Ventricular laryngocele. Air-filled dilation of the saccule or appendix of the laryngeal ventricle. The ventricular appendix was described by Morgagni in 1761 . The first laryngocele was discovered by Abulcasim in the 11th century , and the lesion received its current name from Virchow, in 1867 .
Summary
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- 1 Etiology
- 2 Clinical manifestations
- 1 Internal
- 2 External
- 3 Mixed
- 3 Diagnosis
- 4 Treatment
- 5 Sources
Etiology
The ventricles of the larynx develop from an evagination in the primordial outline of the endolaryngeal structures that appear during the second month of fetal life.
The primitive ventricles extend quite laterally below the floor of the pharynx , and the distal extension, the appendix, may originally be related to the fourth branchial cleft. At birth the appendix is relatively large, but by six years of age it begins to decrease in size relative to the rest of the larynx and ventricle. Individuals of the Caucasian race tend to have large appendages. In the adult, the opening in the appendix is located at the level of the anterior extremity of the roof of the ventricle, and is a hole approximately 8 mm long. The ventricle is lined with ciliated respiratory epithelium, and many seromucinous glands are poured into its cavity.
Although it is recognized that laryngoceles occur in individuals with congenitally large ventricular appendages, the deformity is rare in children . Activity is the most common predisposing factor, leading to a persistent increase in intralaryngeal pressure, such as coughing , straining, use of wind instruments, and excessive use of the voice . Laryngeal air pressure is increased by air retention below the concave interior surface of the false vocal cords , retention that will increase air pressure in the laryngeal ventricle.
Since the ventricle is located outside the chest , the increase in pressure is not compensated by the simultaneous rise in intrathoracic pressure and dilation occurs. Less often, any injury that causes a valve-shaped obstruction in the opening of the ventricle or appendix can cause air retention and dilation of the appendix.
Clinical manifestations
Three types of laryngoceles are distinguished: internal, external and mixed.
Internal
The internal form consists of an air sac, limited to the area of the false chord and the ariepiglottic fold and inside the thyrohyoid membrane.
External
The external form presents as a cystic mass on the lateral surface of the thyrohyoid membrane, attached to the ventricle by a narrow patent duct. This duct passes through the thyrohyoid membrane, in the region of the neurovascular loop, although in general, it is located below the loop.
Mixed
The mixed type consists of air cavities attached to each other and located on both sides of the thyrohyoid membrane. Laryngosceles are rather rare abnormalities that occur almost exclusively in men in their fifties. They can be bilateral.
The symptoms tend to fluctuate; they increase with exertion and disappear during rest. The internal and mixed forms produce hoarseness , stridor, and dyspnea , which worsen with continued use of the voice. The external type may appear as a simple, compressible spherical mass, located in the thyrohyoid membrane and moving with the larynx during swallowing movements.
The “Bryce sign”, characterized by gurgling and whistling in the throat , can occur when the neck mass is compressed , a mass whose size is highly variable and, sometimes, may even be absent. The patient may have a persistent productive cough , especially if there is an infection .
Occasionally, the opening of the laryngocele can become blocked and fill with mucus, turning into a secondary mucocele, which can become infected and produce a laryngopiocele. Ultimately, fever , pain , sensitivity and odynophagia appear.
Diagnosis
The masses of the false cord and the lateral aspect of the neck are revealed by clinical examination, when the patient makes efforts. A soft tissue radiograph of the neck obtained during the Valsalva maneuver will reveal the presence of cystic structures with an aerial content. If infection exists, an aerial level is observed on the radiograph. To rule out a possible neoplasm , direct laryngoscopy and ventricular inspection are indicated.
The laryngoceles are generally covered with ciliated pseudostratified cylindrical epithelium, although there may be areas of stratified squamous epithelium. The walls cannot contain collections of lymphoid tissue, which are typical of the common branchiogenic cyst .
Treatment
Not all laryngoceles require treatment. Asymptomatic small laryngosceles do not require any therapy , and will rarely cause difficulties if causal factors are removed. Excision of symptomatic laryngoceles and laryngopioceles is desirable. External and mixed laryngoscels are better excised by lateral access, through the neck.
The external laryngocele must be excised through a lateral pharyngotomy, but this access carries the danger of permanent alteration of the voice and of stenosis . Uniformly satisfactory results have not been achieved with the use of sclerosing agents and recurrence is frequent.
The acute inflammatory phase of the laryngocele may require immediate incision and drainage and, later, excision during a latency period.
