Laryngeal varices: an atypical cause of globus.

Laryngeal varices are rare and are usually associated with vocal cord trauma secondary to excessive use of voice. This report is the first documented case of laryngeal varices secondary to thyroid goitre. This is a report of an 83-year-old woman with a known retrosternal goitre chiefly with symptoms of globus. Retrosternal goitre was found to be compressing the pharyngeal venous plexus causing laryngeal venous structures bilaterally to be engorged along the aryepiglottic folds, arytenoids, posterior commissure and extending in to the postcricoid region. The presence of laryngeal varices carries a significant increased risk of haemorrhage. This case presents an atypical presentation of globus and the first reported case in the literature of laryngeal varices secondary to a thyroid goitre. © BMJ Publishing Group Limited 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Background

Laryngeal varices are rare and are usually associated with vocal cord trauma secondary to voice abuse. Vocal cord varices present a significant increased risk of haemorrhage, reportedly 10 times greater when compared with non-varix patients.1 To our knowledge this is the first report of laryngeal varices secondary to a thyroid goitre.

Case presentation

An 83-year-old woman with a known retrosternal goitre was referred to the ear, nose and throat (ENT) outpatient department at the Queen Alexandra Hospital in Portsmouth, UK with symptoms of globus. She had undergone a thyroidectomy five decades previously for the treatment of a goitre. Recent observational CT imaging was suggestive of laryngeal varices prompting referral to ENT. The patient had no other comorbidities and took no regular medications. The only presenting symptom was that of a sensation of a foreign body in the throat.

Flexible nasendoscopy was performed by a consultant in the ENT department (see figure 1). Examination revealed dilated venous structures bilaterally along the aryepiglottic folds, arytenoids, posterior commissure and extending in to the postcricoid region. Vocal cord movement was normal bilaterally and there was no visible mass lesion.

Figure 1

Flexible nasendoscopy showing dilated venous structures bilaterally along aryepiglottic folds, arytenoids, posterior commissure and extending in to the postcricoid region. No mass lesions.

Outcome and follow-up

The patient was subsequently discussed in the thyroid multi-disciplinary team meeting. The conclusion of the meeting was that the laryngeal varices were likely secondary to the goitre compressing the pharyngeal venous plexus. Since the patient was asymptomatic, the recommendation was made for conservative management with an interval CT scan in 1 year. If the patient were to develop new or worsening symptoms then a possible therapy might include treatment with radioactive iodine with the intention of reducing the size of the goitre. If the patient were to develop bleeding, then treatment might include examination under anaesthesia and cauterisation of the bleeding blood vessels.

Discussion

To our knowledge, this is the first report of laryngeal varices secondary to a thyroid goitre. One previous case of bleeding secondary to tracheal varices caused by compression of a large intrathoracic goitre has been reported in the literature.2 Pharyngeal and base of tongue varices have previously been reported in the literature but only secondary to portal hypertension.3 4 The presence of laryngeal varices carries a significant increased risk of haemorrhage. This case presents an atypical presentation of globus and the first reported case in the literature of laryngeal varices secondary to a thyroid goitre.

Laryngeal varices secondary to a thyroid goitre may present a rare and atypical presentation of globus.

The presence of laryngeal varices can carry a significant increased risk of haemorrhage.

Treatment options if very symptomatic might include treatment of the goitre with radioactive iodine or cauterisation of the laryngeal varices.