|Year : 2016 | Volume
| Issue : 1 | Page : 18-20
Concomitant vallecular and saccular cysts: A rare entity
Roohie Singh1, Jeevan R Galagali2, N Ramakrishnan3
1 Department of ENT, Military Hospital, Jodhpur, Rajasthan, India
2 Department of ENT and HNS, Command Hospital, Pune, Maharashtra, India
3 Department of ENT and HNS, Command Hospital, Kolkata, West Bengal, India
|Date of Web Publication||5-Apr-2017|
Department of ENT, Military Hospital, Jodhpur - 342 010, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Benign laryngeal cysts have the potential to cause airway compromise. Proper anesthetic and surgical management should be planned in advance to avoid undue complications. We present a case of 52-year-old male with concomitant vallecular and saccular cysts (VaC and SC) which were managed successfully. To the best of our knowledge, this is the first report on concomitant existence of VaC and SC.
Keywords: Concomitant, cricoid, microlaryngoscopic surgery, saccular cyst, vallecular cyst
|How to cite this article:|
Singh R, Galagali JR, Ramakrishnan N. Concomitant vallecular and saccular cysts: A rare entity. J Laryngol Voice 2016;6:18-20
| Introduction|| |
Laryngeal cysts represent 5% of all benign laryngeal lesions. Vallecular cysts (VaC) and saccular cysts (SC) represent 10.5% and 25% of all laryngeal cysts approximately., Sudden airway compromise and even death due to VaC and SC of larynx have been reported in literature.,, In our case, the patient presented with features of airway compromise, but proper clinical assessment, utilization of best available diagnostic modality, and well-planned intraoperative steps led to successful excision with no recurrence in follow-up.
| Case Report|| |
A 52-year-old male presented with a history of change in voice and choking spells in sleep. He denied any odynophagia, dysphagia, and weight loss. However, on repeated asking, he gave a history of noisy breathing on exertion. Medical history was not significant. There was no history of any addiction.
Muffled breathy voice was noticeable. There was no palpable neck mass or lymphadenopathy. Indirect laryngoscopy revealed a VaC of size approximately 4 cm × 3 cm in right vallecular region crossing the median glossoepiglottic fold and partially overlying left vallecula. The epiglottis was pushed posteriorly eclipsing the view of laryngeal inlet. On Fiberoptic laryngoscopy (FOL), coexistent right SC was revealed. Right true cord and anterior one-third of left true cord were not visualized due to posterior displacement of epiglottis; and size, position, and concomitant existence of both cysts [Figure 1].
|Figure 1: Fiberoptic laryngoscopy view of concomitant vallecular (arrow) and saccular (asterisk) cysts|
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Magnetic resonance imaging (MRI) was suggestive of multilocular cyst of size 5 cm × 3.2 cm × 2.7 cm occupying right vallecular region extending into preepiglottic space till right vestibule. Gross airway compromise was also noted [Figure 2].
|Figure 2: Magnetic resonance imaging images (saggittal and axial sections) showing the cysts and airway compromise|
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A diagnosis of concomitant VaC and SC was considered. The patient was urgently scheduled for surgical management under general anesthesia.
Direct laryngoscopic oral intubation with help of styletted endotracheal tube and cricoid pressure with backward, upward, and rightward pressure modification by the anesthesiologist was rewarding in this case. In view of difficult intubation or accidental cyst rupture, fiberoptic intubation and tracheostomy were in standby.
A direct laryngoscope was introduced and findings noted. The displaced epiglottis and endotracheal tube were compromising the working space for dissecting SC. Hence, it was decided to excise VaC followed by SC.
VaC was aspirated to find cheesy mucoviscid secretion. Loculi were broken one by one and traced till a broad base which was lying on vallecula and lingual surface of epiglottis on right side. It was then excised with microscissors and hemostasis achieved by adrenaline-soaked patties [Figure 3].
|Figure 3: Intraoperative view of direct laryngoscopy and excised vallecular cyst (inset)|
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Due to tissue handling, gross circumferential edema of epiglottis developed masking the base of SC. In view of possible incomplete removal of SC at that stage, it was wisely decided to excise it in second sitting. The patient was extubated 24 h postoperatively. Postoperative antibiotics and steroid averted the need for tracheostomy.
The patient was reassessed on postoperative day 7 which showed healing surgical site. The patient was reassessed at 3 weeks postoperatively and underwent a planned microlaryngoscopic surgery. The cyst was retracted medially with microlaryngeal cup forceps and dissected to its origin which lied in roof of laryngeal ventricle. It was then excised along with approximately 2 mm cuff of ventricular mucosa. Gross inspection revealed inspissated mucus. Postoperatively, the patient was on antireflux treatment for 4 weeks. Histopathologic findings of both cysts supported the diagnosis and there was no evidence of malignancy.
On follow-up, after 6 months, there was no recurrence [Figure 4] and patient's voice had returned to normal.
|Figure 4: Fiberoptic laryngoscopy view of follow-up after excision of cysts at 6 months shows no recurrence|
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| Discussion|| |
Laryngeal cysts are rare and are first reported by Abercrombie in 1881. Vallecula is located between base of tongue and epiglottis. Cysts arising in this region are VaCs, also known as epiglottic cysts, preepiglottic cysts, and base of tongue cysts. VaCs are common in adults in fifth and sixth decade of life. In adults, they are usually asymptomatic and discovered during ear, nose, and throat examination or while intubation. Symptoms of VaCs depend on age of presentation, size, and position of the cyst.
Saccule is narrow prolongation of ventricle at its superior extent. An SC is a mucin-filled dilation of saccule secondary to obstruction either congenital or acquired. Symptoms include hoarseness, muffled voice, dyspnea, or neck mass.
Laryngeal cysts have been classified by DeSanto et al. into saccular, ductal, and thyroid cartilage foraminal cysts.
A detailed history, awareness regarding other associated comorbidities, preoperative imaging, and endoscopic studies along with proper discussion of the case between anesthesiologist and otorhinolaryngologist is important to plan efficient management of such cases., In this case, MRI and FOL view of the lesions were clinically correlated which helped both the anesthesiologist and otorhinolaryngologist in meticulous airway assessment and hence proper planning. Each investigation had its own fruitful submission.
A literature search reveals few articles on simultaneous existence of laryngeal cysts with other pathologies such as laryngomalacia, gastroesophageal reflux, and carcinoma.,, The concomitant existence of VaC and SC in this case is a definite emergency that otorhinolaryngologists and anesthesiologists must be aware of. Furthermore, it reinforces that a two-staged management may be required to have good exposure and complete excision of the lesion.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Newman BH, Taxy JB, Laker HI. Laryngeal cysts in adults: A clinicopathologic study of 20 cases. Am J Clin Pathol 1984;81:715-20.
Arens C, Glanz H, Kleinsasser O. Clinical and morphological aspects of laryngeal cysts. Eur Arch Otorhinolaryngol 1997;254:430-6.
Fang TJ, Cheng KS, Li HY. A huge epiglottic cyst causing airway obstruction in an adult. Chang Gung Med J 2002;25:275-8.
Silingardi E, Sola N, Santunione AL, Trani N. Lateral saccular laryngeal cyst and unexpected asphyxial death. Forensic Sci Int 2011;206:e17-9.
Kastowsky TK, Stevenson MP, Duflou JA. Sudden death from saccular laryngeal cyst. J Forensic Sci 2006;51:1144-6.
Abercrombie J. Congenital cyst in larynx. Trans Pathol Soc Lond 1881;32:33-4.
Gutiérrez JP, Berkowitz RG, Robertson CF. Vallecular cysts in newborns and young infants. Pediatr Pulmonol 1999;27:282-5.
DeSanto LW, Devine KD, Weiland LH. Cysts of the larynx – Classification. Laryngoscope 1970;80:145-76.
Gnepp DR. Diagnostic Surgical Pathology of the Head and Neck. 2nd
ed. Philadelphia: Saunders-Elsevier Company; 2009. p. 262-4.
Pilch BZ. Head and Neck Surgical Pathology. 1st
ed. Philadelphia: Lippincott Williams and Wilkins; 2001. p. 237-8.
Jr., Johnson EA, Barcia PJ. The impossible airway: A plan. Chest 1996;109:1649-50.
Thabet MH, Kotob H. Lateral saccular cysts of the larynx. Aetiology, diagnosis and management. J Laryngol Otol 2001;115:293-7.
Wong KS, Li HY, Huang TS. Vallecular cyst synchronous with laryngomalacia: Presentation of two cases. Otolaryngol Head Neck Surg 1995;113:621-4.
Yao TC, Chiu CY, Wu KC, Wu LJ, Huang JL. Failure to thrive caused by the coexistence of vallecular cyst, laryngomalacia and gastroesophageal reflux in an infant. Int J Pediatr Otorhinolaryngol 2004;68:1459-64.
Harrison DF. Saccular mucocele and laryngeal cancer. Arch Otolaryngol 1977;103:232-4.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]