Laryngocele

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Here is a comprehensive review of laryngocele based on Cummings Otolaryngology and KJ Lee's Essential Otolaryngology.

Laryngocele

Definition

A laryngocele is an abnormal air-filled dilatation (diverticulum) of the saccule (appendix) of the laryngeal ventricle, communicating with the laryngeal lumen through a patent saccular orifice. When the orifice becomes obstructed and the sac fills with mucus, it is termed a saccular cyst; when it fills with pus, it becomes a laryngopyocele.

Cummings Otolaryngology, p. 1127

Relevant Anatomy

The laryngeal saccule (appendix) is a small, blind outpouching at the anterior end of the laryngeal ventricle. It extends superiorly between the false vocal fold and the inner surface of the thyroid cartilage, just posterolateral to the petiole of the epiglottis. It contains numerous mucous glands whose secretions lubricate the true vocal folds. Normal saccule length is 6-8 mm in 75% of people, with 25% measuring ≥10 mm.

Classification

Fig. Classification of laryngocele/saccular cyst - Cummings Otolaryngology

By Contents

Type	Contents	Orifice
Laryngocele	Air	Patent
Saccular cyst (mucocele)	Mucus	Blocked
Laryngopyocele	Pus	Blocked

By Location

Type	Description
Internal	Entirely within the thyroid cartilage framework; expands the false vocal fold and aryepiglottic fold medially, may bulge the piriform sinus laterally
External	Dilated air sac passes through the thyrohyoid membrane to present as a neck mass
Combined (mixed)	Has both internal and external components; most common type

Almost 25% of laryngoceles are bilateral.

Etiology

Congenital: In infants, saccular disorders are likely congenital
Increased intrapharyngeal/transglottic pressure: Associated with trumpet players, glass blowers, wind instrument players, and people who use their voice forcefully (though this association may be overstated per Stell and Maran)
Laryngeal carcinoma: An obstructing tumor at the saccular orifice is an important and well-documented cause - 5% to 29% of laryngoceles may be associated with a small ventricular carcinoma
Idiopathic: Often no clear cause is identified
Cummings Otolaryngology, p. 1127; KJ Lee's Essential Otolaryngology, p. 924

Clinical Features

Symptoms (in order of frequency)

Hoarseness - from downward pressure on the vocal fold or premature closure of the laryngeal vestibule at the false-fold level during phonation
Stridor
Dysphagia
Sore throat
Snoring
Cough
Neck mass - external component presents as a lateral neck swelling at the thyrohyoid membrane level; classically increases in size with a "puffing" (Valsalva-like) maneuver

In Infants (congenital lateral saccular cysts)

Abnormal/weak cry
Inspiratory stridor
Cyanosis and dysphagia

Examination Signs

Submucosal bulge of the false vocal fold and aryepiglottic fold on laryngoscopy
Palpable neck mass at the thyrohyoid membrane (external component)
Bryce sign: a gurgling sound heard over a neck mass - classic for laryngocele

Diagnosis

Diagnosis rests on a combination of clinical history, laryngoscopy, and cross-sectional imaging.

Imaging

CT scan is the investigation of choice:

CT neck showing internal laryngocele (arrow) in the right paraglottic space with mass effect on right piriform sinus

Fig. Internal laryngocele on CT - Cummings Otolaryngology. The air-filled laryngocele (arrow) is in the right paraglottic space, causing mass effect on the right piriform sinus.

CT neck showing fluid-filled (intrinsic) laryngocele (asterisk) in the paraglottic fat

Fig. Fluid-filled laryngocele (asterisk) in the paraglottic fat on enhanced CT - Cummings Otolaryngology.

Air-filled laryngoceles appear as sharply defined, air-containing structures on CT
Fluid-filled mucoceles appear as soft tissue density masses; distinction from neoplasm is harder but smooth surface + healthy mucosa on laryngoscopy suggest the diagnosis
An enhancing wall on CT suggests infection (laryngopyocele)
A modified Valsalva maneuver during imaging can improve visualization
CT also demonstrates the external component not apparent on physical examination

MRI: can characterize the lesion; signal varies with degree of proteinaceous debris

Endoscopy

Direct laryngoscopy is mandatory to rule out an obstructing laryngeal carcinoma in the ventricle, especially before surgery
May appear as a soft, localized bulge of the aryepiglottic fold, potentially mimicking a submucosal neoplasm
Cummings Otolaryngology, p. 1127-1130; KJ Lee's Essential Otolaryngology, p. 924

Association with Laryngeal Carcinoma

This is a key clinical point: 5-29% of laryngoceles may harbor an associated ventricular/supraglottic carcinoma that caused saccular obstruction. Therefore, multiple biopsies of the ventricle during endoscopy are strongly recommended before definitive surgery for any laryngocele.

Treatment

Management is surgical for symptomatic lesions.

Infants

First secure the airway
Aspiration of cyst contents under direct laryngoscopy, OR
Endoscopic marsupialization (with or without stripping of cyst lining), optionally using the CO2 laser
Simple unroofing with cup forceps followed by 3-day intubation as a stent has also been described

Adults - Internal Laryngoceles

Endoscopic marsupialization or excision (microlaryngoscopy / CO2 laser) - preferred for internal lesions
Complete endoscopic excision (rather than simple marsupialization) is favored for definitive treatment and lower recurrence, including for large lesions

Adults - External or Combined Laryngoceles

External (transcervical) approach: the neck component is followed through the thyrohyoid membrane; the sac is transected at the saccular orifice; resection of part of the thyroid cartilage lamina may occasionally be needed for access
Complete endoscopic excision has also been described for combined lesions by following the cyst wall over the top of the thyroid cartilage into the neck

Key Operative Caveat

A large lateral cyst that bulges dramatically on awake endoscopy can virtually disappear under general anesthesia. The surgeon should begin by excising the false fold, during which the cyst wall is invariably encountered.

Cummings Otolaryngology, p. 1129-1130; KJ Lee's Essential Otolaryngology, p. 924

Summary Table

Feature	Detail
Origin	Saccule (appendix) of laryngeal ventricle
Content	Air (patent orifice) / Mucus (blocked = mucocele) / Pus (blocked = pyocele)
Types	Internal / External / Combined
Most common type	Combined
Bilateral occurrence	~25%
Key symptom	Hoarseness (most common); neck mass increases with Valsalva (external)
Bryce sign	Gurgling over neck mass
Imaging of choice	CT neck
Mandatory workup	Laryngoscopy + biopsy to exclude carcinoma
Carcinoma association	5-29%
Treatment	Surgical - endoscopic excision / external approach

Sources:

Cummings Otolaryngology Head and Neck Surgery, pp. 1127-1130
KJ Lee's Essential Otolaryngology, p. 924

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