Upper airway obstruction due to a change in altitude: first report in fifty years
© Butskiy and Anderson. 2016
Received: 18 June 2015
Accepted: 25 January 2016
Published: 1 February 2016
Air travel mostly causes minor ear, nose and throat complaints. We describe a second report in literature of airway obstruction caused by a drop in atmospheric pressure during a routine commercial flight.
A 54-year-old male was referred to a head and neck surgeon with a 2 cm left submandibular mass that would enlarge during commercial flights. As the plane gained elevation, the mass would grow and cause him to become stridorous and short of breath. The shortness of breath and stridor would only resolve upon landing of the plane. A CT scan showed a large air sac extending from the larynx at the level of the true vocal cords up to the angle of the mandible. Based on the history and the CT findings a diagnosis of a laryngocele was made. The laryngocele was excised using an external approach, resolving the patient’s difficulty with flying.
This article reports a rare case of upper airway obstruction caused by atmospheric pressure changes during air travel. The reported case is of significance as only a few uncomplicated laryngoceles have been reported to cause airway distress in the literature. This report highlights the epidemiology, presentation, complication and management of laryngoceles.
With the exception of otic barotrauma, air travel has only been reported to cause minor complaints in the ear, nose and throat . We describe a case of upper airway obstruction during a routine commercial flight. Based on our search of Embase®, Pubmed, Google Scholar, and Web of Science™ databases (last search June 2015), we believe this is to be the second case report of airway obstruction caused by airplane’s change in altitude .
Discussion and surgical management
A laryngocele is an air filled abnormal dilation of the laryngeal saccule communicating with the laryngeal lumen. The exact etiology of laryngoceles is unknown. Some authors attribute laryngoceles to congenitally present dilation of the saccule exacerbated by factors that increase intra-glottic pressure such as professional trumpet playing . It is important to remember that laryngoceles are know to present in the setting of laryngeal malignancy, secondary to partial of complete obstruction of the saccular orifice . Laryngoceles are rare. Traditionally, the incidence of laryngocele was reported to be approximately 1 in 2.5 million people . The true incidence of laryngoceles is controversial, as more recent report suggest that laryngoceles might be more common than originally thought . Two anatomical variations of laryngoceles have been reported: internal to the thyroid cartilage and a combined type, consisting of external and internal components. The authors of a recent review reported that the treatment of laryngoceles depends on the anatomical variation: internal laryngoceles tend to be treated with microlaryngoscopy with CO2 laser, while the combined laryngoceles tend to be excised through an external incision .
The patient’s follow up consisted of one office visit, 2 weeks after the operation, and one and a half year phone follow up. He was able to return to work 9 days after the operation and had no complaints at any time. He resumed air travel 3 months following his surgery, and he has not experienced airway obstruction or neck swelling during flights again.
The presented case highlights a typical patient who might present with a laryngocele: a male in his fifth or sixth decade referred with a non-tender neck mass that fluctuates in size . The unusual part of the presented case is the airway obstruction caused by the laryngocele during air travel. Uncomplicated laryngoceles rarely cause airway obstruction . Infected laryngoceles, or laryngopyoceles, can on occasion lead to airway distress  and can potentially be lethal . The airway obstruction experienced by the patient presented in this case was likely due to the drop in the atmospheric pressure in the cabin of an airplane. If the junction of the laryngocele with the laryngeal saccule was intermittently obstructed, the drop in air pressure during the plane’s ascent would have led to laryngocele expansion, explaining the patient’s symptoms.
We searched Embase®, Pubmed, Google Scholar, and Web of Science™ databases (last search June 2015) and found one case reports from 50 years ago of airway obstruction during air travel caused by a laryngocele . In addition, we also found a more recent brief communication by an ophthalmologist recounting her experiences from a commercial flight. Twenty minutes into a flight, she was asked to assist a passenger experiencing bulging on the side of the neck. It is unclear if the passenger had symptoms of airway obstruction. This bulge resolved as the plane made an emergency landing. The author of this brief communication did not follow the patient into the hospital, and was writing to request an opinion with regard to what might have caused this unusual presentation . Given the similarities to the presented case, it is likely that the passenger might have had reversible airway obstruction due to a laryngocele.
The presented case is the second case report of upper airway obstruction during air travel. Given the ubiquity of air travel, it is likely that other patients with laryngoceles have experienced at least some worsening of their symptoms during airplane’s ascent. We encourage practitioners to question the rare patient that presents with a suspicion of a laryngocele about symptom changes with air travel. As illustrated in this case, a change in symptoms during the ascent and descent of air travel can potentially support the physician’s diagnostic suspicion of a laryngocele.
Consent to publish
Patient provided written informed consent for publication of the case report. Editor-in-chief was provided with a copy of the written consent.
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- Morse RP. The effect of flying and Low humidity on the admittance of the tympanic membrane and middle Ear system. JARO J Assoc Res Otolaryngol. 2013;14:623–33.View ArticlePubMedGoogle Scholar
- Krekorian EA. Laryngocele in a jet flyer. Laryngoscope. 1966;76:563–71.View ArticleGoogle Scholar
- Vasileiadis I, Kapetanakis S, Petousis A, Stavrianaki A, Fiska A, Karakostas E. Internal laryngopyocele as a cause of acute airway obstruction: an extremely rare case and review of the literature. [Review]. Acta Otorhinolaryngol Ital. 2012;32:58–62.PubMed CentralPubMedGoogle Scholar
- Celin SE, Johnson J, Curtin H, Barnes L. The association of laryngoceles with squamous cell carcinoma of the larynx. Laryngoscope. 1991;101:529–36.View ArticlePubMedGoogle Scholar
- Stell PM, Maran AG. Laryngocoele. J Laryngol Otol. 1975;89:915–24.View ArticlePubMedGoogle Scholar
- Shandilya M, Colreavy MP, Hughes J, Curran AJ, McShane DP, O’Dwyer T, et al. Endolaryngeal cysts presenting with acute respiratory distress. Clin Otolaryngol Allied Sci. 2004;29:492–6.View ArticlePubMedGoogle Scholar
- Zelenik K, Stanikova L, Smatanova K, Cerny M, Kominek P. Treatment of laryngoceles: what is the progress over the last Two decades? BioMed Res Int. 2014;2014:e819453.View ArticleGoogle Scholar
- Rosen CA, Simpson B, Leden H, Ossoff RH. Operative techniques in laryngology. 2008th ed. Berlin: Springer; 2008.Google Scholar
- Byard RW, Gilbert JD. Lethal laryngopyocele. J Forensic Sci. 2015;60:518–20.View ArticlePubMedGoogle Scholar
- Bergkvist MH. Lateral neck cyst as a cause of partial upper airway obstruction? Ugeskr Laeger. 2012;174:2811.PubMedGoogle Scholar