（conlin）ppt喉气囊肿的占2520（康林）课件

Laryngoceles OtolaryngologyGrandRoundsAnneConlin MD PGY 4November5 2008 Objectives Todiscuss2casepresentationsoflaryngoceleTounderstandtheanatomyandetiologyoflaryngoceles relatedsacculardisordersTodiscusswork upandmanagementoptionsforlaryngoceles relatedsacculardisorders TheCases Case 1 ID 2y o malein patientRFC stridor neckswellingHPI 1wkHxURTISx fever rhinorrhea 1dHxacutestridor rapidneckswellingx10cmw erythema dysphagia andinabilitytolieflatd tairhungerAdmittedtoICU Case 1 PMHx DCR otherwisehealthyDevtHx unremarkableL D Ndev tMeds Allergies nil Case 1 PhysicalExamToxiclooking stridorous distressedpatient10cmwarm erythematousL midline Rneckswelling Case 1 Whatdoyoudo Case 2 ID 68y o maleout patientCC WhenIcough somethingpopsupintothebackofmythroat andIhavetopushitdownwithmyfingers Case 2 HPI CCongoingseveraltimesperdayfor2monthsTransientdysphonia resolvedwithdigitaldisplacementofmassinhismouthNodyspneaorstridorPMHx Zenker sdiverticulum otherwisehealthyHabits deniedEtOH smoking musicalinstrumentsorglass blowing Case 2 Case 2 Whatdoyoudo Laryngoceles RelatedSaccularDisorders Laryngoceles HistoricalContext1stdescribedin1829byNapoleon ssurgeon in chief observedinthemancallingthemassestoprayerinEgypt Laryngoceles DefinitionAbnormaldilationofthesacculeofthelaryngealventricleSpectrumofdisorderscharacterizedbyabnormaldilatationofthelaryngealsaccule Saccule akalaryngealappendixThenormalout pouchingattheanteriorendofthelaryngealventricleAblindsacthatextendsupwardsbetweenthefalseVCsandthethyroidcartilage AnatomyoftheSaccule ContainsmanymucousglandsVestigialairsacPossiblefunctionislubricationoftruevocalfolds AnatomyoftheSaccule Burke Golden LaryngoceleisasacculewhichextendsbeyondthesuperiorborderofthethyroidcartilageBroyles heightof normal saccule15mmin8 popBurke sdef naccepted AnatomyoftheSaccule A Normalanatomy B Anteriorsaccularcyst C Lateralsaccularcyst D Laryngocele externalandmixedtypes Laryngocele SacculefilledonlywithairOrificeremainspatent ClassificationofLaryngoceles ClassificationInternal 40 lieswithintheconfinesofthelarynxbeneaththemucosaofthefalsecords AEFsExternal 25 extendsbeyondthyroidcartilage protrudesthroughthyrohyoidmembraneatpointofinsertionofSLNMixed 45 abnormaldilatationofsacculeonbothsidesofthethyrohyoidmembrane Internallaryngocele Normalanatomy Externallaryngocele Mixedlaryngocele SaccularCyst Sacculefilledwithglandularsecretions orificebecomesobstructedSymptomsareconstant Laryngopyocele ContentsofasaccularcystbecomeinfectedAir fluidseenonimaging8 10 oflaryngoceles Etiology TrueorFalse Laryngocelesarecausedbyplayingwindinstruments suchasthetrumpet TrueorFalse Laryngocelesarecausedbyglassblowing Etiology Uncertain controversialCommonlyfeltduetouseofthevoiceinunusuallyforcefulways hightransglotticpressuresTrumpetplayersGlassblowers Etiology TransglotticPressure Stell Maran JLaryngolOtol 1975Reviewed139casesOnly1caseassociatedw prolonged repeatedblowingagainstresistance trumpetplaying Etiology Carcinoma Celinetal Laryngoscope 1991Pathologyspecimens Laryngealcarcinoma 19 w laryngocelePharyngealcarcinoma 2 w laryngoceleCTfindings Laryngealcarcinoma 29 w laryngoceleNormallarynx 9 w laryngocele Laryngoceledefinedassacculedetectable10mmabovesuperioraspectofthyroidcartilage comparabletoBroyles descriptionsofthesaccule Etology Carcinoma Theory Ball valveobstructionofneckofsacculebytumourAiradmittedintosacculeHowever aircannotescape Etology Carcinoma LimitationstotheTheory Halfoflaryngocelesareipsilateraltolaryngealcarcinoma halfarecontralateralAlternativetheory Abnormalintralaryngealpressuresd tcoughing alteredphonation etc Carcinoma Laryngoceles Micheauetal 1976 CancerLaryngocelepresentin22of120casesThyroidcartilageinvasionin50 cricoidinvasionin10 UpwardspreadVeryinvasive Carcinoma Laryngoceles Canalisetal JOtol 1976131patientsw symptomaticlaryngocelesOccultca 4 15 InaccuracyofendoscopicevaluationCTmandatory Etiology Congenital CongenitalpresenceofabnormallylargesacculeBroylesstudiesonheightofsaccule 15mmin8 pop Etiology Weird Wonderful ComplicationofsurgicaltracheostomyComplicationoflaserexcisionSCCalarynxVoiceabuseIVdruguserneckinjectionsAmyloidosisScleroderma ClinicalPresentation EpidemiologyIncidence 1per2 5millionpeopleperyearMale female 5 1 between2and7 1 MostcommonlyaffectsCaucasianmenintheir50sPatternUnilateral 75 Mixed 45 Symptoms SymptomsintermittentforlaryngocelesDependwhetherthelaryngoceleisinternal external orcombinedHoarsenessNeckswellingStridorDysphagiaSorethroatSnoringCoughGlobus Symptoms Congenital PediatricCases AirwayobstructionFeedingdifficultiesWeakcry Signs SwellingofthefalseVCs aryepiglotticfoldsPalpablemassinlateralneckwhichincreasesw Valsalvamaneuver externaltype Brycesign gurglingorhissingsoundoncompressionoftheneckmass Investigations CTscanTraditionally theprimaryimagingstudyFluid orair filled sharplydefinedsac Investigations CTscanDefinitivedx connectionbtwnairsac airwayUsefulformapping surgicalplanning Investigations MRIUseful especiallytodistinguishbtwnmucus inflammationandmalignancyVisualizationofthyrohyoidmembrane paralaryngealspace truecord falsecords Investigations T1WMRIw gadThinrimofenhancingmucosa T2WMRIHyperintensecystcontents fluid Management Options Observation ConservativeDirectlaryngoscopyExternalapproachEndoscopicapproach Management DirectlaryngoscopyOftenrevealsswellingofthefalsecordandAEFMaybemisleadingb claryngocelereliesonairwaypressuretokeepthecysticstructuredistentedApnea airwaypressureisallowedtoequalize themassmaydecompressspontaneouslyBiopsiesofanysuspiciouslesions Management ExternalLaryngofissureLaterallaryngotomyLateralthyrotomyviathyrohyoidmembraneEspeciallyfor LargeinternallaryngocelesCombined mixed laryngocelesInternallaryngoceles EndoscopicCO2laserEspeciallyfor SmallinternallaryngocelesRoleexpanding Management ExternalApproach Directlaryngoscopy biopsyExternalportionofthesacfollowedthroughthyrohyoidmembranePossiblyw removalofthesuperolateralportionofthethyroidcartilageforeasieraccess Management ExternalApproach Thomeetal 2000 Laryngoscope26yrprospectivealso2pre optracheotomizedptsDecannulationat3 20daysBettervisibilityofandaccesstoparaglotticspaceNorecurrence F U 1yr Management Endoscopic Laryngealventricleexaminedw 0o 90oscopes biopsyMucosaretractedmediallyIncisionw laseroversuperioraspectventricleLateralcomponentdrawnintolaryngeallumenIfonlymarsupialized higherrecurrencerates Management Endoscopic MartinezDevesaetal 2002 Laryngoscope15yrretrospectivestudy f u6mos 5yrs12patientstreatedw endoscopicCO2laser internalnoprimarytracheotomyrequired1complication localwoundinfectionNorecurrences Management Endoscopic Szwarc Kashima AnnalOtoRhinLaryn1997 CombinedlaryngoceleVestibulectomyCompleteexcisionw CO2laserexcisionofinternalportionExternalportionallowedtodrainintolaryngeallumenUsefulinselectcases Management SequentialExternal EndoscopicApproach Ettema Carothers 6 yearsofexperience Externalsegmentdissected ligatedw silkSilksuturedetectedonlaryngoscopyLaserresectionwhileretractingw silksuture Management Advantages Disadvantages ExternalAdvantagesLowrecurrenceEasyaccessDisadvantagesScarLongerin ptstayAnteriorcommissuremorbidityw laryngofissure EndoscopicAdvantagesShorterin ptstayDisadvantagesPossibledamagetoneurovascularbundle RLN TheCasesRevisited Case 1Revisited UrgentORMidlineneckincisionatlevelofcricoidringCystencountered 35mLofpusdrained2largecysticmassesonbothsidesoftrachea anteriortolarynxLaryngoscopy frankpusspillingintoa wPenrosedrainplaced Case 1Revisited Post opClindamycin cefuroximeIVx10daysHomeonclindamycinPO1monthlater ReturnedtoORfor neckdissection dissectedoutf