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Diagnostic and Therapeutic Endoscopy, Vol. 6, pp. 91-94Reprints
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Printed in Malaysia.
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
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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.
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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
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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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