laryngeal saccular cystdownloads.hindawi.com/journals/dte/2000/952763.pdffigure theendoscopic view...

Diagnostic and Therapeutic Endoscopy, Vol. 6, pp. 91-94Reprints available directly from the publisherPhotocopying permitted by license only

(C) 2000 OPA (Overseas Publishers Association) N.V.Published by license under

the Harwood Academic Publishers imprint,part of The Gordon and Breach Publishing Group.

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Laryngeal Saccular CystCRAIG BENOIT* and TERRY DAY

Department of Otolaryngology, Vanderbilt University Medical Center,S-2100 Medical Center North, Nashville, TN 37232, USA

(Received 12 May 1999; Revised 10 August 1999; In finalform 7 September 1999)

We present a case report of a 66-year-old female with a laryngeal saccular cyst that wastreated endoscopically. Although this is an uncommon laryngeal anomaly, when it is recog-nized and managed appropriately early in the course ofits presentation patient complicationsand morbidity can be avoided. The laryngeal saccular cyst can mimic or be associated withother, more serious, laryngeal pathology, including carcinoma of the larynx. Because of theknown association between carcinoma of the larynx and laryngeal saccular cysts, theselesions should be fully evaluated endoscopically and surgically excised. Direct microlaryngos-copy with the use ofthe operating microscope is a safe and effective method for the treatmentof laryngeal saccular cysts.

Keywords: Cyst, Laryngocele, Larynx, Microlaryngoscopy, Saccule

INTRODUCTION

The laryngeal saccular cyst is an unusual laryngealanomaly that can mimic or be associated with morelife threatening conditions. However, when it isrecognized and treated early in the course of thepatient’s disease, serious complications and mor-bidity can be avoided. We present a patient with aninternal laryngeal saccular cyst, including intra-operative and histopathological photographs. Itwas managed safely and effectively with endoscopicexcision without tracheotomy.

CASE REPORT

A 66-year-old female presented to our clinic witha 6-month history of hoarseness and intermittentshortness of breath. She denied any symptoms ofodynophagia, dysphagia, or weight loss. Her pastmedical history was significant for a 36-pack-yearsmoking history. She had no prior history of laryn-geal trauma or malignancy.On examination, she had a breathy dysphonia.

There were no neck masses or palpable adenopathy.Fiberoptic laryngoscopy in the clinic revealed a

* Corresponding author. Tel.: + (615)222-6099. Fax: + (615)222-2384. E-mail: [email protected].

91

92 C. BENOIT AND T. DAY

pedunculated, smooth, round mass arising from theanterior aspect of the left laryngeal ventricle thatprolapsed into the airway with inspiration. The truevocal folds were mobile bilaterally. Due to the sizeand location of the cyst, the middle one third of theleft true vocal fold and the anterior commissure werenot completely visualized with the flexible fiberopticexamination.A direct microlaryngoscopywas performed under

general anesthesia with the patient endotracheallyincubated. The larynx was exposed via suspensionlaryngoscopy, and the operating microscope, with a400-mm lens, was used to view the larynx. The masswas found to be cystic in nature and arose from a4mm stalk attached to the roof of the mid-anteriorlaryngeal ventride on the left (Fig. 1). There wereno other mucosal abnormalities. The lesion wasretracted medially with microlaryngeal articulatingcup forceps. A mucosal incision was performedapproximately 5-mm lateral to the stalk of the cyst.The base of the stalk was bluntly dissected to itsorigin in the roof of the laryngeal ventricle. Thelesion was then sharply excised along with a 2-mm

cuff of ventricular mucosa around the saccularopening. Gross inspection of the lesion revealed asoft mucosal lined sac that was approximately5 x 5 mm containing inspissated mucous. Frozenhistologic sectioning was performed to detect thepresence of any malignant cells. The histology sup-ported the diagnosis of a cyst lined with pseudo-stratified columnar respiratory epithelium withabundant goblet cells (Fig. 2). There was no evi-dence of carcinoma in the specimen.

DISCUSSION

The laryngeal saccule is an opening in the anteriormiddle third ofthe roof ofthe laryngeal ventricle. Itis lined by ciliated respiratory epithelium with any-where from 50 to 100 mucous glands. The functionofthe saccule is the lubrication ofthe vibrating vocalfolds [1]. Blockage of the saccule opening with con-tinued secretion of mucous leads to a saccular cyst.The saccular opening can also become dilated, lead-ing to retrograde filling of the false vocal cord with

FIGURE The endoscopic view of a laryngeal saccular cyst arising from the left laryngeal ventricle.

LARYNGEAL SACCULAR CYST 93

FIGURE 2 The pseudostratified columnar respiratory epithelial lining of a laryngeal saccular cyst (original x200).

air, termed a laryngocele. The masses created bythese pathologic entities can remain confined to thelarynx or spread through the thyrohyoid membraneinto the neck.The classification and nomenclature of saccular

cysts and laryngoceles have been well defined in theliterature. Saccular cysts are mucous filled dilationsof the false vocal folds that are confined to thelarynx. Lateral saccular cysts extend posteriorly andsuperiorly to the aryepiglottic fold. Anterior sac-cular cysts extend medially into the laryngeal lumenbetween the true and false vocal fold [2].

Laryngoceles are air-filled sacs that communi-cate with the larynx via a dilated saccule. They aredivided into three types based upon the extent ofextension from the laryngeal saccule. The internallaryngocele is confined to the larynx, typicallyentirely within the false vocal fold. The externallaryngocele is a dilation of the sac that extendsthrough the thyrohyoid membrane at the site of thesuperior laryngeal neuromuscular bundle and intothe neck. The air-filled mass communicates withthe larynx via the dilated saccule, however, thetract through the false vocal fold is not dilated.

The combined laryngocele has both an externaland an internal component. In addition to con-taining air, laryngoceles can also contain mucousthat may become secondarily infected creating alaryngopyocele.The laryngeal saccular cyst probably represents

25% of all laryngeal cysts, with submucosal cystsof the true vocal folds being the most common [3].They are easily managed endoscopically when prop-erly diagnosed early in the course of the disease [4].Several authors have advocated the use of theCO2 laser [5]. Saccular cysts may be congenital oracquired in the adult by trauma, neoplasm, orinflammation. The incidence of carcinoma asso-ciated with saccular cysts and laryngoceles is welldocumented and ranges from 5% to 30%. Thepathophysiologic process is thought to be theobstruction of the saccule by carcinoma, leadingto dilation by air or inspisated secretions [6,7].

In conclusion, we present this case to illustrateseveral important aspects of laryngeal saccularcysts. (1) Laryngeal saccular cysts can mimic othertypes of more common laryngeal anomalies, andshould be included in the differential of any

94 C. BENOIT AND T. DAY

laryngeal mass. (2) Because of the evidence docu-mented in prior studies that supports the associationbetween carcinoma and laryngeal saccular cyst, theintent to rule out carcinoma should always be con-sidered when evaluating and treating these lesions.(3) Finally, when recognized early in the presenta-tion, laryngeal saccular cysts can effectively andsafely be treated endoscopically.

References

[1] Holinger, L.D. et al. Laryngoceles and saccular cysts. Ann.Otol. Rhino. Laryngol. 1978; 87: 675-685.

[2] Desanto, L.W. Laryngoceles, laryngeal mucoceles, largesaccules, and laryngeal saccular cysts: a developmentalspectrum. Laryngoscope 1974; 84:1291 1296.

[3] Newman, B.H., Taxy, J.B. and Laker, H.I. Laryngeal cystsin adults: a clinicopathologic study of 20 cases. Amer. J.Clin. Pathol. 1984; 81(6): 715-720.

[4] Szwarc, B.J. and Kashima, H.K. Endoscopic managementof a combined laryngocele. Ann. Otol. Rhinol. Laryngol.1997; 1tt6: 556-559.

[5] Myssiorek, D. and Persky, M. Laser endoscopic treatmentof laryngoceles and laryngeal cysts. Otolaryngol. Head NeckSurg. 1989; 11111(6): 538-541.

[6] Harrison, D.N. Saccular mucocele and laryngeal cancer.Arch. Otolaryngol. Head Neck Surg. 1997; 1113: 232-234.

[7] Micheau, C., Luboinski, B. and Cachin, Y. Relationshipbetween laryngoceles and laryngeal carcinomas. Laryngo-scope 1978; 88: 680-688.

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