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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 11  |  Issue : 2  |  Page : 102-105

The role of magnetic resonance imaging in the diagnosis of bilateral laryngocele


Department of Radiology, Rivers State University Teaching Hospital, Port Harcourt, Rivers State, Nigeria

Date of Submission02-Sep-2020
Date of Acceptance20-Dec-2020
Date of Web Publication25-May-2021

Correspondence Address:
Dr. Ebbi Donald Robinson
Department of Radiology, Rivers State University Teaching Hospital, Port Harcourt, Rivers State
Nigeria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjmsr.mjmsr_39_20

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  Abstract 


Laryngocele is a rare anomalous air-filled dilatation of the saccule of the larynx with unclear etiology. The patient in our case presented with a complaint of a painless anterior neck swelling which moved and increased in size on coughing, swallowing, and straining. Physical examination revealed a compressible swelling measuring approximately 2 cm in the widest diameter in the anterior aspect of the neck with normal overlying skin. It was nontender, soft, cystic, fluctuant, and mobile. The advent of magnetic resonance imaging (MRI) has made its diagnosis easier than the use of laryngoscope. The finding revealed multiple, nonenhancing, oval-shaped but lobulated masses in both infrahyoid visceral spaces involving the paraglottic space with an extralaryngeal component. They hypo to isointense on T1-weighted and hyperintense on T2-weighted and short tau inversion recovery images and measured 3.71 cm × 3.06 cm in the right and 1.27 cm × 1.04 cm in the left (right bigger than left). Hence, a diagnosis of bilateral laryngocele was made. In the index report, MRI being a noninvasive imaging modality using radiofrequency with brilliant soft-tissue contrast and spatial resolution was used to diagnose the lesion. The paucity of literature and information with regard to bilateral laryngocele in our environment and the role of MRI have informed this report.

Keywords: Anterior neck mass, bilateral laryngocele, magnetic resonance imaging


How to cite this article:
Robinson ED, Wekhe C. The role of magnetic resonance imaging in the diagnosis of bilateral laryngocele. Muller J Med Sci Res 2020;11:102-5

How to cite this URL:
Robinson ED, Wekhe C. The role of magnetic resonance imaging in the diagnosis of bilateral laryngocele. Muller J Med Sci Res [serial online] 2020 [cited 2021 Jun 21];11:102-5. Available from: https://www.mjmsr.net/text.asp?2020/11/2/102/316696




  Introduction Top


The introduction of computed tomography (CT) and magnetic resonance imaging (MRI) has made the diagnosis of laryngeal pathologies easier because they are less invasive unlike laryngoscope. Laryngocele is a rare anomalous air-filled dilatation of the saccule of the larynx that communicates with the laryngeal airway.[1] It was first reported by Dr. Dominique Jean Larrey in 1829, a Napolean army man in Egypt. However, it was better characterized by Rudolf Virchow in 1867.[1]

The etiology is unclear, however it may be congenital or acquired; the latter is seen in glass blowers, trumpeters, and after Valsalva maneuver, due to forced expiration producing increased pressure in the larynx.[2] Consequently, there is dilatation of the laryngeal ventricle (sinus of Morgagni). Laryngocele can also be seen in patients with chronic obstructive pulmonary disease (COPD).

The incidence of laryngocele is 1 in 2.5 million populations per annum in Great Britain. It has been reported to occur more frequently in men than women, with a peak incidence between the ages of 50 and 60 years.[3] Laryngocele may be classified as internal or mixed: purely external laryngoceles cannot exist as laryngoceles originate in the laryngeal saccule.[2] An internal laryngocele is limited to the anatomic boundaries of the larynx and appears like a mass in the false vocal cord; a mixed laryngocele extends upward and protrudes through the thyrohyoid membrane and so presents as a mass.[3] It could also be classified as primary and secondary. The latter is when there is a mass causing an obstruction. Laryngoceles are unilateral in 85% of cases and bilateral in 15% of cases.[3]

It could present with cough, hoarseness, dysphonia, dysphagia, and dyspnea due to airway compromise. There may or may not be swelling depending on the variety. It may become infected in which case it is called laryngopyocele and may present with symptoms similar to other infections in the head and neck: fever, pain, and leukocytosis.

Radiology remains invaluable in the assessment, management, and treatment of laryngoceles. Various imaging modalities are used beginning from the most affordable and cost-effective, including plain radiographs, ultrasonography, barium studies in cases of dysphagia, Expunge computed tomography (CT), and MRI.

In the index report, MRI being a noninvasive imaging modality using radiofrequency with brilliant soft-tissue contrast and spatial resolution was used to diagnose the lesion. The paucity of literature and information with regard to bilateral laryngocele in our environment and the role of MRI have informed this report.


  Case Report Top


NC, a 53-year-old male patient, presented with the complaint of a painless anterior neck swelling which moved and increased in size on coughing, swallowing, and straining with associated dysphagia for 6 months' duration. History revealed that the patient before presentation had been taking medication from a chemist across the counter in anticipation of a sore throat; however, the symptoms did not abate.

The patient is not a known hypertensive, diabetic, or asthmatic. He does not take alcohol or smoke. There was no previous history of COPD. Physical examination revealed a compressible swelling measuring approximately 2 cm in the widest diameter in the anterior aspect of the neck with normal overlying skin. It was nontender, soft, fluctuant, and mobile. The swelling increased in size on coughing and Valsalva maneuver. A clinical diagnosis of the thyroglossal cyst to rule out the thyroid mass was made. A thyroid ultrasonography was requested which revealed a normal-sized thyroid gland with homogenous parenchyma echogenicity.

Soft-tissue neck MRI was subsequently requested and was done. The techniques involved T2-weighted axial, coronal, and sagittal; T1-weighted pre- and postintravenous gadolinium axial, coronal, and sagittal; as well as T2-short tau inversion recovery (STIR) axial, coronal, and sagittal sections. The finding revealed multiple, nonenhancing, oval-shaped but lobulated masses (right worse than left) in both infrahyoid visceral spaces involving the paraglottic space with an extralaryngeal component. It was hypo to isointense on T1-weighted and hyperintense on T2-weighted and STIR images and measured 3.71 cm × 3.06 cm in the right and 1.27 cm × 1.04 cm in the left (right bigger than left). The mass was compressing the vallecula and narrowing the laryngeal airway, trachea, and entrance to the esophagus (cervical esophagus), as shown in [Figure 1]a, [Figure 1]b, [Figure 2]a, [Figure 2]b and [Figure 3]. A diagnosis of bilateral laryngocele was made and then referred to an ENT surgeon for further management. The patient was requested to undergo screening of full blood count; fasting blood sugar; and electrolyte, urea, and creatinine and retroviral screening in preparation for surgical intervention. The patient absconded with trace until this date.
Figure 1: (a) T2.weighted axial and (b) T2-weighted coronal sections showing multiple, nonenhancing, oval-shaped but lobulated hyperintense masses (right worse than left) in both infrahyoid visceral spaces involving the paraglottic space with an extralaryngeal component

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Figure 2: (a) T1-weighted axial and (b) T1-weighted coronal sections showing multiple, nonenhancing, oval-shaped, lobulated hypointense masses

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Figure 3: T2-weighted sagittal section showing a lobulated hyperintense mass

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  Discussion Top


Laryngocele is an abnormal cystic dilatation of the laryngeal saccule.[1] Its etiology is unclear. Common presenting symptoms include internal or mixed globus sensation, sore throat, cough, pain, snoring, increasing stridor, hoarseness, and air obstruction if lesions are large.[3] If external, a visible or palpable mass in the neck is seen. A laryngoscopic examination may reveal a globular swelling in the laryngeal lumen or a submucosal fullness, but the internal component of a mixed laryngocele may be missed due to deflation and inflation.

There is a well-documented association of laryngocele with laryngeal carcinoma,[4] with supraglottic being the most common. Furthermore, malignancy must be suspected in the elderly and in the case of an acquired saccular cyst in which the mouth of the mucous gland of the saccule is obstructed by the tumor.[1] While it is difficult to establish if a laryngeal cyst is congenital or acquired,[5] a laryngocele must be differentiated from other laryngeal cysts, of which the true cysts may be classified as epithelial, oncocytic, and tonsillar.[6] Epithelial cysts are the most common and include saccular cysts, whereas tonsillar cysts are mostly found in the region of vallecular, epiglottis, or pyriform sinus and bear resemblance to epithelial cysts of the oral cavity.[6]

Oncocytic cysts are more common in the ventricle and seen predominantly in the elderly, may be multiple in number, and have higher rates of recurrence and generally behave like benign neoplasms, though the jury is still out on whether the oncocytic cells containing hypertrophied deeply eosinophilic mitochondria are the result of neoplastic or degenerative change.[7],[8] A laryngocele may coexist with other laryngeal diseases such as respiratory papillomatosis, amyloidosis, and rheumatoid arthritis and may also coexist with oncocytic cysts.[9],[10]

The management of laryngocele includes good history taking, physical examination, radiological investigations, and finally surgical intervention. The following imaging modalities are useful in the evaluation and management of laryngocele: plain radiography, ultrasonography, computed axial tomography (CT), and MRI. The advantage of plain radiography and ultrasound modalities is that they are affordable and accessible, however they are not as accurate as CT and MRI because they are not cross-sectional imaging modalities. Surgical intervention involves observation, endoscopic resection,[11] or resection through an external approach.

Marsupialization using CO2 laser[12] may be done through an endolaryngeal endoscopic or microscopic approach for internal or mixed laryngoceles. The external cervical approach with or without tracheostomy may be employed for mixed and external laryngoceles. The neck should be carefully dissected in order to prevent damage to the neurovascular bundles which penetrate the thyrohyoid membrane at the exit of the external laryngocele.[13]

Differential diagnosis

  1. Saccular cyst
  2. Branchial cyst
  3. Neck abscess
  4. Lymphadenopathy
  5. Laryngeal carcinoma.



  Conclusion Top


Laryngoceles though rare should be considered in any patient presenting with a compressible neck mass even in the absence of known risk factors, and radiology is an invaluable tool in the diagnosis of laryngocele. The complications of laryngocele include airway obstruction, pyocele, and vocal cord paralysis. The prognosis is poor when there is an underlying malignant lesion like carcinoma. Internal laryngoceles can lead to severe airway obstruction which could be fatal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Prasad KC, Vijayalakshmi S, Prasac SC. Laryngocele presentations and management. Indian J Otoryngol. Head Neck Surg 2008;60:303-8.  Back to cited text no. 1
    
2.
Drozd M, Szuber K, Szuber D. The significance of the valve mechanism in pathology of laryngocele. Otolaryngol Pol 1996;50:17-20.  Back to cited text no. 2
    
3.
Pennings RJ, van den Hoogen FJ, Marres HA. Giant laryngoceles: A cause of upper airway obstruction. Eur Arch Otorhinolaryngol 2001;258:137-40.  Back to cited text no. 3
    
4.
Akbas Y, Unal M, Pata YS. Asymptomatic bilateral mixed-type laryngocele and laryngeal carcinoma. Eur Arch Otorhinolaryngol 2004;261:307-9.  Back to cited text no. 4
    
5.
Zawadzka-Glos L, Frackiewicz M, Brzewski M, Biejat A, Chmielik M. Difficulties in diagnosis of laryngeal cysts in children. Int J Pediatr Otorhinolaryngol 2009;73:1729-31.  Back to cited text no. 5
    
6.
Ramesar K, Albizzati C. Laryngeal cysts: Clinical relevance of a modified working classification. J Laryngol Otol 1988;102:923-5.  Back to cited text no. 6
    
7.
Salerno G, Mignogna C, Cavaliere M, D'Angelo L, Galli V. Oncocytic cyst of the larynx: An unusual occurrence. Acta Otorhinolaryngol Ital 2007;27:212-5.  Back to cited text no. 7
    
8.
Oliveira CA, Roth JA, Adams GL. Oncocytic lesions of the larynx. Laryngoscope 1977;89:1708-25.  Back to cited text no. 8
    
9.
McDonald SE, Pinder DK, Sen C, Birchall MA. Oncocytic cyst presenting as laryngocele with surgical emphysema. Eur Arch Otorhinolaryngol 2006;263:237-40.  Back to cited text no. 9
    
10.
Uğuz MZ, Onal K, Karagöz S, Gökçe AH, Firat U. [Coexistence of laryngeal cancer and laryngocele: A radiologic and pathologic evaluation]. Kulak Burun Bogaz Ihtis Derg 2002;9:46-52.  Back to cited text no. 10
    
11.
Ettema SL, Carothers DG, Hoffman HT. Laryngocele resection by combined external and endoscopic laser approach. Ann Otol Rhinol Laryngol 2003;112:361-4.  Back to cited text no. 11
    
12.
Martinez Devesa P, Ghufoor K, Lloyd S, Howard D. Endoscopic CO2 laser management of laryngocele. Laryngoscope 2002;112:1426-30.  Back to cited text no. 12
    
13.
Ingrams D, Hein D, Marks N. Laryngocele: An anatomical variant. J Laryngol Otol 1999;113:675-7.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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