Asymptomatic vallecular cyst: airway management considerations

Bilateral vallecular cyst: transoral robotic resection

Vallecular cyst is more frequent in neonatal life, but could be present in adults. Frequently it is asymptomatic although some people has foreign body sensation upon swallowing and obstructive problems to sleep. The best treatment for these cases is complete resection, as recurrence is usual with any cyst remnant wall causing re-accumulation. We present the case of a patient with symptomatic vallecular cyst treated with transoral robotic surgery. The technique confirmed the advantages related with tridimensional vision close to the cyst, associated with multi-articulated 5 mm EndoWrist^® instruments that made real safe and efficient surgery.

A feasibility study to assess vallecula and pyriform sinus using protocol-based ultrasonic evaluation of floor of mouth and upper airway

PURPOSE

The current study aimed to systematically evaluate the sonoanatomy of floor of the mouth and upper airway using protocol-based ultrasonography (USG); and to assess the feasibility of imaging the valleculae and pyriform fossae.

MATERIALS AND METHODS

An institutional prospective observational study was planned on fifty volunteers of all ages and both sexes, attending outpatient department for nonairway-related diseases. Protocol for ultrasonographic systemic evaluation was designed before starting the trial. All the patients were positioned supine with neck extended (sniffing position), seven steps of ultrasonographic protocol were followed and visualization of structures denoted in each step was documented. Furthermore, time taken to complete each scan was noted.

RESULTS

The USG was completed, and checklist successfully followed in all cases. Floor of mouth structures was easy to evaluate and visualized with ease in all the cases. Epiglottis was visualized in 100% cases in transverse plane. Valleculae and pyriform fossae were identified in 82% and 90% of the cases, respectively, and they appeared either as paired air-filled round structures or air-lined linear structures. Complete visualization of vocal cords was seen in 78% females and 63% males. The average time taken to complete the protocol-based study was 10.4 ± 1.4 min.

CONCLUSIONS

Application of protocol-based USG for upper airway can allow the examination of structures from tongue to thyroid cartilage in a thorough, convenient, and timely manner. The air filled/lined structures such as valleculae, pyriform fossae, and vocal cords can be visualized in majority of the cases.

Use of King Vision® videolaryngoscope in an unanticipated difficult airway in an adult patient with giant vallecular cyst, a case report

Laryngeal cysts are largely asymptomatic and typically described in the context of incidental discovery on routine laryngoscopy. These cysts, in adults are even rarer and can have catastrophic consequences in an anaesthetized patient if airway management is inappropriate. We describe a case of difficult endotracheal intubation and the treatment of an adult patient with an asymptomatic, giant vallecular cyst that was discovered during rapid-sequence induction of general anesthesia in urgent surgery. In conclusion, vallecular cysts can cause extreme problems in securing the airway. It is important to avoid complications associated with repeated attempts at intubation, airway loss, or cyst rupture causing difficulty visualizing vocal cords and aspiration. The use of King Vision^® videolaryngoscope is a good alternative in these cases. Close attention to logistics and the immediate availability of an otolaryngologist is vital.

Airway Management of Incidental Vallecular Cysts in Adults

Vallecular cysts, largely asymptomatic in adults, are typically described only on incidental discovery during laryngoscopy, where they may present a challenge in airway management. The current literature is limited to case reports despite the potential for life-threatening complications. We describe management of such a case complicated by cyst rupture and intensive care unit admission. A literature review of eligible case reports was conducted, demonstrating an association between incidental vallecular cysts and difficult bag-mask ventilation and laryngoscopy with intraoperative otolaryngology consultation and intervention being common. Anesthetic management recommendations are thus presented, highlighting any conflicts with current difficult airway algorithms.

Successful anesthetic management of a large supraglottic cyst

Excision of a huge-sized supraglottic mass nearly obstructing the airway passage is a real challenge to anesthesiologists. Upper airway obstruction due to neoplasm in supraglottic region is traditionally managed by preoperative tracheostomy. However, such a common procedure can potentially have an impact on long-term outcome.

An awake double lumen endotracheal tube intubation using the Clarus Video System in a patient with an epiglottic cyst: a case report

A 54-year-old male patient was scheduled for an elective pylorus-preserving pancreaticoduodenectomy combined with video-assisted thoracic surgery at our hospital. This patient had a history of intubation failure in other institutions due to an epiglottic cyst. An airway assessment of the patient was normal. A preoperative laryngoscopy revealed a bulging epiglottic mass covering most of the epiglottis and occupying most of the pharyngeal space. The patient was administered intravenous midazolam 1 mg, fentanyl 50 µg, and glycopyrrolate 0.2 mg. A bilateral superior laryngeal nerve block was then performed with 2% lidocaine 2 ml on each side. A 10% lidocaine spray was applied on to the oropharynx. After preoxygenation with 100% oxygen over 10 minutes, a rigid fiberscope with an optical stylet loaded with a 37 Fr double lumen endotracheal tube was inserted orally and passed into the glottic aperture. The patient was fully awakened after surgical procedure and was transferred to the recovery room after extubation.

Bilateral vallecular cysts as a cause of Dysphagia: case report and literature review

Cysts of the vallecula are rare, accounting for 10.5% to 20.1% of all laryngeal cysts. Vallecular cysts may present with diverse symptoms affecting the voice, airway, and swallowing. We describe the evaluation and treatment of a 70-year-old woman who presented with dysphagia caused by large bilateral vallecular cysts.

Awake Glidescope® intubation in a patient with a huge and fixed supraglottic mass -A case report-

Intubating patients with a huge, fixed supraglottic mass causing an obstruction of the glottis is difficult to most anesthesiologists. We attempted awake fiberoptic orotracheal intubation assisted by Glidescope® Videolaryngoscope (GVL) following topical anesthesia with 4% lidocaine spray and remifentanil infusion. The glottis could not be identified by the GVL view. However, by entering toward the right side of the mass with bronchoscope, the glottis was found. Due to stiffness of the mass, we were unable to further enter the area using the bronchoscope. Alternatively, we attempted to expose the glottis by GVL blade and then successfully intubated the patient by manually pressing the cricoids cartilage. GVL is nonetheless an excellent instrument in airway management compared to fiberoptic bronchoscope for patients with a huge and fixed supraglottic mass.

Magnetic Resonance Scanning of the Upper Airway following Difficult Intubation Reveals an Unexpected Lingual Tonsil

We present a case of a 40-year-old woman requiring elective surgery who had an unexpected Grade 4 Cormack and Lehane laryngoscopy view. Both curved and straight laryngoscope blades in the sniffing and hyperextended head and neck positions were used. Endotracheal intubation was accomplished with some difficulty using a No. 3 Macintosh blade and Frova intubating catheter in the sniffing position. The cause of the difficult laryngoscopy was a lingual tonsil as shown in postoperative magnetic resonance scans.

We feel that a comprehensive postoperative evaluation should be conducted after every difficult laryngoscopy (Cormack and Lehane Grade 3b and 4). The use of magnetic resonance imaging may provide important objective information for both the anaesthetist and the patient, allowing a better understanding of causes and possible solutions for future airway management.

Adult vallecular cyst: Thirteen-year experience

OBJECTIVE: To assess the characteristics of adult vallecular cyst.

STUDY DESIGN AND SETTINGS: A retrospective chart review from a university affiliated hospital.

SUBJECTS AND METHODS: Clinical manifestations and airway management of 38 consecutive adult patients with vallecular cyst admitted between 1992 and 2004 were studied.

RESULTS: Two distinct groups were identified: infected (n = 24) and noninfected (n = 14). Twenty-two (91.7%) patients of the former group had acute epiglottitis with an abrupt onset culminating in abscess formation in 19 (79.2%) and airway compromise in 9 (37.5%) compared with none in the noninfected group (P = 0.006). In 4 (18.2%) of 22 patients, the origin of the infected vallecular cyst was evident only after symptoms subsided. Three patients had recurrent acute epiglottitis. The noninfected group had a relatively prolonged mild clinical course.

CONCLUSIONS: Two types of vallecular cysts were characterized. Abscess formation was the hallmark of adult infected vallecular cyst.

SIGNIFICANCE: To improve patient care, endoscopic follow-up is advocated. In patients with recurrent episodes of acute epiglottitis, imaging is recommended.

Airway problems related to laryngeal mask airway use associated with an undiagnosed epiglottic cyst

This report describes airway management difficulties in a patient with an asymptomatic and undiagnosed epiglottic cyst. Mask ventilation after induction of general anesthesia was uneventful. Insertion of an LMA resulted in inadequate ventilation. Fiberoptic intubation through an intubating LMA was impossible because the LMA pushed the cyst into the laryngeal inlet. Fibreoptic intubation, assisted by the use of a direct laryngoscope without the LMA was uneventful. Preoperative craniocervical scans performed for assessment of other conditions may reveal asymptomatic pathology in the airway.

Anesthesia induction for a difficult intubation infant with a laryngeal cyst

We report a case of difficult airway in a 37-day-old female with a laryngeal cyst during induction of general anesthesia. This case illustrates that upper airway obstruction can occur during induction of anesthesia with an unusual infantile aryepiglottic fold cyst. In this case, successful orotracheal intubation was achieved with spontaneous respiration, and preoperative information on orientation of the lesion assisted in positioning the patient to minimize the degree of dynamic obstruction.