocele. This is evidenced by reports from Frederick [38] on endoscopic snaring of an internal laryngocele, Komisar [39] & Myssiorek, Persky [40] on three cases of laser marsupialization of internal laryngoceles.

Similar outcomes were seen in all accounts, including good functional recovery, early hospital discharge, and avoidance of tracheotomy. There is still a surgical conundrum with combined or mixed laryngocele. There is just one report of this type, by Szwarc & Kashima [41] in 1997, which details a case treated with endoscopic CO₂ laser resection. They explain how our procedure, which is comparable to theirs, has less surgical morbidity than the external approach and prevents possible injury to the superior laryngeal arteries. According to our observations, the superior laryngeal arteries are shielded from damage by maintaining the dissection plane as medial as feasible. Following the identification and application of traction to the laryngocele capsule, the capsule is separated from the laterally located muscle layer, preventing the dissection from approaching the neurovascular pedicle, which is visible under an operating microscope. In our instance, we chose LASER-assisted microlaryngoscopic excision since it is a minimally invasive procedure that can precisely ablate tissue while causing the least amount of heat harm to adjacent tissues. This method allowed for full excision while maintaining normal laryngeal function and gave great visibility of the laryngocele.

Conclusion

Internal laryngoceles are uncommon benign lesions that can cause vague symptoms and present a management dilemma to the otolaryngologist. Prompt diagnosis and treatment are essential for preventing complications. Endoscopic procedures and laser surgery have revolutionized the treatment of laryngeal disorders. LASER-assisted microlaryngoscopic excision is a safe and effective surgical approach for the treatment of internal laryngoceles, with excellent results and low morbidity.

Acknowledgment

We would like to acknowledge the patient for providing consent for the publication of this case report.

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