Thyrohyoid Membrane Research Articles

Pharyngoceles: A photo‐anatomic study and novel management

Pharyngoceles are outpouchings of the lateral pharyngeal wall through the thyrohyoid membrane. These entities are inconsistently documented in the literature given the varying terminology and poor anatomic description. Open surgical repair has been the mainstay of treatment for symptomatic pharyngoceles. A systematic literature review was conducted to identify articles presenting cases of pharyngoceles. Two case reports supplement the data found. Through a PubMed search, articles were examined specifically for anatomical discussions, presenting symptoms, and management strategies. To this data, we add two cases of bilateral symptomatic pharyngoceles with full multimedia documentation, including one patient treated successfully with novel endoscopic suture pharyngoplasties. Twenty-five articles were identified that described 59 cases of pharyngoceles, for a total of 61 patients reviewed. Few articles include descriptive anatomy and correlate in vivo examples, and none describe intraluminal pharyngocele structure in detail. Both patients at our institution had complete resolution of their symptoms, as determined by interviews and oropharyngeal motility studies. Relatively few true pharyngoceles have been reported in the surgical literature. We offer the first detailed endoscopic anatomic description and formal evaluation of swallowing outcomes, as well as an anatomically-based endoscopic approach. These lesions may be amenable to endoscopic repair with minimal long-term morbidity.

Bilateral Mixed Laryngocele

ABSTRACT Laryngocele is a rare, benign dilatation of the laryngeal saccule that may extend internally into the airway or externally through the thyrohyoid membrane. The incidence of laryngocele is 1 per 2.5 million people per year. It may be asymptomatic or sometimes may present with cough, hoarseness, stridor, sore throat and as a swelling on one or both sides of the neck. We are reporting a case of bilateral mixed laryngocele in a 41 years old male, its clinical presentation and investigations along with a review of literature. How to cite this article Gupta R, Gupta S, Bhat A, Kalsotra P, Singh KP, Prakash O, Gupta S. Bilateral Mixed Laryngocele. Int J Phonosurg Laryngol 2013;3(2):69-72.

Comparative Analysis on the Efficiency of the Injection Laryngoplasty Technique Using Calcium Hydroxyapatite (CaHA): The Thyrohyoid Approach Versus the Cricothyroid Approach

Temporary or permanent vocal paralysis can occur after head and neck surgery for thyroid cancer, esophageal resection, a chest operation that includes lung parenchymal resection due to a vagus or recurrent laryngeal nerve injury, and so forth. These days, the main treatment for vocal fold paralysis is the injection laryngoplasty through the cricothyroid (CT) approach. However, the CT approach is difficult in that an operator cannot see from the tip of the needle to the vocal fold. The aim of this study was to determine the efficacy of the thyrohyoid (TH) approach compared with the CT approach using calcium hydroxyapatite (CaHA) in patients with permanent unilateral vocal fold palsy. From March 2008 to July 2012, 68 consecutive injection laryngoplasties were performed in patients with unilateral glottic insufficiency. Percutaneous injection was performed under local anesthesia into the vocalis muscle, using disposable 25 gauge, 11cm long spinal needles through the CT membrane or TH membrane. Of the 68 patients, videostroboscopic findings and acoustic, perceptual, and subjective evaluations were completed for 64 patients before injection and at 3 months after injection. In the 64 patients, the CT and TH approaches were used in 30 and 34 patients, respectively. The videostroboscopic findings, acoustic and perceptual parameters (maximum phonation time, jitter, shimmer, and noise-to-harmonic ratio), and Voice Handicap Index significantly improved after the injection in both the CT and TH groups (P<0.05). Based on the results of this trial, injection laryngoplasty using the TH approach is an effective alternative to the CT approach, especially for the injection of CaHA in patients with permanent unilateral vocal fold palsy.

Clinical analyses of 113 aryepiglottic fold diseases

To analyze the distribution and treatment of aryepiglottic fold diseases. The clinical data of the inpatients with aryepiglottic fold diseases at our department from January 2000 to May 2011 were retrospectively evaluated. Among 113 cases, there were benign (n = 108) and malignant (n = 5) diseases. The three major symptoms were abnormal sensation of throat (n = 79), hoarseness (n = 29) and throat pain (n = 26). Among 108 benign cases, there were surgery under direct laryngoscopy (n = 100), aryepiglottic fold hemangioma undergoing laser under indirect laryngoscopy (n = 4), one with cyst and another with hemangioma undergoing tumor removal via an external thyrohyoid membrane approach (n = 2) and inflammation of aryepiglottic fold undergoing conservative treatment (n = 2). Among 5 malignant tumors, the procedures included total laryngectomy (n = 2) and semi-laryngectomy (n = 2). One patient had not any treatment after a definite diagnosis. Most aryepiglottic fold diseases are benign. Their major symptoms include abnormal sensation of throat, hoarseness and throat pain. Surgery under direct laryngoscopy is performed for benign diseases while laryngectomy for malignant ones. CO(2), Ho-YAG and KTP laser may also be used.

Combined hyoid bone flap in laryngeal reconstruction after extensive partial laryngectomy for laryngeal cancer

Patients undergoing extensive partial laryngectomy require laryngeal reconstruction to restore function. Several techniques have been described, but they are associated with complications such as laryngeal stenosis. The aim of this study was to describe a new technique of combined hyoid bone and thyrohyoid membrane flap in laryngeal reconstruction after tumor resection, and to evaluate outcome. Eight patients requiring an extensive vertical or frontal partial laryngectomy for cancer were enrolled. Following radical tumor resection, laryngeal reconstruction was performed using the hyoid bone with a thyrohyoid membrane flap. Postoperative recovery time, complications, vocal quality, and cancer outcome were evaluated. The procedure was successful in all patients. There were no deaths, and no reports of postoperative dyspnea or dysphagia. Decannulation was performed in all patients after a median duration of 3 days (range 2-5 days). Swallowing and respiratory function were satisfactory and laryngeal stenosis did not occur during the mean follow-up period of 30.5 months. One patient had a local recurrence and required a salvage operation. A combined hyoid bone and thyrohyoid membrane flap is a reliable and relatively safe procedure that can be successfully performed for laryngeal reconstruction after extensive vertical or frontal partial laryngectomy.

A case of mixed type laryngocele presented with deep neck infection and review of the literature

Laryngocele is an abnormal dilatation of the laryngeal ventricular saccule that may extend into the subcutaneous tissues of the neck through the thyrohyoid membrane or confined to the endolarynx. The etiology is still unclear. Many laryngoceles are asymptomatic. An asymptomatic laryngocele appears and produces symptoms only as it enlarges or when it becomes infected. In this report, we present a 40-year-old female patient, which had an asymptomatic neck swelling for 20 years, referred for deep neck infection, dysphonia and dyspnea.

Pharyngoceles: Photo‐Anatomic Study and Novel Management

Objective: Pharyngoceles are outpouchings of the lateral pharyngeal wall through the thyrohyoid membrane. They are often noted as incidental findings on pharyngoesophageal imaging studies and are rarely symptomatic. Open surgical repair has been the mainstay of treatment for symptomatic pharyngoceles, save 2 reports of stapling which lack detailed anatomical description. Method: A systematic review was conducted to identify papers presenting cases of pharyngoceles. Articles were examined specifically for anatomic discussions, figures delineating the anatomy, and management strategies. To this data, we add 2 cases of bilateral symptomatic pharyngoceles with full multimedia documentation, including one treated successfully with a novel endoscopic suture-pharyngoplasty. Results: Thirty papers were identified which described 49 cases of pharyngoceles, for a total of 51 with our cases. The anatomic boundaries of the pharyngocele space are the hyoid bone, thyroid cartilage, and thyrohyoid ligament with close involvement of the superior laryngeal nerve. Both unilateral and bilateral pharyngoceles have been reported, presenting with a variety of symptoms including dysphagia, globus, and neck-swelling. One reported case of bilateral pharyngoceles was asymptomatic. Of those patients symptomatic enough to require surgery, all endorsed resolution of symptoms postoperatively. Both of our patients had complete resolution of symptoms, as determined by interview and oropharyngeal motility study. Conclusion: Relatively few true pharyngoceles have been reported in the literature. We offer the first detailed endoscopic anatomic description of pharyngoceles and a novel technique of endoscopic suture pharyngoplasty, as well as a formal evaluation of swallowing outcomes postoperatively. These lesions may be amenable to endoscopic repair with minimal morbidity.

Novel Techniques in Head and Neck Ultrasound

Objective: 1) Report new uses of ultrasound within the head and neck. 2) Emphasize how the use of ultrasound can enhance patient management and alter treatment delivery. Method: Present a series of 7 cases from the past year at a single academic institution where ultrasound was used in a novel way to enhance patient care. Compare the ultrasound images obtained with other imaging modalities. Results: Three patients underwent ultrasound-guided fine- needle aspiration (FNA) of tongue base tumors, which avoided the necessity of a tracheotomy in 1 patient with a difficult airway. Two patients underwent ultrasound-guided FNA of supraglottic tumors through the thyrohyoid membrane, which obviated the need for biopsy with general anesthesia. One noncancer patient had a highly metabolic enlarged lymph node on PET/CT though it demonstrated benign characteristics on ultrasound. Both ultrasound-guided FNA and incisional biopsy confirmed the lymph node’s benignity. One patient had a vallecular foreign body seen on ultrasound but not on flexible laryngoscopy, and it was retrieved in the operating room. Conclusion: Ultrasound can be used to guide FNA for tissue diagnosis from tongue base and larynx tumors. Ultrasound-guided FNA may eliminate the need for biopsy under general anesthesia for some patients. Ultrasound has an expanding array of applications and is a useful tool in the otolaryngologist’s hands.

Transoral robotic surgery total laryngectomy

has been reported with feasibility trials andpromising initial data. The combination of the two proce-dures, supraglottic and hypopharyngeal TORS resection,can be adapted to perform a TORS total laryngectomy(TORS-TL). In the past, TORS-TL has been met with skep-tical criticism as to its ultimate clinical benefit. Conversely,the authors suggest that the minimally invasive TORSapproach offers significant benefits toward improvingpatient recuperation and the avoidance of substantial post-operative morbidity. However, such benefits can only bedemonstrated following repeated clinical experience. It isthe purpose of this report to describe the surgical protocolutilized by the authors to encourage further application andstudy of this promising surgical advancement.

Double‐bend needle modification for transthyrohyoid vocal fold injection

Our objective was to describe an injection needle modification for awake in-office vocal fold injections through a percutaneous transthyrohyoid approach. Two separate 45° angle bends are created at the hub and 1 cm from the needle tip of a 25-gauge, 1.5-inch needle. After adequate endolaryngeal anesthesia, the needle is passed via the thyrohyoid membrane into the airway. The needle tip is at a 90° angle to the syringe, providing access to the entire vocal fold surface, regardless of chin position or thyroid cartilage angulation. The bend at 1 cm also serves as a marker to measure the depth of the needle within the soft tissue. The double-bend needle modification allows for complete access to the entire length of the true vocal fold in one pass as well as a marker to measure depth of the needle in the tissue. Limitations may include bleeding from the injection site, insufficient needle length in patients with a long anterior-posterior dimension of the larynx, and potential difficulty passing a needle through a calcified thyrohyoid membrane.

Redefining Anatomy in a Case of Midline Subhyoid Ectopic Thyroid

ABSTRACTEctopic thyroid is an uncommon embryological aberration of the thyroid descent. Subhyoid median ectopic thyroid gland is a result of incomplete descent of the thyroid anlage and is characterized by a cosmetically unacceptable ovoid mass of thyroid tissue in the midline overlying the thyroid cartilage and thyrohyoid membrane. A normally placed thyroid gland is not detectable and in most cases all functioning thyroid tissue is located within the mass. Usually it is mistaken for a thyroglossal cyst and excised. Severe myxedema follows removal. Many cases have been reported in the literature, none of which was recognized prior to operation. All patients were operated upon for removal of a thyroglossal duct cyst. The diagnosis was missed at operation and in these cases severe myxedema was universal. The cause of the myxedema was not always immediately recognized. Therefore, many diagnostic tests including thyroid function test, ultrasound of the neck and thyroid scanning had been recommended in the preoperative evaluation of a thyroglossal cyst. Here, we present a case of ectopic thyroid mass which was the only thyroid tissue present in the neck. So division and repositioning of the thyroid mass thereby redefining the anatomy was done with good cosmetic result.How to cite this articleNaik KM. Redefining Anatomy in a Case of Midline Subhyoid Ectopic Thyroid. Int J Head and Neck Surg 2012;3(3):179-181.

156 Utility of Bedside Ultrasound as Airway Assessment Tool in Patients Receiving Procedural Sedation

156 Utility of Bedside Ultrasound as Airway Assessment Tool in Patients Receiving Procedural Sedation

Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part III. Cadaveric Representation of the Course of Second and Third Cleft and Pouch Fistulas

"Stepladder" surgery for fistula from second or third pharyngeal cleft and pouch is "blind." Neither intraoperative methylene blue injection and probing nor preoperative imaging (fistulogram ultrasound, computed tomography, magnetic resonance imaging) reveal three-dimensional anatomic relations of fistulas. This article describes the most common second and third fistula courses and demonstrates representation of their tracts with wires in human cadavers. A second cleft and pouch fistula, at its external opening, pierces superficial cervical fascia (and platysma), then investing cervical fascia, and travels under the sternocleidomastoid muscle, superficial to the sternohyoid and anterior belly of omohyoid. It ascends along the carotid sheath, and at the upper border of the thyroid cartilage it pierces the pretracheal fascia. Characteristically, it courses between the carotid bifurcation and over the hypoglossal nerve. After passing beneath the posterior belly of the digastric muscle and the stylohyoid, it hooks around both glossopharyngeal nerve and stylopharyngeus muscle. The fistula reaches the pharynx below the superior constrictor muscle. The course of a third cleft and pouch fistula is similar until it has pierced pretracheal fascia; then it passes over the hypoglossal nerve and behind the internal carotid, finally descending parallel to the superior laryngeal nerve, reaching the thyrohyoid membrane cranial to the nerve.

Ultrasound-guided fine needle aspiration diagnosis of supraglottic laryngeal cancer

Although intraoperative laryngoscopic examination and biopsy of patients who present with locally advanced supraglottic carcinomas remains the standard of care, there are occasions when a more expedited biopsy can be helpful. We describe a quick diagnostic technique of ultrasound-guided fine needle aspiration of endolaryngeal advanced supraglottic carcinomas, which can be performed in the clinic without any preparation. Ultrasound scanning is performed through the thyrohyoid membrane. The tumor is visualized as an irregular hypoechoic mass. While continuing to visualize the mass, a 21-gange needle attached to a syringe is passed through the contralateral thyrohyoid membrane into the mass. Suction is applied, and the aspirate is sent for cytologic study. When formal intraoperative laryngoscopy and biopsy is not feasible or timely, ultrasound-guided fine-needle aspiration biopsy enables a rapid diagnosis and eliminates the cost, side effects, and risks of a direct laryngoscopy.

Pilot Study to Determine the Utility of Point‐of‐care Ultrasound in the Assessment of Difficult Laryngoscopy

Prediction of difficult laryngoscopy in emergency care settings is challenging. The preintubation clinical screening tests may not be applied in a large number of emergency intubations due to the patient's clinical condition. The objectives of this study were 1) to determine the utility of sonographic measurements of thickness of the tongue, anterior neck soft tissue at the level of the hyoid bone, and thyrohyoid membrane in distinguishing difficult and easy laryngoscopies and 2) to examine the association between sonographic measurements (thickness of tongue and anterior neck soft tissue) and difficult airway clinical screening tests (modified Mallampati score, thyromental distance, and interincisor gap). This was a prospective observational study at an academic medical center. Adult patients undergoing endotracheal intubation for an elective surgical procedure were included. The investigators involved in data collection were blinded to each other's assessments. Demographic variables were collected preoperatively. The clinical screening tests to predict a difficult airway were performed. The ultrasound (US) measurements of tongue and anterior neck soft tissue were obtained. The laryngoscopic view was graded using Cormack and Lehane classification by anesthesia providers on the day of surgery. To allow for comparisons between difficult airway and easy airway groups, a two-sided Student's t-test and Fisher's exact test were employed as appropriate. Spearman's rank correlation coefficients were used to examine the association between screening tests and sonographic measurements. The mean (±standard deviation [SD]) age of 51 eligible patients (32 female, 19 male) was 53.1 (±13.2) years. Six of the 51 patients (12%, 95% confidence interval [CI] = 3% to 20%) were classified as having difficult laryngoscopy by anesthesia providers. The distribution of laryngoscopy grades for all subjects was 63, 25, 4, and 8% for grades 1, 2, 3, and 4, respectively. In this study, 83% of subjects with difficult airways were males. No other significant differences were noted in the demographic variables and difficult airway clinical screening tests between the two groups. The sonographic measurements of anterior neck soft tissue were greater in the difficult laryngoscopy group compared to the easy laryngoscopy group at the level of the hyoid bone (1.69, 95% CI = 1.19 to 2.19 vs. 1.37, 95% CI = 1.27 to 1.46) and thyrohyoid membrane (3.47, 95% CI = 2.88 to 4.07 vs. 2.37, 95% CI = 2.29 to 2.44). No significant correlation was found between sonographic measurements and clinical screening tests. This pilot study demonstrated that sonographic measurements of anterior neck soft tissue thickness at the level of hyoid bone and thyrohyoid membrane can be used to distinguish difficult and easy laryngoscopies. Clinical screening tests did not correlate with US measurements, and US was able to detect difficult laryngoscopy, indicating the limitations of the conventional screening tests for predicting difficult laryngoscopy.

Topographic anatomy of the internal laryngeal nerve: Surgical considerations

This study is focused on the topographic features of the internal branch of the superior laryngeal nerve (ibSLN) at the thyrohyoid membrane area using as anatomic landmarks the posterior border of the thyrohyoid muscle and the superior border of the thyroid cartilage. Thirty-six fresh adult cadavers were dissected to determine the topography and branching pattern of the ibSLN and the superior laryngeal artery. The ibSLN prior to thyrohyoid membrane's penetration was divided into 3 or 2 branches, in 72.22% and 27.78% of cases. The trifurcated ibSLN was more common than the bifurcated in both sexes and in both sides of the neck. In over 80% of cases the ibSLN penetrated the thyrohyoid membrane 0.1 to 0.9 cm far from the posterior border of the thyrohyoid muscle and 0.1 to 1.2 cm far from the superior border of the thyroid cartilage. We provide a schematic overview of the ibSLN penetration zone at the thyrohyoid membrane, the so-called danger zone, to avoid ibSLN damage.

Patterns of extralaryngeal spread of laryngeal cancer

Laryngeal preservation programs for patients with advanced laryngeal squamous cell carcinomas (SCC) have generally excluded patients with T4 disease. The accuracy of preoperative imaging in evaluating thyroid cartilage penetration and extralaryngeal spread (ELS) has previously been questioned. Clinically, SCC spread into noncartilaginous structures may have less of a functional impact when compared with thyroid cartilage penetration. The current study was designed to characterize and quantify the routes and frequency of ELS. A total of 103 laryngectomy specimens with preoperative contrast-enhanced neck computed tomography scans were coded according to the observed extent of disease by pathological and radiological data. Previously irradiated tumors or those of pyriform sinus origin were omitted. Routes of spread were categorized as anterior (thyroid cartilage penetration), posterior (arytenoid cartilage destruction and thyroarytenoid space widening), inferior (conus elasticus penetration), and superior (base of tongue, thyrohyoid membrane or thyroid notch penetration involvement). Sixty-three cases of ELS were identified. Anterior spread by thyroid cartilage penetration occurred in 44% of all instances of ELS, followed by both inferior and posterior spread each representing 33% of ELS cases. Superior spread occurred with a frequency of 24%. Although thyroid cartilage penetration is a common route of ELS of glottic and supraglottic SCC, ELS into surrounding structures with thyroid cartilage penetration was found to occur in only 44% of the cases of ELS in the current study. As illustrated, advanced SCC spreads in a variety of pathways. Once these patterns are better understood and identified at the time of initial evaluation, subgroups of patients with ELS who may still be candidates for laryngeal preservation may be identified.

Endoscopic CO 2 laser excision of combined laryngocoele

Virchow described a laryngocoele as a saccule extending above the thyrohyoid membrane. Total excision and marsupialisation are established surgical techniques for external and internal laryngocoeles. The external cervical approach is advocated for external and combined laryngocoeles. We describe here a case of combined laryngocoele that was treated endoscopically, using a CO 2 laser. Both the internal and external components of the laryngocoele were excised completely; its internal supraglottic component was excised followed by the external component into the neck. The CO 2 laser with its property of minimal trauma to adjacent tissues, quick tissue recovery, reduced hospital stay and avoidance of tracheostomy makes it useful for treatment of laryngocoele. Endoscopic CO 2 laser excision also avoids the necessity of an external approach.

An unusual presentation of thyroglossal duct cyst associated with papillary thyroid carcinoma

Thyroglossal duct cyst is the most common form of congenital malformations in the neck. Thyroglossal duct cyst presents characteristically as a midline cervical mass at the level of thyrohyoid membrane. Approximately 25% are located within 2 cm of midline. Carcinoma arising in thyroglossal duct cyst constitutes a very uncommon clinicopathological entity (about 1% of thyroglossal duct cyst) This is a report of an unusual location of thyroglossal duct cyst (supraclavicular region) associated with papillary carcinoma. Papillary thyroid carcinoma is the most common cancer of the thyroid gland (about 90% of cases) and represents also the most frequently encountered carcinoma in thyroglossal duct cyst.

Atypical Presentation of Thyroglossal Duct Cyst in a Pediatric Patient

Atypical Presentation of Thyroglossal Duct Cyst in a Pediatric Patient