See also: Saccular Cysts and Laryngoceles; Laryngocele (saccular cyst) with histopathology (laryngocoele); Saccular cyst of the larynx case example endoscopic removal
Modified Operative Note
Preop Dx: Right sided combined (internal; large external) laryngocele
Postop Dx: Same
Procedure:
Open resection of external laryngocele combined with:
- Endoscopic laser resection of internal component via microdirect CO2 laser laryngoscopy
- Tracheostomy (Bjork flap)
Anesthesia: General OETT intubation (grade 1 view) with 6-0 Tenax laser tube
Findings:
Extensive R laryngocele/saccular cyst partially filled with frothy clear mucoid fluid
Resected through R neck, suture ligated and laryngeal component removed via CO2 laser via concurrent MicroDL approach
Bjork flap at 2nd tracheal ring, sutured inferiorly, thyroid isthmusectomy, secured with trach strap
Operative details:
Informed consent was reviewed with the patient and his friend who accompanied him to the preoperative area. The CO2 laser was test fired prior to bring the patient back. The patient was brought back to the operating room and laid supine on the operating table. Preinduction check was performed and all present were in agreement.
General endotracheal anesthesia was induced and Tenax 6-0 laser safe endotracheal tube was placed the patient was turned 90 away from anesthesia. A timeout was performed. A proposed incision was marked on the right neck over the laryngocele and approximately 5 mL of 1-100,000 epinephrine was injected along the mark.
A moist eye pad and gum protector was placed to protect the edentulous upper maxillary alveolus. The adult Lindholm was placed and suspended to expose the larynx. There was excellent exposure. The right false cord and AE fold region appeared fuller than the left. The piriform sinus mucosa was intact.
A 0 degree scope was used to photo document these findings. Sterile saline was placed in the proximal (closest to vocal cords) cuff of the laser safe Tenax endotracheal tube. The laryngoscope, suspension arm and the surgical field was prepped and draped in standard sterile fashion.
A 15 blade was used to incise the skin. Hemostats were then immediately used to dissect and divide with the scalpel the subcutaneous tissue and platysma. The laryngocele was immediately encountered underneath the platysma. With combination of blunt dissection with hemostats and Kitners, the sac was dissected free from the surrounding tissue.
The strap muscles were identified along the anterior aspect of this was swept anteriorly off the surface of the laryngocele. Dissection continued until the narrowest point of the laryngocele was identified as it penetrated the thyrohyoid membrane and tract medial and inferior to the thyroid cartilage into the larynx. At this point 2-0 silk sutures were used to tie off the neck and the suture needles were used to enter into the larynx to allow for retraction.
Attention was redirected to the endolarynx and a saline soaked large neurosurgical cottonoid pledget was placed into the subglottis. The operating microscope was brought into the field. A laser platform was placed to protect the right vocal cord into the ventricle.
Moist eye patches were placed to protect the eyes and secured with cloth tape. Moist towels were placed to protect the face.
With traction on the two silk sutures directing resection, the CO2 laser was then used to incise the mucosa overlying the laryngocele on the false cord. Initial settings of 4 W intermittent upgraded to 6W continuous- all laser safe processes followed (lowering FiO2; placement of saline soaked neuropaddies under vocal cords over saline filled laser safe endotracheal tube with use of suction platform to protect the true vocal cords.)
Hemostasis was obtained with monopolar cautery on the suction catheter. Afrin-soaked pledget was placed on the wound to obtain further hemostasis.
Attention was then directed to closure of the neck. Two 1/4 inch Penrose drains were placed, 1 tracking superiorly towards the lateral aspect of the hyoid, and 1 tracking medially along the track of the laryngocele to the thyroid cartilage. The drains were secured with 3-0 nylon to the skin. The platysma was then reapproximated with 3-0 Vicryl stitches. Buried deep dermal 3-0 Vicryl was placed and short segment running 4-0 nylon was used to reapproximate the skin.
The tracheostomy was then performed: The laryngeal landmarks along the anterior neck were palpated and marked. Approximately 4 mL of 1% lidocaine with 1-100,000 epinephrine was injected into the deep soft tissue of the neck just below the cricoid cartilage. A vertical incision was made in the midline centered just below the cricoid cartilage.
An anterior cervical lipectomy was performed with monopolar cautery and the anterior cervical fat was sent for permanent specimen. The midline raphae was identified and divided. Hemostat dissection was performed down to the cricoid cartilage and a pretracheal tunnel was created, elevating the thyroid isthmus off the trachea.
The thyroid isthmus was clamped with hemostats on each side and divided with monopolar cautery. The isthmus was sent as a permanent specimen.
A 3-0 silk stitch was used to suture ligate in a baseball fashion the isthmus on each side. Hemostasis was obtained and was pristine. At this point the endotracheal tube was advanced and with fine hemostats the intercartilaginous space between rings 1 and 2 was penetrated and divided with a scalpel. Lateral vertical cuts were then made with heavy scissors.
The cut second ring was then sutured with two 3-0 Vicryl sutures inferiorly to the skin as a Bjork flap. The endotracheal tube was then withdrawn such that the tip was superior to the tracheotomy. A 6 cuffed Shiley tracheostomy tube was then placed and hooked up to the circuit. There was confirmation of end-tidal CO2. The superior aspect of the vertical incision was then approximated with a single 3-0 Vicryl stitch. The trach tube was then secured with a Velcro trach strap and a Mepilex dressing was placed inferiorly to pad the inferior neck skin.
At this point direct laryngoscopy was then performed again with first a MAC 3 then a Dedo blade placed in suspension. Blood was suctioned out of the supraglottic larynx and trachea. Slight oozing from the false cord resection site was addressed with topical afrin on a neurosurgical pledget along with the metal suction catheter and monopolar cautery.
The trach tube appeared to be in adequate position. Photodocumentation was obtained with the 0 degree rigid endoscope. The neck was cleansed and bacitracin was applied. Fluffs and burn netting was placed over the neck incision.
The patient was then turned back to anesthesia for emergence and was taken to PACU in stable condition.
Findings: as per photos - extensive nature of external component with communication into warranted tracheostomy to preserve airway.
After trach the larynx was again inspected showing minimal oozing from false cord/internal laryngocele resection address with suction cautery and afrin well controlled.
Plan: antibiotics for 7 days (unasyn in house, augmentin as outpatient); likely trach change day 3
- Assess for possible PO tomorrow afternoon; target trach change with staff surgeon in attendance on Sat am (have 5-0 and 6-0 Jacksons as well as flexible laryngoscope
References
Ettema SL, Carothers DG, Hoffman HT. "Laryngocele resection by combined external and endoscopic laser approach." Ann Otol Rhinol Laryngol. 2003:112;361-364