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Upper airway obstruction due to a change in altitude: first report in fifty years Butskiy, Oleksandr; Anderson, Donald W Feb 1, 2016

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CASE REPORT Open AccessUpper airway obstruction due to a changein altitude: first report in fifty yearsOleksandr Butskiy1* and Donald W. Anderson1,2AbstractBackground: Air travel mostly causes minor ear, nose and throat complaints. We describe a second report inliterature of airway obstruction caused by a drop in atmospheric pressure during a routine commercial flight.Case presentation: A 54-year-old male was referred to a head and neck surgeon with a 2 cm left submandibularmass that would enlarge during commercial flights. As the plane gained elevation, the mass would grow and causehim to become stridorous and short of breath. The shortness of breath and stridor would only resolve uponlanding of the plane. A CT scan showed a large air sac extending from the larynx at the level of the true vocalcords up to the angle of the mandible. Based on the history and the CT findings a diagnosis of a laryngocele wasmade. The laryngocele was excised using an external approach, resolving the patient’s difficulty with flying.Conclusion: This article reports a rare case of upper airway obstruction caused by atmospheric pressure changesduring air travel. The reported case is of significance as only a few uncomplicated laryngoceles have been reportedto cause airway distress in the literature. This report highlights the epidemiology, presentation, complication andmanagement of laryngoceles.Keywords: Airway obstruction, Air travel, Neck mass, LaryngoceleBackgroundWith the exception of otic barotrauma, air travel hasonly been reported to cause minor complaints in the ear,nose and throat [1]. We describe a case of upper airwayobstruction during a routine commercial flight. Basedon our search of Embase®, Pubmed, Google Scholar, andWeb of Science™ databases (last search June 2015), webelieve this is to be the second case report of airwayobstruction caused by airplane’s change in altitude [2].Case presentationA 54-year-old male smoker was referred to a head andneck surgeon with a 2 cm left submandibular mass. Onhistory, the patient described a chronic non-painful leftneck mass that fluctuated in size over the years. The pa-tient’s chief complaint, however, was the problem he ex-perienced during commercial flights. During the plane’sascent, the left neck mass would enlarge, and he wouldbecome short of breath and stridorous. These symptomswould only resolve upon the plane’s descent. Duringthese episodes he never sought medical attention. How-ever, these episodes were severe enough that he has beenavoiding all air travel, and he only pursued surgicalconsultation to attend his daughter’s wedding abroad.On palpation of the neck, no neck mass, swelling, norlymphadenopathy were appreciated. Flexible laryngos-copy showed an infantile type epiglottis. A CT scan ofthe neck was ordered and showed a large air-containingsac in the left neck, extending from the level of the vocalcords to the level of the angle of the mandible. The airsac, insinuated between the left strap muscles and leftsternocleidomastoid, was causing mass effect on the leftsubmandibular gland and the laryngeal structures (Fig. 1).Based on the history and CT findings, a diagnosis of alaryngocele with internal and external components wasmade and the patient was counseled regarding its sur-gical excision.Discussion and surgical managementA laryngocele is an air filled abnormal dilation of the la-ryngeal saccule communicating with the laryngeal lumen.* Correspondence: butskiy.alex@gmail.com1Division of Otolaryngology Head and Neck Surgery, Department of Surgery,Vancouver General Hospital & University of British Columbia, Vancouver, BC,CanadaFull list of author information is available at the end of the article© 2016 Butskiy and Anderson. Open Access This article is distributed under the terms of the Creative Commons Attribution4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Butskiy and Anderson Journal of Otolaryngology - Head and Neck Surgery (2016) 45:9 DOI 10.1186/s40463-016-0121-yThe exact etiology of laryngoceles is unknown. Someauthors attribute laryngoceles to congenitally present dila-tion of the saccule exacerbated by factors that increaseintra-glottic pressure such as professional trumpet playing[3]. It is important to remember that laryngoceles areknow to present in the setting of laryngeal malignancy,secondary to partial of complete obstruction of the saccu-lar orifice [4]. Laryngoceles are rare. Traditionally, theincidence of laryngocele was reported to be approximately1 in 2.5 million people [5]. The true incidence of laryngo-celes is controversial, as more recent report suggest thatlaryngoceles might be more common than originallythought [6]. Two anatomical variations of laryngoceleshave been reported: internal to the thyroid cartilage and acombined type, consisting of external and internal compo-nents. The authors of a recent review reported that thetreatment of laryngoceles depends on the anatomicalvariation: internal laryngoceles tend to be treated withmicrolaryngoscopy with CO2 laser, while the combinedlaryngoceles tend to be excised through an external inci-sion [7].Given the size of the external component of the laryn-gocele presented in this report, an external approach, tothe laryngocele excision was taken. A detailed descriptionof the external surgical approach is available elsewhere [8].In brief, a lateral thyrotomy without tracheostomy waschosen to resect the laryngocele. Strap muscles werereflected down together with the raised left thyroid alaperichondrium (Fig. 2a). An inverted triangular section ofthe left thyroid lamina was resected, taking care to stayanterior and parallel to the left oblique line (Fig. 2b). Thelaryngocele was dissected away from the surroundingparaglottic space down to the laryngeal ventricle (Fig. 2c).The communication between the laryngocele and thelaryngeal ventricle was then clamped, tied and cut, deliver-ing the laryngocele out of the neck (Fig. 2d). Followingwound closure, the patient was successfully extubated inthe operating room. He spent the night in the hospital forobservation, and was discharged home with no changes inhis voice, swallowing or breathing.The patient’s follow up consisted of one office visit, 2weeks after the operation, and one and a half year phonefollow up. He was able to return to work 9 days after theoperation and had no complaints at any time. He re-sumed air travel 3 months following his surgery, and hehas not experienced airway obstruction or neck swellingduring flights again.The presented case highlights a typical patient whomight present with a laryngocele: a male in his fifth orsixth decade referred with a non-tender neck mass thatfluctuates in size [7]. The unusual part of the presentedcase is the airway obstruction caused by the laryngoceleduring air travel. Uncomplicated laryngoceles rarelycause airway obstruction [3]. Infected laryngoceles, orlaryngopyoceles, can on occasion lead to airway distress[7] and can potentially be lethal [9]. The airway obstruc-tion experienced by the patient presented in this casewas likely due to the drop in the atmospheric pressurein the cabin of an airplane. If the junction of the laryn-gocele with the laryngeal saccule was intermittentlyobstructed, the drop in air pressure during the plane’sascent would have led to laryngocele expansion, explain-ing the patient’s symptoms.We searched Embase®, Pubmed, Google Scholar, andWeb of Science™ databases (last search June 2015) andfound one case reports from 50 years ago of airway ob-struction during air travel caused by a laryngocele [2]. Inaddition, we also found a more recent brief communica-tion by an ophthalmologist recounting her experiencesfrom a commercial flight. Twenty minutes into a flight,she was asked to assist a passenger experiencing bulgingon the side of the neck. It is unclear if the passenger hadsymptoms of airway obstruction. This bulge resolved asthe plane made an emergency landing. The author ofthis brief communication did not follow the patient intothe hospital, and was writing to request an opinion withFig. 1 CT of the neck with contrast demonstrating a laryngoceleButskiy and Anderson Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:9 Page 2 of 3regard to what might have caused this unusual presenta-tion [10]. Given the similarities to the presented case, itis likely that the passenger might have had reversible air-way obstruction due to a laryngocele.ConclusionsThe presented case is the second case report of upperairway obstruction during air travel. Given the ubiquityof air travel, it is likely that other patients with laryngo-celes have experienced at least some worsening of theirsymptoms during airplane’s ascent. We encourage prac-titioners to question the rare patient that presents with asuspicion of a laryngocele about symptom changes withair travel. As illustrated in this case, a change in symp-toms during the ascent and descent of air travel can po-tentially support the physician’s diagnostic suspicion of alaryngocele.Consent to publishPatient provided written informed consent for publica-tion of the case report. Editor-in-chief was provided witha copy of the written consent.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsAD conceived this report and reviewed the manuscript. OB prepared themanuscript. Both authors read and approved the final manuscript.AcknowledgementsNone.Author details1Division of Otolaryngology Head and Neck Surgery, Department of Surgery,Vancouver General Hospital & University of British Columbia, Vancouver, BC,Canada. 2Gordon & Leslie Diamond Health Care Centre, 4th. Fl. 4299B-2775Laurel Street, Vancouver, BC V5Z 1 M9, Canada.Received: 18 June 2015 Accepted: 25 January 2016References1. Morse RP. The effect of flying and Low humidity on the admittance of thetympanic membrane and middle Ear system. JARO J Assoc Res Otolaryngol.2013;14:623–33.2. Krekorian EA. Laryngocele in a jet flyer. Laryngoscope. 1966;76:563–71.3. Vasileiadis I, Kapetanakis S, Petousis A, Stavrianaki A, Fiska A, Karakostas E.Internal laryngopyocele as a cause of acute airway obstruction: anextremely rare case and review of the literature. [Review]. ActaOtorhinolaryngol Ital. 2012;32:58–62.4. Celin SE, Johnson J, Curtin H, Barnes L. The association of laryngoceles withsquamous cell carcinoma of the larynx. Laryngoscope. 1991;101:529–36.5. Stell PM, Maran AG. Laryngocoele. J Laryngol Otol. 1975;89:915–24.6. Shandilya M, Colreavy MP, Hughes J, Curran AJ, McShane DP, O’Dwyer T,et al. Endolaryngeal cysts presenting with acute respiratory distress. ClinOtolaryngol Allied Sci. 2004;29:492–6.7. Zelenik K, Stanikova L, Smatanova K, Cerny M, Kominek P. Treatment oflaryngoceles: what is the progress over the last Two decades? BioMed ResInt. 2014;2014:e819453.8. Rosen CA, Simpson B, Leden H, Ossoff RH. Operative techniques inlaryngology. 2008th ed. Berlin: Springer; 2008.9. Byard RW, Gilbert JD. Lethal laryngopyocele. J Forensic Sci. 2015;60:518–20.10. Bergkvist MH. Lateral neck cyst as a cause of partial upper airwayobstruction? Ugeskr Laeger. 2012;174:2811.ADCBFig. 2 Resection of the laryngocele. (a) Strap muscles reflected inferiorly, bringing the laryngocele into view; (b) Planning to resect a portion ofleft thyroid lamina to gain further exposure; (c) Laryngocele dissected away from the paraglottic space down to the laryngeal ventricle; (d)Laryngocele delivered out of the neckButskiy and Anderson Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:9 Page 3 of 3

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