Multidetector computed tomography in nonmalignant laryngeal disease:

Transcervical Excision of Mixed Laryngocele: A Case Report with Step-by-step Surgical Guide

Laryngocele is the benign cystic dilatation of the laryngeal saccule which is a blind pouch arising from the anterior roof of the laryngeal ventricle and ascends in the loose areolar tissue of the pre-epiglottic space posterior to the thyroid cartilage. It is a rare clinical entity. We, hereby report a case of mixed laryngocele who presented with complain of both swelling in the neck and change in voice who was treated with transcervical surgical excision. A step-by-step surgical guide to demonstrate intra-operative procedure such that it can be standardized and reproduced by any ENT surgeon was the underlying rationale for this case report.

Laryngocele: Report of two rare cases and review of the literature

Laryngocele is a rare clinical condition characterized by an abnormal dilation of the laryngeal saccule. The present study focused on two separate cases of diagnosed patients. The first patient suffered from internal laryngocele and complained of hoarseness for almost 1 year. Plasma was used to treat the internal laryngocele and the outcomes were satisfying. The patient did not undergo any tracheostomy due to previous endoscopic surgery. The second patient included in the present study was diagnosed with mixed laryngocele and complained of swelling on the left side of the upper aspect of the neck with considerable pain for >1 month. The patient was prepped for excision by an external transcervical technique under general anesthesia. None of the two patients had any recurrence or other changes during follow-up. The purpose of reporting these two cases of laryngocele was to increase awareness of this condition. Surgery is still the first-line treatment for diagnosed cases, but with the advent of new microscopic techniques, the use of plasma in an inter-pharynx setting has become more common. The results observed after using plasma to treat one internal laryngocele may be relevant to better understanding the application of this method and confirm that it may be a new suitable approach to treat this condition.

Mixed laryngocele mimicking thyroid nodule

Laryngocele is defined as a dilation of the laryngeal saccule forming an air sac. Some differential diagnoses for laryngocele have been reported. The aim of the present paper was to describe a case of a patient referred for the evaluation a suspected thyroid nodule that was subsequently diagnosed as a mixed laryngocele. A 31-year-old male with no clinical manifestations was referred by an endocrinologist to undergo Doppler ultrasonography and fine-needle aspiration biopsy due to a preliminary ultrasonographic diagnosis of a nodule apparently in the thyroid. The diagnosis of laryngocele was raised considering the cytopathological analysis and imaging exam. Computed tomography of the neck confirmed this hypothesis. The patient was counseled to consult a surgeon, but, up to the end of this report, continued asymptomatic and in follow-up. We report a mixed laryngocele with different clinical behavior, showing that laryngocele may appear to be another entity and drawing the attention of clinicians to imaging similarities.

The role of imaging in the evaluation of hoarseness: A review

Hoarseness is a common symptom indicating an abnormal change in the quality of voice and has a lifetime prevalence of around 30%. There are multiple causes of hoarseness, ranging from acute laryngitis, chronic laryngitis, laryngopharyngeal reflux, functional dysphonia due to vocal overuse or abuse, vocal cord paralysis (VCP), to various pathologies and masses in the larynx. A detailed history and thorough physical examination, and in many cases, laryngoscopy by a clinician are the initial steps in its management. Laryngoscopy should be considered if hoarseness persists for more than 2 weeks without a known benign cause. An Ear Nose and Throat surgeon performs direct visualization by laryngoscopy to rule out VCP or a lesion in the larynx, and it should be performed before ordering any imaging. CT with contrast is the imaging of choice to evaluate the laryngeal tumors and find the etiology of VCP. Typical findings of VCP are ipsilateral dilatation of the pyriform sinus and laryngeal ventricle, thickening and medialization of the ipsilateral aryepiglottic fold, medialization of the arytenoid cartilage and posterior aspect of the true vocal cord (TVC) atrophy of the TVC, and loss of the subglottic arch. The lesions causing the VCP may extend from the medulla, jugular foramen, carotid space, and upper mediastinum. CT neck must cover the aorticopulmonary window when evaluating the left VCP to cover the left recurrent laryngeal nerve's origin.

A radiologic review of hoarse voice from anatomic and neurologic perspectives

The differential diagnosis for hoarseness is extensive and includes a multitude of etiologies that span a large geographic area from the brainstem to the mediastinum. Therefore, localizing a causative lesion can be extremely difficult for clinicians and radiologists alike. In this review, we will first discuss the normal anatomy of the larynx and its innervation via the vagus and recurrent laryngeal nerves. We will then proceed with a guided tour of the various infectious/inflammatory, neoplastic, congenital, and traumatic/iatrogenic causes of hoarseness subdivided by anatomic location (brainstem, skull base, carotid sheath, thyroid, larynx, and superior mediastinum). Along the way, we will discuss the various cross-sectional imaging modalities best suited to detect the often subtle signs of recurrent laryngeal nerve injury. With thorough knowledge of these entities, radiologists can impact patient care by suggesting the appropriate imaging test and tailoring their search patterns to detect the subtle findings of laryngeal dysfunction.

Internal Laryngocele: Unusual onset in a 91-year-old female patient

While internal laryngoceles rarely cause major clinical complaints, they may lead to airway obstruction and require emergency intervention on rare occasions. We report a 91-year-old patient who was referred to the Ear, Nose & Throat Clinic of the Policlinico Santa Maria alle Scotte, Siena, Italy, in 2017 due to recurrent episodes of severe dyspnoea. A flexible nasopharyngolaryngoscopic examination revealed an internal laryngocele of approximately 1.5 cm in diameter that moved up and down the glottic plane, occasionally invading the subglottic space during inspiration and impeding airflow. This caused cyanosis and dyspnoea so severe that an emergency tracheotomy was considered. Luckily, after considerable effort, the patient was able to cough, causing the mass to move above the vocal plane and allowing normal breathing. The laryngocele was subsequently removed via laryngomicrosurgery. Although the incidence of internal laryngoceles is quite rare, physicians should consider this potentially life-threatening condition among patients with dyspnoea.

Imaging of laryngeal trauma

External laryngeal trauma is a rare but potentially life-threatening situation in the acutely injured patient. Trauma mechanism and magnitude, maximum focus of the applied force, and patient related factors, such as age and ossification of the laryngeal cartilages influence the spectrum of observed injuries. Their correct diagnosis and prompt management are paramount in order to avoid patient death or long-term impairment of breathing, swallowing and speaking. The current review provides a comprehensive approach to the radiologic interpretation of imaging studies performed in patients with suspected laryngeal injury. It describes the key anatomic structures that are relevant in laryngeal trauma and discusses the clinical role of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) in the acute emergency situation. The added value of two-dimensional multiplanar reconstructions (2D MPR), three-dimensional volume rendering (3D VR) and virtual endoscopy (VE) for the non-invasive evaluation of laryngeal injuries and for treatment planning is discussed. The clinical presentation, biomechanics of injury, diagnostic pitfalls and pearls, common and uncommon findings are reviewed with emphasis of fracture patterns, involvement of laryngeal joints, intra- and extralaryngeal soft tissue injuries, and complications seen in the acute emergency situation. The radiologic appearance of common and less common long-term sequelae, as well as treatment options are equally addressed.