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Background
Neck swelling associated with positive pressure such as glass blowing or playing musical instruments may be as a result of a pharyngocele or laryngocele. Both are incredibly rare and differentiating between the two can be difficult. Despite being well described, pharyngoceles are often underdiagnosed or misdiagnosed as laryngoceles. While differences can often be subtle, correct diagnosis can be made confidently with targeted investigation and a high index of suspicion.
We present a case of bilateral neck swelling and discuss the differentiating features, investigations and treatment options of both laryngoceles and pharyngoceles.
Case presentation
A 20-year-old male trumpet player was referred to our tertiary ear, nose and throat clinic with a 5-year history of bilateral neck swelling. This was only associated with playing the trumpet, with complete resolution between episodes. He was otherwise fit and well with no difficulty breathing, dysphagia or dysphonia. Previous investigations, including imaging at the referring clinic had revealed no cause for the swelling. The patient was asked to attend clinic with the trumpet in order to reproduce the symptoms.
At rest, head and neck examination was grossly normal with no visible or palpable neck lumps or swellings. Interestingly, blowing the trumpet produced significant bilateral external neck swelling ( figure 1 ). Videostobolaryngoscopy during trumpet blowing showed marked expansion of both piriform fossa confirming the diagnosis of a pharyngocele ( figure 2 ). The remaining supraglottic structures were unremarkable with normal movement of the vocal cords bilaterally.
A CT scan was requested while trumpet playing to enable estimation of the size of the defect and to allow for surveillance and future comparison. This was initially reported as 'large bilateral gas filled laryngoceles' ( figure 3 ), however following further review and identification of the grossly enlarged piriform fossa seen in figure 3 B this was amended to a diagnosis of a pharyngocele.
Barium swallow performed subsequently (without positive pressure as it will be impossible to blow and swallow at the same time) to look for pockets or pouches of the hypophayrnx was normal ( figure 4 ).
Given the absence of symptoms, the patient was managed conservatively and advised regarding healthy oral hygiene and the use of scarf tying while playing.
Discussion
A laryngocele can be defined as an 'abnormal dilation...