Fixity of vocal cords and laryngocele in acromegaly

Abstract

Acromegalic patients have a reduced life expectancy mainly due to cardio-, cerebrovascular and respiratory disorders and increased prevalence of neoplasias. Particularly, the pathogenesis of respiratory disorders in acromegalics is debated. Laryngeal abnormalities are not yet well clarified even if they are frequently involved in the occurrence of respiratory insufficiency. In this study, we report on a 65 year-old acromegalic male suffering from frequent and severe dyspnea attacks and clinical findings of respiratory upperway obstruction, besides the common acromegalic features. At the external examination of the larynx, a bilateral painless and soft mass, located in the laterocervical region under the hyoid bone, was detected. Fiberoptic laryngoscopy, showed bilateral swelling between the aryepiglottic fold and the false vocal cords, whose size increased during the expiration and the phonation, fixity of the vocal cords in paramedian position, with a marked reduction of the respiratory space and increase in arytenoid cartilage size and mucosal edema. Neck and mediastinum CT scan showed the presence of an air containing bilateral swelling, crossing the thyrohyoid membrane. Bilateral cricoarytenoidal joint chondrocalcification, associated to a mixed-type bilateral laryngocele, was diagnosed. Laryngoceles were both surgically removed and a left monolateral arytenoidectomy was performed, using fiberoptic microlaryngoscopy with CO₂ laser. The clinical evaluation, one month later, confirmed the complete disappearance of dyspnea and a partial improvement of phonation. Three months later, laryngoscopy showed the bilateral restoration of vocal cords motility and a significant improvement of phonation. This case presents an uncommon and severe respiratory problem in acromegaly such as the fixity of vocal cords associated to laryngocele. Circulating GH and IGF-I hypersecretion caused edema and laxity of laryngeal mucosa as well as bilateral ankylosis of cricoarytenoidal joints. The use of CO₂ laser technique via micro-laryngoscopy successfully resolved laryngeal abnormalities.