| Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Cysts of the Larynx Laryngeal cysts are rare, generally benign lesions which can affect all age groups. This presentation will summarize the various types of cysts encountered and make suggestions as to their proper diagnosis and treatment. A discussion of laryngeal cysts requires a thorough understanding of the anatomy of the laryngeal ventricle and its tiny appendage, the saccule. The ventricle is a deep fossa bounded by the false vocal fold and the true vocal fold. The anterior portion of the ventricle leads upward to a pouch known as the saccule. The saccule is lined with the openings of between 60 and 70 mucous glands. Mucous glands also line all other surfaces of the larynx, with the exception of the free edge of the true vocal cord. Therefore, cysts can occur at any location with this one exception. The classifications of cysts most often referred to are those by Desanto in 1970 and Newman in 1983. Desanto divided laryngeal cysts into three types: saccular cysts, both anterior and lateral, ductal cysts and the thyroid cartilage foraminal cyst. He felt that each cyst could be classified based on the site and size of the lesion, and its relationship to the laryngeal mucosa. The anterior saccular cyst, a derivative of the saccule, is located at the anterior ventricle, overhanging the glottis. It is small and submucosal. The lateral saccular cyst is located above the ventricle in the region of the false vocal cords and aryepiglottic folds. In comparison to the anterior cyst, these are quite large. The ductal cyst arises from the obstruction of a mucous duct, and can involve any structure in the larynx except for the free edge of the true vocal cord. These are variable in size. The thyroid cartilage foraminal cyst was described as a herniation of the subglottic mucosa through a persistent foramen in the thyroid ala. This type of cyst is not considered a significant part of the Desanto system. Newman argued that the anatomic relationships which comprise Desanto's system are usually destroyed during surgery, making an accurate pathologic diagnosis on these groundsimpossible. He states that the epithelial lining can be used to better characterize these cysts. Epithelial cysts, in his system, correspond to the lesions described by Desanto, both ductal and saccular. In addition, he introduces the tonsillar and oncocytic cysts. Tonsillar cysts are typified by a preponderance of follicular lymphoid tissue. Oncocytic cysts were typified by a lining epithelium which had undergone oncocytic metaplasia. Newman felt that these epithelial types had clinical significance in describing the behavior of the cysts. Tonsillar cysts were more likely to be found in young patients and to be located in the vallecula, epiglottis and pyriform sinuses. Oncocytic cysts were found in older patients, were located around the ventricle, were more likely to be multiple and more likely to recur. The diagnosis of a laryngeal cyst starts with a history and physical findings. Signs and symptoms in adults and infants should be considered separately since the presentations can be quite different. By far the most common presenting symptom in infants is airway obstruction with inspiratory stridor. Other symptoms include labored respiration, feeding difficulties and voice changes. A full 40% of these infants will present with respiratory distress in the first several hours of life. Adults, on the other hand, very rarely present with respiratory distress. By far the most common symptom in adults is hoarseness. Other symptoms include a foreign body sensation, pain, dysphagia, and occasionally difficulty breathing. A fair number are incidental findings in asymptomatic patients. Visualization of the larynx is then attempted. If this is not possible, lateral soft tissue x-rays of the neck can be helpful. For further evaluation of the cyst, CT scanning can be valuable in demonstrating the extent of the cyst, or when the diagnosis of the mass is in question. There are a number of surgical modalities that can be employed in the treatment of laryngeal cysts; these include tracheotomy, needle aspiration, endoscopic removal and various external approaches. The use of tracheotomy is usually discussed in relationship to the pediatric patient who presents with airway obstruction. The need for tracheotomy in pediatric patients has varied from 0 to 60% depending on the series. It is apparent from this great disparity that a consensus on the use of tracheotomy has not been reached. Earlier writings advocated repeated aspiration of the cyst with a needle as an atraumatic and successful method of treatment; however, subsequent literature has shown a high rate of recurrence with this method. Currently, needle aspiration is considered a temporizing method in life-threatening airway obstruction. Endoscopic treatment is the preferred method in the pediatric age group. Simple unroofing of the lesion with biting forceps was long the preferred treatment; however, with this type of incomplete excision, recurrences are not uncommon. For this reason, Van de Water in 1973 recommended a more complete excision with stripping of the cyst lining from the cyst bed. Finally, the CO2 laser has recently been advocated as an excellent method for removing cysts with minimal trauma to surrounding tissue. These endoscopic techniques have been advocated in virtually all cysts in the pediatric population and in small ductal cysts in all age groups. In addition, they can be employed in certain cases of saccular cysts in the adult population, such as when the patient objects to a neck scar, or is felt to be medically unfit to undergo an external approach. Otherwise, the literature supports an external approach to adult saccular cysts. New, in 1939, described a lateral thyrotomy approach. Vertical thyroid cartilage splitting is performed and the cyst is resected through this opening. Schall, in 1959 described an alternate approach consisting of an incision between the thyroid cartilage and thyrohyoid membrane. The thyroid lamina is then resected with the use a rongeur to expose the underlying lesion. Yarington and Frazer in 1966 suggested a similar approach but felt that resection of the thyroid cartilage was not necessary. Case Presentation A 19 year old white male presented originally to his private otolaryngologist with a one year history of change in his voice. Both he and his parents had noticed a progressively muffled and guttural quality to his voice which had made him increasingly difficult to understand. Indirect laryngoscopy revealed the presence of a smooth, mucosa covered mass along the anterior aspect of the larynx which almost completely obscured the glottis. He was then referred to The Methodist Hospital for further evaluation and treatment. On examination he was found to have a relatively normal voice during low frequency phonation, but was unable to produce sounds in the higher registers. Flexible laryngoscopy confirmed the lesion. MRI of the larynx was obtained which showed a rounded nonenhancing mass in the left laryngeal wall which was felt to be consistent with a cartilaginous neoplasm or a cyst. He was taken to the operating room where suspension laryngoscopy with endoscopic removal of a laryngeal cyst was performed. The pathology was interpreted as a ventricular cyst with mixed squamous and respiratory columnar epithelium. He tolerated this procedure well and at two weeks follow-up was speaking with a normal voice. Bibliography Abramson AL, Zielinski B: Congenital laryngeal saccular cysts of the newborn. Laryngoscope 94:1580-2, 1984. Booth JB, Birck HG: Operative treatment and postoperative management of saccular cyst and laryngocele. Arch Otolaryngol 107:500-2, 1981. DeSanto LW: Laryngocele, laryngeal mucocele, large saccules, and laryngeal saccular cysts: a development spectrum. Laryngoscope 84:1291-96, 1974. DeSanto LW, Devine KD, Weiland LH: Cysts of the larynx - classification. Laryngoscope 80:145-76, 1970. Harrison DFN: Saccular mucocele and laryngeal cancer. Arch Otolaryngol 103:232-4, 1977. Henderson LT, Denneny JC, Teichgraeber J: Airway-obstructing epiglottic cyst. Ann Otol Rhinol Laryngol 94:473-6, 1985. Holinger LD, Barnes DR, Smid MD, Holinger PH: Laryngocele and saccular cysts. Ann Otol 87:675-85, 1978. Lawrence PA, Burgess PA, Wim DWS: Laryngeal cyst of the thyroid cartilage. Arch Otolaryngol 111:826, 1985. Mitchell DB, Irwin BC, Bailey CM, Evans JNG: Cysts of the infant larynx. J Laryngol Otol 101:833-37, 1987. Myerson MC: Cysts of the larynx. Arch Otolaryngol 18:281-90, 1933. Myssiorek D, Persky M: Laser endoscopic treatment of laryngoceles and laryngeal cysts. Otolaryngol Head Neck Surg 100:538-41, 1989. Newman DH, Taxy JB, Laker HI: Laryngeal cysts in adults: a clinicopathologic study of 20 cases. Am J Clin Pathol 81:715-20, 1984. Ophir D, Lifschitz-Mercer B: Oncocytic cystic lesions of the upper respiratory tract. Ear Nose Throat 68:237-44, 1989. Ramesar K, Albizzati C: Laryngeal cysts: clinical relevance of a modified working classification. J Otolaryngol Otol 102:923-5, 1988. Schall LA: An extralaryngeal approach for certain benign lesions of the larynx. Ann Otol Rhinol Laryngol 68:346-55, 1959. Schilling HE, Neal GD, Nathan M, Aufdemorte TB: Aneurysmal bone cyst of the larynx. Am J Otolaryngol 7:370-4, 1986. Slotnick D, Som PM, Giebfried J, Biller HF: Thyroglossal duct cysts that mimic laryngeal masses. Laryngoscope 97:742-5, 1987. Van De Water FW: Laryngeal cysts - their surgical management. Laryngoscope 83:1185-94, 1973. Wansa SA, Jones NS, Watkinson J: Unusual laryngeal cyst. J Laryngol Otol 104:145-6, 1990. Yarington CT, Frazer JP: An approach to the internal laryngocele and other submucosal lesions of the larynx. Ann Otol Rhinol Laryngol 75:956-60, 1966.
Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
|