La ryngocele

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MARVIN

M. LINDELL,

JR.,’

BAO-SHAN

JING,1

EDWARD P. FISCHER,2’3 SIDNEY WALLACE’

Laryngocele occurs more commonly than the literature indicates. Until recently, most were diagnosed clinically in the symptomatic patient. Although laryngocele is usually asymptomatic, greater numbers are being diagnosed because more patients suspected of head and neck cancer are undergoing sophisticated diagnostic radiographic procedures. Of 2,068 patients studied at M. D. Anderson Hospital and Tumor Institute for suspected laryngeal or hypopharyngeal cancer, 87 (4.2%) had laryngoceles. Three types of laryngocele are recognized: internal, external, and combined. They may be congenital or acquired and occur at any age. The coexistence of carcinoma and laryngocele has been discussed often enough In the literature to suggest a direct relationship; however, this series yielded no substantive evidence to implicate laryngocele as a precursor of carcinoma. The radiographic procedures currently used which readily establish the presence of laryngoceles are lateral soft tissue radiography of the neck, anteroposterior tomography of the larynx, and contrast laryngography.

Between

77030. Address 2

Department

reprint

requests

cally

geal

to M. M. Lindell,

1963 and 1976, 2,068 patients

contraindicated.

mass

The

includes:

anteroposterior

all patients.

procedures

We select

131:259-262, Roentgen

Avenue,

Augu1978

Ray Society

to our

of the larynx unless clini-

evaluation

of

a laryn-

soft tissue radiography of the neck, of the larynx, and laryngography.

tomography

All three diagnostic

were referred

carcinoma examination

radiographic

lateral

AND

Methods

are not routinely

studies

that

performed

best demonstrate

on

the disease

process.

Lateral soft tissue radiography of the neck. This examination is performed using both single emulsion film and xeroradiography which allow maximum latitude so that bone, soft tissue, and air densities can be appreciated with the same factors.

Exposures

are made with the patient

the nose when a laryngeal lesion through the mouth when a lesion

consideration.

This procedure

Anteroposterior grams are usually nation to a depth

breathing

quietly

through

is suspected and, in addition, in the oropharynx is of primary

is performed

on all patients.

tomography of the larynx. Multiple tomoexposed at 3.0 mm increments during phoof 3.0 cm. When a laryngocele is present or

suspected,

it is best visualized

during

the

modified

cheeks

with closed

when

Valsalva

glottis

tomograms

maneuver,

which

are obtained

a puffing

causes

out

an increase

of the

in intralar-

yngeal pressure. Laryngography.

Contrast laryngography is done in the anteroposterior, lateral, and oblique projections. Films are obtamed during quiet respiration, phonation, modified Valsalva and Valsalva maneuvers, and reverse phonation. Using these radiographic techniques, the soft tissues of the larynx are beautifully portrayed. The manifestations of laryngocele

depend

upon

mass distorting

the

laryngocele,

which

shadow

size

most

is projected

supraglottic

and

the normal

In

is the

our

experience,

by anteroposterior

types

of

are

laryngography. Internal laryngocele in the

supragiottic

of

the

are

defined

larynx.

most

and by

demarcated

It may

air

of the

tomography,

exquisitely

in a

lucent

or midportion

is seen as a sharply region

the

laryngoceles

demonstrated

most

rounded

air is present case,

the anterior

often

laryngocele

of a smooth

When

frequently

over

larynx.

location

anatomy.

all

contrast

air sac

extend

upward

and laterally from the ventricle within the substance of the false cord and aryepiglottic fold. It is best seen on lateral soft tissue radiography and anteroposterior and lateral laryngography

(fig. 2). External

is best visualized as a sharply defined within the soft tissues of the neck lateral to the hyoid bone and above the thyroid cartilage. It may enlarge during the modified Valsalva maneuver and is well demonstrated on anteroposterior tomography and lateral soft round

30, 1978. System Cancer

or

laryngocele

oval

tissue

radiography,

ternal

laryngocele

Center,

radiolucency

especially was

M. D. Anderson

found

xeroradiography. in this

Hospital

and

No

purely

ex-

series.

Tumor

Institute,

Houston,

Texas

Jr.

of Surgery, Section of Head and Neck Surgery, University of Texas System Cancer Center, M. D. Anderson

Institute, Houston, Texas 77030. 3 Present address: 4001 Union Am J Rontg.nol 0 1978 American

after revision March University of Texas

and

institution for evaluation of suspected or hypopharynx. All had radiographic

.

I

M. GUILLAMONDEGUI,2

Subjects

Laryngocele, as described by Virchow in 1867, is an abnormal saccular dilatation of the appendix of the laryngeal ventricle of Morgagni [1-11]. The sac is lined with pseudostratified columnar ciliated epithelium and communicates with the ventricle by a narrow stalk. The laryngeal appendix or appendage arises from the lateral recess in the anterosuperior aspect of the ventricle (fig. 1). If the appendage projects above the upper border of the thyroid cartilage, it is considered abnormally long, 1 .0 cm or longer [6, 12]. The saccular dilatation of this appendix, by definition, is a laryngocele. There are three types of laryngoceles: internal, external, and combined. Internal laryngoceles may remain small and localized, or elongate and extend beyond the upper border of the thyroid cartilage to the epiglottis and even into the base of the tongue. The external type is formed when the dilated appendage penetrates the thyrohyoid membrane and extends into the subcutaneous tissues of the neck [13]; this occurs in about 20%. A pure acquired external laryngocele probably does not exist. It is but an extension of the internal type and thus represents the external component of a combined laryngocele. The combined laryngocele exhibits both internal and external components [5]. Since Larrey’s first description in 1829, laryngoceles have been reported in 344 patients [1-4 , 14] We present the radiographic features and clinical implications of laryngoceles found in 87 patients at the M. D. Anderson Hospital and Tumor Institute. Received November 15, 1977; accepted Department of Diagnostic Radiology,

OSCAR

Bakersfield,

California

Hospital and Tumor

93305.

259

0361

-803X/78/08--0259

$00.00

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260

LINDELL

Fig. 1 . - Laryngeal and lateral valleculae;

laryngograms 6 = pyriform

ET

AL.

appendix. A, Anteroposterior laryngogram showing laryngeal appendix on right (arrow). B and C, Drawings showing laryngeal appendix (large arrows). 1 = true cord; 2 = laryngeal ventricle; 3 = false cord; 4 sinus; 7 = laryngeal surface of epiglottis; 8 = thyroid cartilage; 9 = hyoid; 10 = arytenoid.

In 36

cases

exhibited

ipsilateral

25

was

patients.

laryngocele

bilateral

cele,

no tumor in

found.

5

=

Benign disease was 26 patients with five of whom exhibited

There

were

and tumor,

laryngoceles

from anteroposterior aryepiglottic fold:

=

, seven

with

contralateral

six with

bilateral

tumors

and unilateral

and four with In no instance

bilateral

tumors

and

laryngo-

laryngocele,

bilateral

laryngoceles.

did tumor arise in a laryngocele (fig. 5). Among the 87 patients, 75 complained of hoarseness. Of these, 42 had vocal cord carcinoma, 25 inflammatory disease, and 11 neither neoplastic nor inflammatory disease. Among benign lesions reported were papilloma, cord

leukoplakia,

cord

weakness

and

paralysis,

and

supraglottic edema. Of 13 patients who complained of dysphagia and/or sore throat, two had laryngeal carcinoma, eight extrinsic laryngeal carcinoma, and two benign

disease. Discussion

Laryngoceles may be congenital or acquired and occur at any age. Laryngocele is reported to be less common in the female [11 ; 15]. In this series, incidence in females was Fig. 2. -Internal yngogram showing

laryngocele. Anteroposterior larlarge, bilateral internal laryngo-

gent

celes (arrows). Combined laryngocele has features of both forms. Anteropostenor tomography may demonstrate that the lucency has an hourglass configuration, because one segment of the sac is within the larynx and the other is extralaryngeal. A small airfilled

channel

(figs.

3 and

the internal

is often

seen

4). Laryngography

joining

is quite

the

two

useful

segments

28%,

med.

[5,

10]

in demonstrating

Results

Of 2,068 patients, 87 (4.2%) had demonstrable laryngoceles. There were 51 cancers (58%) in these 87 patients: 43 were laryngeal and eight were hypopharyngeal.

males

upon

the

constituted of

75%

congenital

presence

times

the

extend

into

laryngocele

develop

fold

and

sicians.

disease,

6, 10,

13,

Clinically symptomatic, sensation

fled

quality

respiratory

cough,

dilata-

saccular

[7, 8].

in persons

pations cause high intralaryngeal documented in glass blowers

with

examis contin-

An increase sac to distend

aryepiglottic

may

Chronic

patients

of a congenital

appendage. may cause the

quired

of

laryngocele

tion of the ventricular laryngeal pressure

associated

component.

but

Development

of intraand at

The

whose

pressure. This wind instrument especially

is not an uncommon

ac-

occuis well muwhen

cause

[1

, 5,

16-18]. most laryngoceles are the patient commonly associated

of the

with

voice

noisy

[1].

asymptomatic. suffers respiration

There

is often

When a choking and

a muf-

hoarseness

261

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LARYNGOCELE

Fig. 3.-Combined laryngocele. Anteroposterior involving left aryepiglottic fold and false cord with

laryngograms foreshortening

surgery.

(white arrows).

Note air-fluid

level in external

component

performed during quiet breathing (A) and phonation (B) showing soft tissue mass of ventricle and narrowing of pyriform sinus (black arrows). Laryngocele proven by C. Anteroposterior tomogram showing air-filled internal component on left (arrow).

Fig. 4.-Combined mogram showing

ments

on left

pyriform

sinus.

laryngocele. Anteroposterior tointernal (a) and external (b) compartside. Note large carcinoma of right

and reflex cough due to encroachment of the laryngeal space. Fluid may be expectorated during coughing spells, and severe choking and dysphagia may occur. Dyspnea is most often marked in infants and younger children, and laryngocele has caused sudden obstruction and death [3, 4, 6-8, 10]. There are usually no physical signs [4]. A soft reducible mass in the lateral cervical region which becomes more pronounced during

Fig. 5.-Carcinoma of right pyriform sinus and rigit laryngocele. Anteroposterior tomogram showing lare right pyriform sinus carcinoma and internal laryngo-

cele uninvolved

the modified 3, 5, 7, 10, mucoid Secondary

by tumor

Valsalva 15, 16,

material, infection

(arrow).

maneuver suggests laryngocele 19-22]. If the saccule is filled

it is termed may

lead

a laryngomucocele to formation

[1,

with

(fig. of pus

within

6).

LINDELL

262

ET AL. REFERENCES

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1 . Putney FJ: Laryngocele. Soc 52:107-113, 1968

Trans

Pac

Coast

Otoophthalmol

2. Holinger PH, Brown WT: Congenital webs, cysts, laryngoceles and anomalies of the larynx. Ann Otol Rhinol Laryngol 76:744-752, 1967 3. Canalis RF: Observations of Iaryngocele and cancer.

on the simultaneous occurence J Otolaryngol 5:207-212, 1976 4. Giovanniello J, Grieco RV, Bartone NF: Laryngocele. Am J Roentgenol 1 08 : 825-829, 1970 5. Glanz I, Grunebaum M: The radiographic appearances of ventricular laryngocele. lsr J Med Sci 7 : 1 1 55-1 1 59, 1971

6. Macfie DD: Asymptomatic bandsmen Arch Otolaryngol

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.

7. Mosallam

I: The

laryngocele.

J Laryngol

1967 8. Ferguson GB: Laryngocele. 1967 9. Mehta BS, Bhargava MK: Fig . 6. - Laryngomucocele. gram showing soft tissue

cord, aryepiglottic fold, pyriform sinus (arrows).

Anteroposterior mass involving

right

tomoright false

side of ventricle,

Laryngomucocele

proven

81 :1163-1170, 1967 English GM, DeBlanc

10.

and

with acute 1968

by

surgery.

11

LD Jr,

review

the sac, which then is termed a pyocele or laryngopyocele [1 , 4, 5-10, 21]. In our series there was a 58% incidence of associated tumor, which is higher than previous reports but understandable in view of the nature of this institution. The reported incidence of laryngocele and laryngeal appendage in the presence of cancer of the larynx and hypopharynx is variable, ranging from 6.18% to 37% [3, 6, 7, 11, 14, 23, 24]. The coexistence of cancer and laryngocele has been observed often enough to suggest a direct relationship. The question of which entity is primary has not been resolved. Theoretically, increased intralaryngeal pressure may lead to the development of laryngocele in the elongated appendix. Carcinoma obstructing the ventricle may change an incipient laryngocele into a clinical one. Bilateral laryngoceles not infrequently coexist with unilateral carcinoma and may exist without any laryngeal or hypopharyngeal disease. We have found no substantive evidence that indicates laryngocele is a precursor of carcinoma. The presence of tumor on the side of the laryngocele or laryngeal appendage may cause obstructive changes that lead to enlargement of that saccule. Inasmuch as laryngoceles are usually asymptomatic, patients with symptoms of laryngeal origin should be thoroughly evaluated, including biopsy of suspicious lesions, in order not to overlook associated malignant or benign disease.

GB:

Laryngoscope

81 :483-494, 77:1368-1375,

Laryngocele.

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obstruction.

TA: Laryngocele: case report and Laryngoscope 74 : 396-412, 1964 12. Issa P: Laryngocele ventriculaire (a propos de 4 cas). J Radiol Electrol Med Nucl 42 :8-16, 1961 13. Kov#{224}csA: Laryngeal function in laryngocele. Acta Radiol [Diagn] (Stockh) 8:519-528, 1969 14. Silvagni C: Rilieri clinici-statistici sull’ associazione tra laringocele e cancro della laringe. Valsalva 41 :465-479, .

Wright

airway

Otol

instrument

Maguda

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FJ: Laryngocele.

16. Krekorian

Laryngoscope

EA: Laryngocele

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17.

18. Sokolova Zh Ushn

ZN: A case of laryngeal Nos

Gorl

Bolezn

19. Johnson TH, Fioranelli cele): a laryngographic 1969 20. Annunziata A: Su di un Laringol 66:67-76, 1967 21 Walpita PR: Laryngocele .

844,

78 : 749-755, 1968 Laryngoscope

in a jet flyer. contributo

1966 cancer

31 :93-94,

clinico-radiol-

with laryngocele.

1971

RJ: Laryngeal cyst (filled laryngodiagnosis. Radiology 93:875-877, caso di laringocele

esterno.

in an infant. J Pediatr

Surg

Ann

1 0 : 843-

1975

22. Buytendijk Laryngocele 81 :583-586,

HJ, Maesen TH, Twaalfhoven et Brekel BVD: extra-laryng#{233}e bilat#{233}rale.Ann Oto Laryngol 1964

23. Bassett LW, Hanafee WN, Canalis RF: The appendix of the ventricle of the larynx. Radiology 1 20 : 571 -574, 1976 24. Alajamo E, Boccuzzi, V, Fini-Storchi 0: Osservazioni sull’ associazionecancro-laringocele. Boll Malat Orecchio Gola Naso 82:672-686, 1964 25. Burke EN, Golden JL: External ventricular laryngocele. Am J Roentgenol

80:49-53,

1958