Abstract
Objectives
Laryngoceles are pathologic air filled dilations of the laryngeal ventricle. They are most often benign and incidental findings. Resection may be necessary in the setting of infection, airway obstruction, dysphagia, and phonatory disturbances. External laryngoceles are almost universally treated with open resection via a lateral or midline cervical approach. Care must be taken to resect the laryngocele in its entirety to avoid recurrence. In cases of recurrent infection, normal surgical planes are often fibrosed and obscured increasing the risk of neurovascular sacrifice and functional losses.
Methods
We are reporting a case of recurrent infections in a large, palpable external laryngocele. During resection the patient was ventilated using an endotracheal tube (ETT). Additionally, a laryngeal mask airway (LMA) was inserted posterior to the ETT, resting in the hypopharynx and attached to a Jackson Rees circuit. Air was passed through the LMA to inflate the laryngocele and better define its borders. The LMA was also used to identify the root of the laryngocele in the paraglottic space and ensure its airtight closure.
Results
The LMA assisted our dissection and helped progress the surgery safely in a fibrosed surgical field. We have not seen this method described previously. The patient continues to be free of recurrence 2 years after surgery.
Conclusion
While in most cases, with careful surgical technique, even a fibrotic and scarred laryngocele can be excised in its entirety without neurovascular sacrifice. In some cases where this may be difficult with a traditional approach, we offer the intra-operative trumpet maneuver as a viable method of better delineating the borders of a laryngocele.
1
Introduction
Larrey first described air filled neck masses in 1829 and the term laryngocele was later coined by Virchow in 1867 . Although they are common incidental radiologic and postmortem findings, they are rarely symptomatic . Classically, laryngoceles are classified by location and whether they traverse the thyrohyoid membrane. Internal laryngoceles are confined to the paraglottic space whereas external or mixed laryngoceles have extension into the central or lateral neck. Resection may be necessary in the setting of infection, airway obstruction, dysphagia, and phonatory disturbances. There has been much debate about the ideal surgical treatment of laryngoceles. Recent literature suggests improved preservation of normal laryngeal structures and function with endoscopic management of internal laryngoceles . External laryngoceles, however, are almost universally treated with open resection via either a lateral or midline cervical approach. Care must be taken to resect the laryngocele in its entirety to avoid recurrence. In cases of recurrent infection, the normal surgical planes are often fibrosed and obscured, increasing the risk of recurrence, neurovascular sacrifice and functional losses. We are reporting a case of recurrent infections in a large, palpable external laryngocele. During resection the patient was ventilated using an endotracheal tube (ETT). Additionally, to help identify the margins of the laryngocele, a laryngeal mask airway (LMA) was inserted to inflate the laryngocele intraoperatively. To our knowledge this is the first reported case of an LMA being used to assist intraoperatively in defining the margins of a laryngocele.
2
Case presentation
A 44 year old female was referred to our service for evaluation of a recurring neck mass found to be an external laryngocele ( Image A ). She recalled several episodes of painful right neck swelling that were treated with multiple antibiotics and repeated aspirations. On fiberoptic exam, the larynx was grossly normal. She was scheduled for excision of the laryngocele via a lateral neck approach.
Prior to sedation, a fibrotic field was anticipated due to her prior infections. We discussed our concerns with the anesthesiology team and our desire to inflate the laryngocele intraoperatively if the operation became difficult. After routine induction of anesthesia our patient was easily intubated with an endotracheal tube. While being ventilated via the endotracheal tube (ETT), a size 4 Laryngeal Mask Airway Supreme (Teleflex Inc, Limerick, PA) was inserted into the pharynx ( Image B ) The ETT and LMA were positioned in a fashion similar to the Bailey maneuver used by anesthesiologists to facilitate deep extubation without bucking . A Jackson Rees circuit was then attached to the LMA. While the patient was ventilated utilizing the traditional ventilator circuit, the Jackson Rees circuit was attached to, and inflated with, the auxiliary oxygen port.
During the case, specifically as we approached the hypoglossal nerve and the superior laryngeal neurovascular bundle, gentle pressure was used to pass oxygen from the Jackson Rees circuit into the supraglottis and laryngocele via the laryngeal ventricle. The laryngocele easily inflated allowing for an easier identification of its true margins ( Image C ). Dissection was carried along the perichondrium of the thyroid cartilage. The root of the laryngocele was clearly identified prior to ligation. The LMA was again used to identify the root of the laryngocele in the paraglottic space and ensure its airtight closure. All neurovascular structures were identified and intact at the end of the procedure.
