Saccular Cyst

A saccular cyst is a benign, mucus-filled, closed sac that results from obstruction of the laryngeal saccule. The two normal saccules are open diverticula of the larynx whose mouths empty into the anterior portion of the laryngeal ventricle. Each saccule extends superiorly and contains numerous mucous glands that serve to lubricate the vocal folds. When the opening of one or both saccules becomes obstructed—whether congenitally or because of inflammation, trauma, or tumor—the saccule can no longer drain its secretions.

An analogy for a saccular cyst is a velvet drawstring bag used to hold coins: when the drawstring is pulled tight, the opening closes and the contents are trapped. Similarly, when the mouth of the saccule becomes blocked, not only retained mucus but also newly produced mucus from the glands within the saccule can no longer escape through its normal opening into the anterior ventricle. The result is progressive distention of the sac.

Anterior vs Lateral

The pattern of expansion varies. In some cases, the cyst expands medially from the ventricle, presenting as an anterior saccular cyst. In other cases, the expanding cyst tracks superiorly and laterally, bulging the false vocal cord and the aryepiglottic fold, producing a lateral saccular cyst. With continued enlargement, the cyst may extend over the superior border of the thyroid cartilage and present as a neck mass. Depending on its size and location, a saccular cyst may cause symptoms such as hoarseness, dysphagia, stridor, or airway compromise, particularly in infants and young children.

Treatment

Some small anterior saccular cysts are asymptomatic and remarkably stable, requiring no intervention. If enlargement leads to downward pressure on the true vocal fold, resulting hoarseness typically prompts endoscopic excision. For large, symptomatic lateral saccular cysts, endoscopic marsupialization has been described but is frequently associated with recurrence.

Consequently, definitive excision is generally preferred. This involves incision and partial resection of the false vocal cord to identify the cyst wall and then tracing it to its apex for complete removal. Even cysts with significant extension over the superior border of the thyroid cartilage can sometimes be removed via this endoscopic approach.

If the cyst is extremely large and presents predominantly as a cervical mass, an open lateral cervical approach may be preferred.

Saccular Cyst vs. Laryngocele

A related entity, the laryngocele, also arises from the saccule but is dilated by air rather than mucus. Laryngoceles are classically associated with occupations or activities that generate sustained increased intralaryngeal pressure, such as glassblowing or playing brass instruments. They may be observed to inflate during these activities and deflate at rest.

Saccular Cyst vs. Laryngopyocele

A third related entity is the laryngopyocele, which may be more accurately described as an infected saccular cyst. Some saccular cysts appear to become intermittently infected during upper respiratory infections, leading to acute pain and, at times, airway compromise. Acute management may consist of simple drainage and antibiotics to control infection, followed by definitive excision of the now-quiescent saccular cyst.