see: Saccular cyst of the larynx case example endoscopic removal and Endoscopic removal of laryngocoele with histopathology; External Laryngocele (Laryngocoele) / Sacular Cyst Resection Combined Approach with Operative Note

GENERAL CONSIDERATIONS

• Laryngoceles are uncommon congenital anomalies of the supraglottic larynx. They form as a result of air or fluid filled dilations of the laryngeal ventricle, which communicate with the laryngeal lumen. They are typically classified as "internal" or "external". Internal laryngoceles,  are comprised of a collection of air or serous fluid and mucous in the anterior portion of the laryngeal ventricle. They have the potential to enlarge into the false vocal fold. Internal laryngoceles are classified as such because their sac remains within the confines of the thyroid cartilage. In contrast, as external laryngoceles enlarge, their sac may protrude through the thyrohyoid membrane and present as a anterior neck mass. Laryngoceles may be congenital and may also be acquired. They are often seen in glassblowers due to continual forced expiration producing increased pressures in the larynx which leads to dilatation of the laryngeal ventricle. It is also seen in people with chronic obstructive airway disease.
• Saccular cysts represent 25% of all laryngeal cysts. They are also fluid filled dilations of the laryngeal ventricle but do not communicate with the laryngeal lumen.

Differences between Laryngocele and Saccular Cyst

2. Presenting symptoms: Lateral Compressible Neck Mass that increases in size with intralaryngeal pressure (external); Cough, Hoarseness (internal), possible airway compromise. Laryngoceles may also become infected, in which case they are called Laryngopyoceles. These may present with symptoms similar to other infections in the head and neck: fever, pain, leukocytosis etc.

3. *Evaluation: *Any of the following may be appropriate in the examination of these patients: Indirect mirror exam, Flexible fiberoptic laryngoscopy, endoscopic examination, videostroboscopy, CT of  the neck with IV contrast.

4. *Treatment: *Removal of internal laryngoceles and saccular cysts can be performed endoscopically. External laryngoceles and combined internal and external laryngoceles are often managed through an open approach. In both  approaches the patient is supine. All procedures, both open and endoscopic, typically begin with upper airway endoscopy to evaluate the lesion completely. Operative intervention is not always required, observation may be appropriate in select patients.

PREOPERATIVE PREPARATION (See protocol describing Direct Suspension Laryngoscopy)

1. Evaluation
   1. Essential preoperative studies (benign lesions)
      1. Speech pathology assessment
      2. Consider trial of nonsurgical therapy
      3. Videolaryngoscopy - note: videostroboscopy as we perform it (by Speech Pathology - usually with a rigid scope through a transoral route) is a good way to evaluate the vocal folds and permits concurrent high-quality voice recording. Transnasal fiberoptic examination by an Otolaryngologist often provides a more comprehensive examination of the pharynx and, in selected cases, permits a better view of the vocal folds and subglottic area.
   2. With history of neck arthritis or neck surgery/injury: Lateral neck radiographs in flexion and extension
   3. Optional studies: Acoustic and aerodynamic evaluation (see The Voice Clinic protocol)
   4. Offer to most patients with dentition: Dental prosthetics evaluation preoperatively to fashion a tailored (custom-made) acrylic dental splint
      1. To prevent dental injury more effectively than the standard plastic "gump"
      2. To patients who will undergo multiple microscopic direct laryngoscopy procedures (hence greater possibility of dental exposure; ie, RRP) (see suggested reading "Dental Protection During Rigid Endoscopy")
      3. To improve exposure of the larynx by permitting greater pressure to be distributed across the custom dental guard
      4. Less expensive dental protectors may be purchased and prepared by the patient - see Custom Dental Guards for Micro Direct Laryngoscopy (Suspension Laryngoscopy).
2. Consent for Surgery
   1. Describe procedure and expected recovery: Placement of rigid tube through your mouth into your voice box to expose the vocal cords. With a bright light attached for illumination and a microscope in place for magnification, the vocal cords will then be . . . (depends on the procedure to be done)
   2. Potential complications (not inclusive)
      1. Bleeding, infection, reaction to the anesthesia
      2. Damage to adjacent structures
         1. Lips, teeth, tongue
         2. Larynx, pharynx
         3. "numb tongue, altered taste, TMJ syndrome, dental injury"
      3. Potential hoarseness, breathing, or swallowing problems
      4. "A surgical incision - whether it be on the vocal cords or elsewhere - always results in a scar. Our goal is to minimize the amount of scarring with an effort to make it imperceptible."
      5. Mention prolonged intubation or temporary tracheotomy if it is more than an extremely remote possibility.
      6. Mention possibility hypoglossal nerve paralysis from pressure of the laryngoscope (usually temporary).

PROCEDURE

 ** Note: *The surgeon should be prepared for a difficult intubation and to manage the airway with the assistance of the anesthesia staff. It may be prudent to give a peri-op dose of intravenous (IV) steroids and a single perioperative dose of antibiotics directed at skin flora.

Endoscopic Removal:

The procedure begins with  exposure of the larynx and suspension of the patient for direct laryngoscopy. This may be done using a Lindholm laryngoscope. Alternatively, the Weerda (bivalve) laryngoscope may afford the best exposure for instrumentation. Thorough inspection of the lesion is then performd with 0- and 30-degree telescopes in an attempt to determine the origin of the lesion, if possible, and the fullest extent of the lesion within the paraglottic space. Beginning  over the middle of the lesion (between the aryepiglottic fold and the free edge of the false vocal fold), incision may be made with either a CO2 laser or a sickle knife. Great care should be taken to avoid rupture of the cyst at this point to facilitate dissection and prevent partial excision. Marsupialization of the lesion is an accepted technique, but can allow reformation of the cyst. Attempt  is then made to identify the “ stalk ” or initiating pore of the lesion anteriorly. Dissection is easily performed with blunt instruments in combination with the laser. Great care should be taken not to injure the superior vocal fold mucosa because this may result in scarring and permanent dysphonia. Closure of the false vocal fold mucosa is not necessary. Redundant false vocal fold or aryepiglottic fold mucosa may be trimmed at the conclusion of the procedure. 

The cyst is removed in its entirety along with the majority of the false vocal cord. An adequate specimen for histopathologic assessment is submitted to evaluate for possible cancer obstructing the duct orifice. If the cyst extends sufficiently far into the neck to preclude full resection endoscopically, an external approach is used.

External Approach:

The external (lateral) approach provides excellent exposure, minimal morbitidity and reduced chances of recurrence. To manage internal portions of a laryngocele, a small portion of thyroid cartilage may have to be removed to allow adequate exposure. External and combined laryngoceles can be dissected via the thyrohyoid membrane and cartilage sacrifice is not required.

The surgeon approaches the mass through a horizontal incision over natural skin crease just over the region of thyrohyoid membrane. The mass overlies this area hence there may not be any difficulty in identifying the thryohyoid membrane area. Skin flaps are elevated in the subplatysmal plane. The bulging strap muscles may be transected for better exposure of the mass. The carotid sheath is pushed posteriorly. The ansa cervicalis nerve may be adherent to the laryngocele and may be dissected out / transected if necessary. When the laryngocele is delivered there is dehiscence in the thryohyoid membrane which is closed with absorbable sutures.

During this procedure the superior laryngeal nerve must be identified and carefully preserved since it could be intimately related to the mass. Tracheotomy is often not necessary with this approach, but should be discussed during the preoperative consent process.

NURSING CONSIDERATIONS

1. Room Setup: See Panendoscopy Room Setup.
2. Instrumentation and Equipment
   1. Standard
      1. Direct Laryngoscope Tray
         1. included Dedo laryngoscope and Lindholm
      2. Bronchoscopy Tray, Adult
      3. Lewy Laryngoscope Holder Tray
      4. Laryngoscope Instrument Tray, Microscopic Direct
      5. Telescope, Storz, Hopkins straight 0° 5.5 mm x 20 cm
      6. Telescope, Storz, Hopkins straight 0° 4.0 mm x 30 cm
      7. Telescope, Storz, Hopkins 70°, 4 mm x 30 cm
      8. Storz fiberoptic light cable
      9. Stryker camera adapter (if flexible bronchoscope used)
      10. Microscope plus video unit
   2. Special
      1. Tracheotomy Tray (available only)
3. Medications (specific to nursing)
   1. 4% lidocaine solution, topical: Draw up in Luer Lock syringe to secure 25-gauge needle (used to spray vocal cords) with 25 gm x 1.5 in ndL. Lidocaine should be preservative free.  
   2. 1% Lidocaine with 1:100,000 epinephrine
   3. Oxymetazoline HCL nasal spray, 0.05% (for hemostasis on 1/2 in x 1/2 in neuropatties). 4% cocaine can also be used for topical hemostasis.  
   4. FRED (fog reduction elimination device); used to defog the telecscopes used in imaging the larynx; FRED is variable in effectiveness to prevent fogging; HH's preference: use hot water to warm the tip of the telescope to prevent fogging
   5. Kenalog 40 mixed 1:3 with 1% Lidocaine with 1:100,000 epinephine (final dilution: Kenalog 10) for granuloma injections.
4. Prep and Drape
   1. No prep
   2. Drape
      1. No need for shoulder roll if patient appropriately positioned on table:
         1. Head of patient at end of bed with 'head extension' flexed down
         2. Raise back of bed 30 degrees to elevate head above abdomen
      2. Two unfolded pillowcases with towel clamp for a head drape oriented to protect eyes
      3. Tape eyes (employ moistened eye pads and cloth tape if use of laser is possible)
      4. Cloth drape across chest
5. Drains and Dressings
   1. None are indicated for the endoscopic approach.
   2. A small penrose or suction drain may be placed for external approaches as indicated.
6. Special Considerations
   1. Keep small amount of clean saline set aside to place biopsies in and to clean off biopsy forceps to avoid cross-contamination between specimens.
   2. Open 18-gauge needle when taking biopsies to remove tissue from forceps. Place on Telfa for pathology.
   3. May use silver nitrate sticks to control extensive bleeding from the pharynx or supraglottic larynx (not recommended on the vocal folds). Alternatively, have the monopolar cautery available to touch to suction as it is applied to bleeding site through the laryngoscope with care to avoid contact with the laryngoscope; a safer monopolar cautery is the shielded Freche micro-cautery unit.
   4. Topical 1:100,000 epinephrine or oxymetazoline for application to vocal folds on 1/2 in x 1/2 in neurosurgical cottonoid for hemostasis. Topical cocaine can also be used. 
   5. Patients may have premade tooth guards.
   6. Instruments should be set up prior to induction and remain assembled until patient is extubated and patent airway is established.
   7. Tracheotomy Tray should be available for emergency tracheotomy.
   8. Second Mayo stand may be used for support for surgeon to rest hands during microlaryngeal surgery may be useful in selected cases.
   9. Rigid telescope with fiberoptics attached to camera and printer with Polaroid film for immediate still pictures to be entered into chart at time of laryngoscopy. Ideally, 0-degree and 70-degree telescopes will be available for imaging.
   10. Laser is generally not used except for papillomata and occasionally for malignancy to improve the airway. Laser attachment to the microscope can be placed preoperatively if lateral cordotomy is to be made to "spot weld" the mucosa back together (rarely needed).
   11. Laryngoscopes
       1. Jackson laryngoscope: Rarely used, best to introduce rigid bronchoscope
       2. Hollinger anterior commissure laryngoscope: Poor monocular exposure; useful when exposure is impossible with other laryngoscopes
       3. Dedo laryngoscope: The "workhorse" provides adequate exposure of the glottis in most patients; limited for laser surgery by absence of smoke evacuation port
       4. Ossoff-Karlan laryngoscopes: Good exposure but cannot be used in all patients because of larger size; best for laser surgery because of smoke evacuation port
       5. Weerda laryngoscope: Expands both proximally and distally to provide excellent exposure for supraglottic surgery
       6. Lindholm scope: good for supraglottic exposure and glottic exposure, not useful for difficult airways requiring endolaryngeal exposure. May supplement with laryngeal spreader.
          1. note - the Jackson and Lindholm scope have more acute angles at the corners allowing the surgeon to rest the laryngeal instrumentation with greater stability than other scopes, specifically the Kleinsasser.
   12. Concept of 'floating the lesion': Video of Endoscopic Resection of Vocal Cord (Fold) Leukoplakia "Floating the Lesion"

ANESTHESIA CONSIDERATIONS

1. General Anesthesia
   1. Communication with anesthesia staff is essential
      1. Oral endotracheal intubation with small (4.0 to 6.0) endotracheal tube (MLT tube = microlaryngeal/tracheal tube)
      2. Use laser-safe endotracheal tube if intraoperative laser use is planned
      3. Short-term paralysis (duration dependent on procedure; communicate with anesthesiologist)
      4. Consideration for alternative methods
         1. Jet anesthesia
         2. Apnea with intermittent mask
         3. Spontaneous ventilation
         4. Local anesthesia with sedation (see Local Anesthesia for Rigid Endoscopy protocol)
         5. The surgeon should be in the operating room during induction if there is potential for airway compromise.
2. Preoperative Systemic Medications
   1. Glycopyrrolate 0.1 to 0.2 mg IM on call to operating room
      1. The drying effect improves exposure; consider avoiding in patients with xerostomia, cardiac disease; contraindicated with glaucoma or urinary retention
      2. Vagolytic effect
      3. IM administration has longer half-life than IV, but onset of action for IM is 15-30 minutes, versus 1 minute for IV
   2. Consider Decadron 8 to 10 mg IV when IV started to diminish edema
      1. Contraindications: diabetes, ulcer disease, other
   3. Antibiotics administered only if biopsies or incisions are made in an infected or contaminated region (not usually employed for vocal fold surgery) (see Antibiotic Prophylaxis in Head and Neck Surgery protocol)
3. Positioning
   1. Head of table turned 90° from anesthesia
   2. Arms tucked for placement of suspension laryngoscopy support
   3. Placement of a shoulder roll is generally not necessary for endoscopic examination and instrumentation in these cases but may assist with exposure in external approaches.  

REFERENCES

Devesa PM, Ghufoor K, Lloyd S, Howard D.  "Endoscopic CO2 Laser Management of Laryngocele."  The Laryngoscope.  2002:112;1426-1430.

Dursun G, Ozgursoy OB, Beton S, Batikhan H.  "Current diagnosis and treatment of laryngocele in adults."  Otolaryngology- Head and Neck Surgery.  2007:136;211-215. 

Ettema SL, Carothers DG, Hoffman HT.  "Laryngocele resection by combined external and endoscopic laser approach."  Ann Otol Rhinol Laryngol.  2003:112;361-364