Management of laryngoceles by transoral robotic surgery

Bilateral Combined Laryngocele: Comprehensive Review of the Literature

Laryngocele, an abnormal dilation of the appendix of the laryngeal ventricle filled with air, is a rare condition predominantly presenting unilaterally. However, bilateral occurrences are exceedingly rare. In this article, we present a case of bilateral laryngocele along with a comprehensive literature review. A 57-year-old male presented with dyspnea, stridor, and bilateral neck masses. His medical history included chronic cough and intermittent hoarseness. Over a 3 month period, the neck masses progressively enlarged, resulting in respiratory distress. Interestingly, he denied experiencing weight loss, decreased appetite, or fever. Clinical examination revealed sizable, soft masses on both sides of the neck, obstructing lymph node assessment. Computed tomography (CT) imaging confirmed the presence of a left combined laryngopyocele and a right combined laryngocele. Subsequently, the patient underwent tracheostomy. Benign biopsy results excluded malignancy. Surgical excision of bilateral laryngoceles resulted in an uneventful recovery. The term "laryngocele" was introduced by Virchow in 1867 to describe the abnormal dilation of the saccule associated with Morgagni's ventricle. Diagnosis involves a thorough patient history, physical examination, and radiological imaging, notably CT, to differentiate laryngoceles from other conditions. Typically asymptomatic, they are often incidentally discovered around age 50, although symptoms such as voice changes or breathing difficulties can manifest. A review of the literature identified 77 documented cases, primarily in males, exhibiting various symptoms and treatment modalities. This case underscores the rarity of bilateral combined laryngocele, emphasizing the importance of timely diagnosis and surgical intervention for favorable outcomes. Comprehensive research reveals diverse clinical aspects, highlighting the necessity for continued investigation to enhance management strategies.

Endoscopic CO2 Laser Resection Using the Inversion Technique in 22 Combined Laryngoceles

OBJECTIVE

To demonstrate the feasibility of transoral resection of, even large, combined laryngoceles by endoscopic CO2 laser resection using the inversion technique.

METHODS

A retrospective study over a 25-year period of 20 patients with 22 combined laryngoceles. All patients were operated on using the CO2 laser inversion technique. Pre- and postoperative computed tomography (CT)-scans or magnetic resonance (MR) imaging were available in all patients.

RESULTS

There were no surgical problems during all procedures. One patient required a tracheotomy pre-operatively due to a compromised airway. All procedures were without intraoperative complications. Postoperatively, there were two complications: one hemorrhage, and one patient developed a granuloma with airway compromise. In two patients, residual disease was detected on postoperative imaging. One of them was re-operated several years later due to the progression of this residual external component of the laryngocele. One patient had a non-significant small internal laryngocele recurrence. The recurrence rate in this series was 2/22 (9.1%). The majority of patients (15/20) could be discharged from the hospital the day after surgery.

CONCLUSION

The results of this study show excellent control of combined laryngoceles using the CO2 laser inversion technique, with a short hospital stay and a low rate of complications and recurrence. Even in large combined laryngoceles, CO2 laser excision using the inversion technique should be considered.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2742-2746, 2023.

CO2 Laser Marsupialization for Internal and Combined Laryngocele

Introduction  Laryngocele is an air-filled dilatation of the laryngeal saccule that can be classified according to its extent (internal, external, or combined) and contents (laryngocele or laryngopyocele). To date, there is no consensus on the best treatment for laryngocele. Objective  The present study aims to demonstrate for the first time the effectiveness of CO2 laser marsupialization for internal and combined laryngoceles. Methods  A retrospective study was accomplished in our ENT Clinic of the University Hospital, from 2010 to today, recruiting patients according to strict criteria. All patients had internal or combined laryngocele/laryngopyocele treated with CO2 laser marsupialization. Results  A total of 15 patients were enrolled for a total of 17 laryngoceles; 66.67% of the patients were males and the mean age was 54.4 (±14.12) years old. Internal laryngoceles accounted for 64.71% of the total, and only 7 cases were laryngopyoceles. At the 3-year follow-up, no signs of recurrence were found. Conclusion  CO2 laser marsupialization is efficacious in the treatment of laryngocele or laryngopyocele, both internal and combined, in terms of efficiency, safety, and fast postoperative recovery, without need for tracheotomy or open surgery.

Minimally invasive treatment of laryngoceles: a systematic review and pooled analysis

Laryngoceles are best treated with surgery. The goal of this study is to compare patient outcomes and complications in patients undergoing removal of laryngoceles with either transoral endoscopic/microlaryngoscopic or robotic approaches. A systematic review of the published literature was conducted using Pubmed, Web of Science, and the Cochrane Clinical Trials databases. A pooled analysis of individual data was used to compare outcomes between robotic and endoscopic approaches. A total of 30 studies were included. Nine studies with 95 patients were included in the final analysis. Eighty-one (85.26%) were treated with microlaryngoscopic surgery and 14 (14.74%) were treated with robotic-assisted surgery. The rates of tracheostomy (RR = 1.44, 95% CI = 0.389-5.332), complications (RR = 0.329, 95% CI = 0.047-2.294) and recurrence (RR = 0.354, 95% CI = 0.021-5.897) were not statistically different between groups. Within the endoscopic subgroup, 66 laryngoceles (78.57%) were completely excised, while 18 (21.43%) laryngoceles were treated with marsupialization. Marsupialization was associated with an increased risk of recurrence (RR = 4.889, 95% CI = 1.202-19.891). In the robotic subgroup, there was an increased risk of nasogastric tube use (RR = 103.867, 95% CI = 6.379-1619.214) and a longer mean length of hospital stay (p = 0.0001). Transoral treatment of laryngoceles has complication and recurrence rates of 18.95% and 7.37%, respectively. Robotic approaches are associated with higher rates of NGT use and increased hospital stay, however much of this is due to one robotic surgeon's preference for routine NGT placement and higher rates of combined laryngocele removal via robotic approach. Complete excision of combined laryngoceles is possible with transoral approaches. Marsupialization, reported in traditional endoscopic approaches, is associated with a significantly higher rate of recurrence (22.22% vs. 4.76%).

Systematic review of laryngocele and pyolaryngocele management in the age of robotic surgery

OBJECTIVE

A laryngocele is a space that develops as a result of pathological dilatation of the laryngeal saccule. However, the reported management of laryngoceles varies. We conducted a systematic review of the literature regarding the surgical management of laryngoceles and pyolaryngoceles, to understand the evolving nature of treatment for this rare condition.

METHODS

We searched for publications in the PubMed, Cochrane Library, JBI Library of Systematic Reviews, and Ovid databases using the terms "laryngocele", "pyolaryngocele", and "laryngopyocele", and reviewed the identified articles.

RESULTS

After removal of repeated studies and filtering for relevance and studies written in English, a total of 227 studies were included in this review. No meta-analyses or randomized controlled trials have been published. The identified studies have been summarized in 14 reviews conducted since 1946. The meta-analysis determined that endoscopy was the preferred approach for internal laryngoceles, while combined laryngoceles benefited from both internal and external surgical approaches.

CONCLUSIONS

Laryngocele management has progressed since its initial description, from open surgery to an endoscopic approach, and more recently to a robotic-assisted surgical approach. The uptake of robotic surgery as a possible treatment modality over the last decade shows much promise for the treatment of these conditions.

Alternative Applications of Trans-Oral Robotic Surgery (TORS): A Systematic Review

Background: The role of robotic surgery in the field of oncology has been widely described, in particular for the tumours of the oropharynx and larynx, but its efficacy for benign pathology is inconsistent. Methods: An exhaustive review of the English literature on trans-oral robotic surgery (TORS) for benign conditions was performed using PubMed electronic database. Results: The research was performed in March 2019 and yielded more than eight hundred articles, with 103 meeting the inclusion criteria and considered in the present study. Conclusions: The application of TORS for the treatment of obstructive sleep apnoea syndrome seems to be particularly well documented. Additionally, there exists a special interest in its use where high precision in limited anatomic space is required. There are still different structural and economic limitations for the application of TORS, however, the progressive technologic innovations and the increasing adoption of robotic surgery seem to encourage the uptake of this technique.

Transoral robotic excision of laryngocele: Surgical considerations

BACKGROUND

Transoral robotic surgery (TORS) has emerged as a novel, safe, and feasible procedure for the resection of malignant supraglottic laryngeal cancers. The purpose of this study was to demonstrate the surgical technique with extension of the use of TORS to excise a laryngeal cyst.

RESULTS

Laryngeal cyst resection, along with its tract, was accomplished with preservation of both false and true vocal cords. There was no perioperative or early postoperative complications. The patient was extubated immediately after surgery. Oral diet was initiated within 24 hours. No tracheostomy was required. A video demonstration of the surgical technique is included on Head & Neck's website.

CONCLUSION

TORS is a safe and feasible procedure for excision of selected laryngeal cysts.

Transoral robotic resection of benign tumors of the upper aerodigestive tract: Experience of the French group of GETTEC

BACKGROUND

The purpose of this study was to assess the current use of transoral robotic surgery (TORS) in benign tumors of the upper aerodigestive tract through a case series and a literature review.

METHODS

This multicentric retrospective study was conducted in 6 French centers between November 2009 and July 2017.

RESULTS

Twenty-one patients had a TORS resection of a tumor at varied locations with differing histopathologic characteristics. The mean postoperative hospital stay was 6.1 days. Eight patients had nasogastric tubes, which were removed after a mean of 5.6 days. Two patients had a prophylactic tracheostomy for an average of 5.5 days. A third tracheostomy was performed secondarily for postoperative bleeding. No recurrences were observed during the 2-year follow-up.

CONCLUSION

This technique caused few complications and resulted in short hospitalization, with satisfactory functional and recurrence outcomes. However, the risk of bleeding and edema must be considered, and the need for a tracheostomy must be approached wisely.