Single Stage Conservative Surgery to Avoid Recurrence in Combined Laryngocele: Important Modifications

Abstract

Laryngocele is very uncommon and no consensus regarding its surgical management is yet established. While traditional external approach is still being recommended some suggest a better microlaryngoscopic management assisted by CO₂ laser that has gained popularity. Recurrence is better known with conservative surgery but this paper presents a modified single stage endolaryngeal technique for combined laryngoceles to overcome the same. The salient features are (1) A comparatively larger operculum is created and all the visible mucosa is excised; (2) the base of residual postoperative cavity is moistened with cotton soaked with concentrated carbolic acid for 1 min and (3) the residual ‘charred’ base with intermittent oozing is packed with single layer of surgicel. The reader is further encouraged to see surgical video of entire procedure.

Electronic supplementary material

The online version of this article (10.1007/s12070-020-01955-1) contains supplementary material, which is available to authorized users.

Introduction

Laryngocele is uncommonly encountered in otolaryngology practice with an incidence of 1 per 2.5 million population per year [1]. It is five times more common in males. The term laryngocele is now preferred for symptomatic lesion that is visible either during laryngoscopic examination, or externally above the thyroid cartilage [2]. More over former classification (internal, external, and combined types) is debatable as external laryngoceles cannot exist without internal component. Whereas the internal laryngocele is confined within the false vocal fold, medial to the thyrohyoid membrane, a combined laryngocele extends into the neck through the thyrohyoid membrane [3]. Apart from congenital etiology, increased intra-laryngeal pressure (e.g. in glass blowers/wind instrument players leading to gradual dilation of saccule) [4], and mechanical obstruction [5, 6] has also been implicated. The obstruction at the neck of laryngocele (tumours/chronic inflammation of larynx), may cause mucus (produced by the mucosal glands of epithelium) retention resulting into a laryngomucocele that when infected, is called laryngopyocele [7]. With a global literature of only 63 cases in last 2 decades [8] there is currently no consensus regarding its surgical management. While the traditional external approach is still being recommended by some [3, 9]; the microlaryngoscopic management assisted by CO₂ lasers has gained popularity [10–12]. The external surgeries include transthyrohyoid membrane approach, thyrotomy with resection of upper 1/3 of thyroid cartilage, and V-shaped thyrotomy. The endolaryngeal (conservative) surgeries include marsupialisation/microlaryngoscopy using cold instruments/CO₂ laser, and robotic surgery. Overall the consensus till now suggests that external component is better excised through an external cervical approach, while a pure internal laryngocele is better marsupialised laryngoscopically. The risk of recurrent laryngeal nerve (RLN) injury exists with external approach whereas recurrence per se is more common with laryngoscopic approach. The later is mainly due to re-stenosis of surgically created opening while residual mucosa inside regenerates to form a similar (may be a lesser sized) sac. Although many authors recommend microlaryngoscopy technique for combined laryngoceles [12] having smaller external component, others recommend repeated such attempts for even a large external laryngocele [13]. The latter philosophy aims to reduce morbidity with ‘safe’ conservative procedure. The re-recurrence even with repeated attempts is possibly due to a gross presence of mucosa corresponding to the external component of the laryngocele. Hence unless the entire mucosa is destroyed and the walls of the residual cavity get fibrosed/obliterated, such recurrences are possible. This paper highlights a modified technique to manage large external laryngocele with a single stage endolaryngeal resection as well as to further promote its fibrotic obliteration.

Observations and Results

Case 1

A 39 year male (archival records) with a combined laryngocele since 2 years underwent classical open transcervical excision. There was no underlying pathology or any malignancy. The post operative phase was uneventful except for a change in quality of voice with an unsightly skin scar. Follow up was not available.

Case 2

A 42 year male with combined laryngocele since 8 months revealed a classical inflatable lateral cervical swelling on valsalva manoeuvre (Fig. 1) corresponding to a classical ballooning of false vocal fold (laryngoscopy) and air filled pathology (CT scan: Fig. 2). A microlaryngoscopic marsupilization was undertaken where the most prominent part of the ballooned vestibular fold was excised exposing inside cavity. Subsequently as much mucosa of the cavity as possible was removed by simultaneous medial traction assisted by blunt microdissection and external pressure. Accordingly a major part of mucosa corresponding to external component was pulled inside. The post operative phase was uneventful and the patient became asymptomatic. A small recurrence was seen 8 months post surgery probably following re-stenosis of small opercula created during first surgery. Hence the second microlaryngosopic surgery was undertaken in the similar way except for (1) a wider resection of the vestibular fold extending down up to the ventricle and much more in posterosuperior direction, and (2) the base of residual postoperative cavity was moistened with cotton soaked with concentrated carbolic acid for 1 min to control local ooze. A relatively more fibrotic sac was appreciated this time and chemical cautery was hence thought to further stiffen the sac (and prevent recurrence). The postoperative phase was uneventful and the swelling disappeared completely. The patient remained recurrence free for next 3 years.

Fig. 1.

plain X-ray neck showing air filled cavity on valsalva manoeuvre

Fig. 2.

CT scan neck (axial cut) showing external component of combined laryngocele protruding out through thyrohyoid membrane

Case 3

A 43 year male with a large combined laryngocele (Fig. 3) was admitted with altered voice quality but without any other underlying pathology. With the past experience a microlaryngoscopic procedure was undertaken with following modifications: (1) A comparatively larger operculum was created (as in case 2) and all the visible mucosa was excised (Fig. 4); (2) the base of residual postoperative cavity was moistened with cotton soaked with concentrated carbolic acid for 1 min and (3) the residual ‘charred’ base with intermittent oozing was packed with single layer of surgicel. The reader is encouraged to see the entire surgical video demonstrating the above procedure. The postoperative mild pain persisted for a couple of weeks and voice improved drastically with complete disappearance of swelling. Histopathology did not reveal any associated malignancy. The patient was further followed up for next 2.5 years with no recurrence.

Fig. 3.

Laryngoscopic view of laryngocele showing ballooned vestibular folds overhanging the glottis chink. Swelling is slightly retracted laterally to reveal the position of vocal cords

Fig. 4.

Laryngoscopic picture of the postoperative cavity packed with cotton for hemostasis. Note the wide opening created supero-medially and the position of the intact vocal cord. The cavity is packed with surgicel subsequently and pressure sustained for 5 min with cotton plug to achieve final hemostasis

Discussion

A comparison of 3 surgical approaches is summarized in Table 1. An ideal option would be a single stage conservative surgery providing (1) complete resolution, (2) no morbidity, and (3) no recurrence. This technique stands out as the best option but still needs validation particularly with long term follow-up. A smaller (opercular) opening incompletely visualizes the mucosa at the base of sac and also runs a risk of re-stenosis (case 2). Hence creating a larger superior-medial opening seems mandatory. The external pressure may not help much in mobilizing the mucosa of the external component but traction from inside with blunt microdissection may better promote its in-drawing within larynx. It is possible to leave some mucosal islands even after meticulous exteriorization. Accordingly a chemical cauterization of created cavity is more likely to ‘destroy’ such residual mucosa. Furthermore such chemical is also likely to trickle further laterally into the external component, thereby also cauterizing the ‘out of reach’ mucosa. Such cauterization ultimately results in fibrosis, adhesions and ultimately obliterating the sac permanently. Some remnant functional mucosa without any communication with airway remains unnoticed as the inflatable nature disappears and with time may either involute or alternatively (theoretically) form a mucocele.

Table 1.

Comparison of three different surgical approaches for laryngoceles

External/open cervical approach	Conservative (endolaryngeal) approach	Modified conservative/endolaryngeal approach
More suited for combined laryngocele with large external component	Suited for internal laryngocele but may be used for combined laryngocele with small external component	Suited for both internal laryngoceles and large combined variety with substantial external component
Complete resection of mucosa	Incomplete resection in large combined laryngocele	Complete/near total resection in large combined laryngocele
Potential risk of laryngeal nerve injury	Nil	Nil
Comparatively intraoperative haemorrhage is more	Minimal haemorrhage specially with laser	Mild to moderate bleeding well controlled with chemical cautery and surgicel
Prolonged hospital stay	Minimal	Minimal
Moderate postoperative pain	Mild	Mild to moderate
Increased cost of surgery	Minimal	Minimal
External scar on neck	Nil	Nil
Recurrence is rare	Common	rare
Revision surgery difficult	Easy	Easy
No requirement of specialized infrastructure	Full infrastructure for microlaryngoscopy required. In addition Laser adds further to expensive infrastructure	Full infrastructure for microlaryngoscopy required
Normal tissue healing contributes to fibrotic obliteration		Enhanced fibrogenesis secondary to chemical inflammation leads to deep fibrotic obliteration

The use of chemical cautery may provide hemostasis for small vessels but haemorrhage from a relatively larger vessel during mucosal avulsion or chemical erosion is better controlled with pressure and the use of surgicel. Surgicel is a sterile cellulose based thrombogenic material used to control bleeding originating from delicate and/or friable tissues [14]. It is generally inert and bioabsorbable [14]. The hemostatic action of surgicel is by formation of a gelatinous mass upon saturation with blood, which leads to formation of a stable clot [14, 15]. Hence resolution of this thickened clot is more likely to cause deep fibrosis in postsurgical cavity ‘impregnated’ with surgicel. The role of chemical cauterization and surgicel induced hemostasis may have a synergistic role on the fibrogenesis promoting obliteration of cavity. The presence of the postoperative pain is expected with deep fibrosis (case 3) involving sensory nerves of supraglottis. Using cold instruments with microlaryngoscopy seems better since laser does not promote much fibrosis. The later is desirable for complete obliteration and reduction in expansibility. Fibrosis is desirable for reduction in expansibility and fibrogenesis is better as surgicel promotes thick clot, as compared to laserisation resulting in avascular raw surface. Robotic surgery on the other hand is largely unavailable, yet seems promising, but the potential advantages have yet to be proven.

Conclusion

This novel single stage conservative technique seems ideal in terms of compliance, QOL and recurrence, and is likely to replace the other surgical options for large laryngoceles.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Compliance with Ethical Standards

Conflict of interest

No conflict of interest declared.

Ethical Approval

All procedures performed in this study were in accordance with the ethical standards of the institutional ethics committee of King George Medical University (KGMU), Lucknow (India), as well as with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.