A laryngocele is usually a cystic dilatation of the laryngeal saccule. The etiology behind its occurrence is still unclear, but congenital and acquired factors have been implicated in its development [1, 2].
Laryngoceles appear to be an atavistic remnant from the higher apes, particularly those who use their arms with the thoracic cage fixed whilst swinging through the trees. In an excellent review of 139 laryngoceles, Stell and Maran showed that the sex incidence is 5:I in favor of men, and the maximum age incidence is in the sixth decade. The authors suggested that two out of three laryngoceles are unilateral and they may be combined, external or internal, with roughly equal frequency; about 8 per cent become infected and present as pyocele. Furthermore they reported as case where the laryngocele could have been caused by prolonged and repeated valsalva. They suggested that the increased air pressure in the larynx may make an already existing laryngocele manifest [1]. In another review of the aetiology of this entity it was suggested that local laryngeal pathologies are perhaps the main determinant factors in the pathogenesis of the disease [2].
Congenitally, the laryngeal saccule is a remnant corresponding to the lateral laryngeal air sacs of the higher anthropoid apes, which may on occasion, manifest suddenly in response to pressure caused by coughing, straining at stool, or trumpet playing (i.e. valsalva maneuvers). An acquired laryngocele may develop when the laryngeal ventricle becomes functionally obstructed as a result of an increase in intraglottic pressure, e.g. excessive coughing, playing a wind instrument or obstruction of appendicular ostium [1, 2].
Three types of laryngoceles are described. An internal laryngocele is confined to the interior of the larynx and extends posterosuperiorly into the false vocal cord and the aryepiglottic fold; this type appears on laryngoscopy as a smooth swelling of the supraglottis. An external laryngocele extends superiorly to appear laterally in the neck through the opening in the thyrohyoid membrane for the superior laryngeal nerve and vessels; these clinically present as a swelling in the neck at the level of the hyoid bone anterior to the sternocleidomastoid muscle. The simultaneous existence of both features is termed a combined laryngocele [1–4].
The simple laryngocele is an uncomplicated air-filled dilatation of the appendix of the laryngeal ventricle. When the neck of the laryngocele is obstructed, it becomes filled with mucus, and air-fluid level or fluid filled laryngocele forms. This lesion is named as laryngopyocele if it is infected. Approximately 10% of laryngoceles become infected. A laryngopyocele usually presents as an airway obstruction and/or an infected neck mass. The symptoms of laryngopyocele include hoarseness, dysphagia, dyspnea, a 'full' sensation in the throat. Glottic obstruction varies from minimal to complete. Fever may not exist in all patients [2–5].
Erdogmus et al. reported a laryngocele in a patient with ankylosing spondylitis. It was believed that its development might be a result of increased intra-abdominal pressure, caused by rheumatoid arthritis, with associated increased intralaryngeal pressure [1].
The relationship between laryngoceles and laryngeal carcinoma is still debated. Akbas et al. presented a case of bilateral asymptomatic laryngoceles in a 45-year-old male patient suffering laryngeal squamous cell carcinoma [6]. Another interesting case implicating cancer with laryngocele was reported in a 70-year-old man, who had a laryngeal tumor discovered by otolaryngological examination during admission for suspicion of facial nerve paralysis. Unfortunately the laryngocele wasn't identified and the patient was found dead in bed on the seventh hospital day. An autopsy revealed an internal type laryngocele in the right larynx and infarction of the left dorso-lateral portion of the medulla oblongata. Suffocation resulted from mucous sputum filling his larynx, which had been narrowed by a laryngocele from the right, in an unfortunate association with movement disturbance of the left larynx caused by the infarction of the left dorso-lateral portion of the medulla oblongata, and was considered the cause of death as no cardiovascular-respiratory problems were identified [2].
A patient with a history of psychiatric disorder presented with severe subcutaneous facial, palpebral and cervical emphysema, dysphonia, dysphagia and slight respiratory difficulty. Fiberoptic bronchoscopy revealed upper airway obstruction due to edema in an intact airway. Successive CT scans gave evidence of hyoid fracture and laryngocele, in addition to the corresponding emphysema of the subcutaneous area and pneumomediastinum [7].
We present a case of laryngocele in a 77-year-old Caucasian female following surgical tracheostomy. To the authors' knowledge, and from a review of the literature, this combination has not been previously described.