Melley, Lauren E

Ramadan, Omar

Sataloff, Robert T

Witcher, Ryan

English

Philadelphia College of Osteopathic Medicine: DigitalCommons@PCOM

Philadelphia College of Osteopathic Medicine DigitalCommons@PCOM Otolaryngology (ENT) Resident Research Graduate Medical Education Research 12-26-2023 Vocal Fold Paresis and Bilateral Anterior Laryngeal Saccular Cysts in a Singer. Ryan Witcher Lauren E Melley Philadelphia College of Osteopathic Medicine Omar Ramadan Robert T Sataloff Follow this and additional works at: https://digitalcommons.pcom.edu/ent_residents  Part of the Otolaryngology Commons Recommended Citation Witcher, Ryan; Melley, Lauren E; Ramadan, Omar; and Sataloff, Robert T, "Vocal Fold Paresis and Bilateral Anterior Laryngeal Saccular Cysts in a Singer." (2023). Otolaryngology (ENT) Resident Research. 112. https://digitalcommons.pcom.edu/ent_residents/112 DOI: https://doi.org/10.1177/01455613231216850 This Article is brought to you for free and open access by the Graduate Medical Education Research at DigitalCommons@PCOM. It has been accepted for inclusion in Otolaryngology (ENT) Resident Research by an authorized administrator of DigitalCommons@PCOM. For more information, please contact jaclynwe@pcom.edu. https://doi.org/10.1177/01455613231216850Ear, Nose & Throat Journal 1 –2© The Author(s) 2023Article reuse guidelines: sagepub.com/journals-permissionsDOI  10.1177/0 45561323 216850journals.sagepub.com/home/earCreative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and  Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).Laryngoscopic ClinicSignificance StatementThe case highlights the importance of comprehensive analysis of the root cause of dysphonia. On examination, bilateral supraglottic cysts were detected; however, the vocal fold paresis and compensatory hyperfunction were the primary causes of his symptoms. This case demon-strates that targeted voice therapy can yield substantial improvement in vocal endurance and range, ultimately avoiding the need for surgical intervention in select cases.A 42-year-old male singer presented to our office com-plaining of voice fatigue and dysphonia. He was the lead singer in a 4-piece band. Starting a year prior to our evalu-ation, he had encountered difficulties singing, often strain-ing his voice to compensate during performances, which resulted in odynophagia. He struggled with intermittent phonation breaks and gradual development of voice fluc-tuations without diplophonia. His past medical history was significant for laryngopharyngeal reflux which had been treated with esomeprazole and he was referred due to bilat-eral vocal fold masses observed on flexible laryngoscopic examination by a laryngologist elsewhere. Our office examination revealed bilateral vocal fold paresis which was confirmed with laryngeal electromyography showed bilateral recurrent laryngeal nerve (RLN) paresis and right superior laryngeal nerve (SLN) weakness with 40% to 50% decreased recruitment in both thyroarytenoid muscles and 20% decreased recruitment in the right cricothyroid mus-cle. Strobovideolaryngoscopy showed bilateral supraglot-tic masses, considered to be a right saccular cyst or possibly a right laryngocele, and a left saccular cyst extending slightly more cephalad (Figure 1). The cysts were in con-tact intermittently with the superior surfaces of the vocal folds and impaired movemement primarily on the right, especially during efforful phonation. Computerized tomog-raphy (CT) scan ruled out laryngocele. Both the vocal fold masses and the vocal fold paresis were concurrently con-sidered as the possible root cause for the patient’s dyspho-nia, and initial treatment began with vocal therapy.Vocal fold paresis involves weakness in the RLN, SLN, or a combination of the 2. These conditions can have numerous causes, including iatrogenic injury during sur-gery, neurologic diseases, infections, trauma, and others. The clinical manifestations of vocal fold paresis and paral-ysis include symptoms such as dysphonia, hoarseness, breathiness, throat pain, and decreased vocal stamina. Unilateral RLN injury often presents as a breathy voice and may lead to diplophonia, aspiration, and dysphagia, while SLN injuries can result in changes in pitch, relatively monotone voice, decreased projection and vocal stability, and reduced high pitch range. Compensatory mechanisms such as muscle tension dysphonia may develop. In some cases, reinnervation occurs, but it often leads to synkinesis resulting in immobility or reduced mobility of the vocal fold. Treatment ranges from conservative voice therapy to surgical alteration of vocal fold position.1Laryngeal cysts are categorized by Desanto et al2 as either ductal or saccular. Ductal cysts, typically smaller than 1 cm, are mucus retention cysts originating from the mucous membranes. They can be visualized on a CT scan as fluid-filled structures located from the inferior bound-ary of the hyoid bone to the vestibular folds. Saccular 1216850 EARXXX10.1177/01455613231216850Ear, Nose & Throat JournalWitcher et al.research-article20231  Doctor of Osteopathic Medicine Program, Lake Erie College of Osteopathic Medicine-Bradenton Campus, Bradenton, PA, USA2  Department of Otolaryngology-Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA3  Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, PA, USA4  Department of Otolaryngology-Head and Neck Surgery, Senior Associate Dean for Clinical Academic Specialties, Drexel University College of Medicine, Philadelphia, PA, USAReceived: October 14, 2023; revised: November 6, 2023; accepted: November 9, 2023Corresponding Author:Robert T. Sataloff, MD, DMA FACS, Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, 219 N. Broad Street, 10th Floor, Philadelphia, PA 19107, USA.Email: rtsataloff@phillyent.comVocal Fold Paresis and Bilateral Anterior Laryngeal Saccular Cysts in a SingerRyan Witcher, BS1 , Lauren E. Melley, DO2 , Omar Ramadan, MD3, and Robert T. Sataloff, MD, DMA FACS42 Ear, Nose & Throat Journal 00(0)cysts, are typically larger, often measuring between 1 cm and 7 cm. Saccular cysts arise from the submucosal plane within the laryngeal saccule and can be visualized on a CT scan as fluid-filled cysts.3 Saccular cysts can develop con-genitally, presenting with early obstructive dyspnea and noisy breathing in neonates.4 Acquired saccular cysts sel-dom result in airway compromise; more commonly, acquired saccular cysts present later in life with voice changes.5 Saccular cysts can be classified further as ante-rior or lateral. Anterior saccular cysts are found within the saccular orifice and are visible in the anterior glottic air-way. Lateral saccular cysts expand into the laryngeal ves-tibule, and can affect supraglottic anatomy at the level of the aryepiglottic folds, false vocal folds, and epiglottis.6,7In this patient, differential diagnoses included laryngo-cele, which is seen on a CT scan as an air-filled dilation originating from the laryngeal saccule and enlargens dur-ing a Valsalva maneuver.8 This differs from saccular cysts, which remain fairly stable during a Valsalva maneuver and which are not filled with air. Rare cystic causes of dyspho-nia associated with distortion of supraglottic structures include thyroglossal and third brachial cleft cysts. These conditions typically present with physical exam findings in the external neck, in addition to classic features visible on a CT scan.9,10This patient’s symptoms were primarily due to vocal fold paresis and associated hyperfunctional compensation, not the cysts. The patient underwent conservative management with voice therapy, which significantly improved his vocal stamina. Subsequently, the patient was able to achieve a greater voice range, including higher tones. When the hyperfunction was eliminated, the cysts did not contact the vocal folds and were not symptomatic. So, surgery was not requried.Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.FundingThe author(s) received no financial support for the research, authorship, and/or publication of this article.ORCID iDsRyan Witcher  https://orcid.org/0000-0001-5234-3636Lauren E. Melley  https://orcid.org/0000-0003-2673-8129Robert T. Sataloff  https://orcid.org/0000-0001-5146-6319References 1. Rubin AD, Sataloff RT. Vocal fold paresis and paraly-sis. Otolaryngol Clin N Am. 2007;40(5):1109-1131. doi: 10.1016/j.otc.2007.05.012 2. Desanto LW, Devine KD, Weiland LH. Cysts of the lar-ynx—classification. Laryngoscope 1970;80(1):145-176. 3. Heyes R, Lott DG. Laryngeal cysts in adults: simplifying classification and management. Otolaryngol Head Neck Surg 2017;157(6):928-939. 4. Abramson AL, Zielinski B. Congenital laryngeal saccular cyst of the newborn. Laryngoscope 1984;94(12):1580-1582. 5. Hogikyan ND, Bastian RW. Endoscopic CO2 laser exci-sion of large or recurrent laryngeal saccular cysts in adults. Laryngoscope 1997;107(2):260-265. 6. Rosen CA, Simpson CB. Operative techniques in laryngol-ogy. Springer Science & Business Media; 2008. 7. Shaik FB, Chowdary KK. A clinical study of laryngeal cysts. Int J Phonosurg Laryngol 2012;6(2):53-56. 8. Desanto LW. Laryngocele, laryngeal mucocele, large sac-cules, and laryngeal saccular cysts: a developmental spec-trum. Laryngoscope 1974;84(8):1291-1296. 9. Venkatesan SK, Manoharan KS, Parida PK, Alexander A, Gopalakrishnan S. Stridor in an elderly woman: an unusual presentation of a giant thyroglossal cyst. Case Rep Otolaryngol 2013; 2013:2-3. 10. Li Z, Zhang J, Yang Y, He X. Third branchial cleft cyst as a cause of hoarseness: a case report. J Int Med Res 2021;49(5):03000605211012549.Figure 1. Stroboscopic examination at high pitch showing the right saccular cyst located in the anterior ventricle near the midline (black arrow) and the left-sided saccular cyst above the left false vocal fold near midline (white arrow).

Vocal Fold Paresis and Bilateral Anterior Laryngeal Saccular Cysts in a Singer.

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Vocal Fold Paresis and Bilateral Anterior Laryngeal Saccular Cysts in a Singer.

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