Management of Laryngocele with Internal and External Components
Combined laryngoceles with both internal and external components should be managed with surgical excision using either a combined endoscopic and external approach, or preferably with transoral robotic surgery (TORS) when available, as this minimizes morbidity while achieving complete excision.
Surgical Approach Selection
The management strategy for combined (mixed) laryngoceles differs fundamentally from purely internal lesions because the pathology extends from the supraglottic larynx through the thyrohyoid membrane into the neck 1.
Primary Treatment Options
For combined laryngoceles, the traditional approach involves both internal and external surgical techniques:
- External approach via lateral thyroidotomy or transcervical approach is necessary to address the external component that extends beyond the thyrohyoid membrane 2, 3
- Endoscopic CO2 laser excision can address the internal component, but alone is insufficient for combined lesions 2
- Combined approach (both endoscopic and external) has been the historical standard for complete excision 4
Emerging Preferred Approach: Transoral Robotic Surgery (TORS)
Recent evidence demonstrates that TORS represents a superior alternative to traditional combined approaches:
- TORS allows complete excision of both internal and external components through a single transoral approach 1
- This technique reduces morbidity compared to external approaches while maintaining complete excision 1
- Recovery is faster with shorter hospitalization (typically 2 days) and earlier return to normal diet 1
- No recurrence has been reported with TORS approach in available case series 1
- The systematic review confirms that robotic-assisted surgery shows much promise and represents the evolution of laryngocele management over the last decade 4
Critical Management Considerations
Emergency Presentations
If the laryngocele is infected (laryngopyocele) and causing acute airway obstruction:
- Emergency tracheotomy may be inevitable to secure the airway 5
- Laryngopyoceles can cause rapid and alarming airway obstruction, presenting with hoarseness, stridor, and fever 5
- Immediate endoscopic drainage is the recommended initial treatment for infected laryngoceles 5
- Definitive surgical excision should follow after acute infection is controlled 5
Diagnostic Workup
Computed tomography (CT) of the neck is critical for:
- Determining the exact nature and extent of the lesion 5
- Distinguishing internal, external, or combined components 5
- Planning the appropriate surgical approach 5
- Ruling out underlying laryngeal malignancy, which should always be considered in the differential 3
Surgical Technique Details
For Traditional Combined Approach
When TORS is not available, the combined approach requires:
- Endoscopic CO2 laser resection of the internal component with excision of the laryngocele in toto with its surrounding capsule 2
- External transcervical approach for the external component extending beyond the thyrohyoid membrane 3
- Average postoperative hospital stay of 1.8 days with traditional endoscopic approach 2
For TORS Approach
- Complete transoral excision of both components using the da Vinci surgical robot system 1
- Typically requires 2-day hospitalization 1
- Initial liquid diet with nasogastric tube supplementation, progressing to regular diet 1
- Voice outcomes are excellent with normal stroboscopy findings by 1 month postoperatively 1
Common Pitfalls to Avoid
- Do not attempt purely endoscopic CO2 laser excision for combined laryngoceles - this is only appropriate for internal laryngoceles 3, 4
- Do not delay tracheotomy in patients presenting with acute airway obstruction from infected laryngoceles 5
- Always obtain histopathological examination to rule out underlying laryngeal malignancy 3
- Ensure complete excision with capsule to prevent recurrence 2