Airway Management of Incidental Vallecular Cysts in Adults

Rare cause of voice muffling: pyogenic vallecular cyst

A vallecular cyst is a benign laryngeal cyst that rarely causes symptoms in adults. We report a rare case of an infected vallecular cyst in a man who is in his 60s with diabetes mellitus. The patient presented to us with acute onset of voice muffling and respiratory distress. He showed signs of sepsis and upper airway obstruction. He had spikes of high-grade fever with an elevated total white cell count (predominantly neutrophil count) and C reactive protein level. Plain cervical X-ray revealed a large, smooth, lobulated mass in the vallecular area. Direct laryngoscopic findings supported the diagnosis of an infected vallecular cyst with suppuration, which originated from the vallecula fossa. The cyst was drained and excised completely, and the pus culture revealed the presence of Klebsiella pneumoniae The patient responded well to the administration of intravenous cefuroxime for 2 weeks according to the sensitivity and culture test. He was discharged after the completion of the course of antibiotics, having recovered fully. This case illustrates the versatility of a plain cervical X-ray in giving clues about this rare, unexpected pathology.

Aspiration as the first-choice procedure for airway management in an infant with large epiglottic cysts: A case report

BACKGROUND

Epiglottic cysts is a rare but potentially lethal supraglottic airway pathology in infants due to the high risk of cannot intubation or cannot ventilation. Awake fiberoptic intubation appeared to be the safest technique, but it is very challenging in infants with large epiglottic cysts. Even it has the risk of airway loss. We report that cyst aspiration is an effective treatment as the first-choice procedure for airway management in an infant with large epiglottic cysts.

CASE SUMMARY

A 46-day-old male infant weighing 2.3 kg presented to the emergency room with difficulty feeding, worsening stridor, and progressive respiratory distress. Epiglottic cysts was diagnosed, but fibro bronchoscopy examination failed, as the fiberoptic bronchoscope was unable to cross the epiglottic cysts to the trachea. The infant was transferred to the operating room for emergency cystectomy under general anesthesia. Spontaneous respiration was maintained during anesthesia induction, and cyst aspiration was performed as the first procedure for airway management under video laryngoscopy considering that the preoperative fibro bronchoscopy examination failed. Then, the endotracheal tube was intubated successfully. Cystectomy was performed uneventfully, and the infant was safely transferred to the intensive care unit after surgery. The infant was extubated smoothly on the third postoperative day and discharged on the eighth day after surgery. On follow-up 1 year after the surgery, a normal airway was found by fibro bronchoscopy examination.

CONCLUSION

Epiglottic cyst aspiration can be considered the first procedure for airway management in infants with large epiglottic cysts.

A Retrospective Case Series of Anesthetic Patients With Epiglottic Cysts

Previously undiagnosed or asymptomatic epiglottic cysts may be coincidentally detected during intubation. This retrospective case series identified undiagnosed epiglottic cysts that were discovered during intubation in 4 patients who underwent oral surgery under general anesthesia at our hospital during a 6-year period. Including 2 additional cases, 1 previously diagnosed and 1 detected during preoperative imaging, epiglottic cysts were observed in 6 of 1112 cases (0.54%) total. Among the undiagnosed epiglottic cyst cases, mild dyspnea on effort or snoring was reported in 2 patients, but all others were asymptomatic. Upon discovering previously undiagnosed epiglottic cysts during intubation, it is essential to proceed cautiously, remain alert for potential airway management difficulties, and avoid injuring or rupturing the cysts. In addition, any available preoperative imaging should be reviewed as information pertinent to the airway and any abnormalities may be useful. This report discusses the anesthetic care of 6 patients with epiglottic cysts that were previously known or initially discovered during intubation.

Gold laser removal of a large ductal cyst on the laryngeal surface of the epiglottis

Laryngeal cysts are rare lesions of the larynx that are often described on incidental discovery. We report an unusual presentation of a large ductal cyst located on the laryngeal surface of the epiglottis. The patient presented with a low tone voice while displaying bilateral normal appearing vocal cords with normal mobility. Computed tomography scans and flexible laryngoscopy showed a round supraglottic mass approximately 2 cm in diameter on the right lateral laryngeal surface of the epiglottis. The mass was removed surgically during microsuspension laryngoscopy with excision of the mucocele utilizing a gold laser. Postoperatively, the patient's voice returned to baseline with no complications.

Laryngeal Cysts in Adults: Simplifying Classification and Management

Objective

Laryngeal cysts may occur at any mucosa-lined location within the larynx and account for 5% to 10% of nonmalignant laryngeal lesions. A number of proposed classifications for laryngeal cysts exist; however, no previously published classification aims to guide management. This review analyzes contemporary laryngeal cyst management and proposes a framework for the terminology and management of cystic lesions in the larynx.

Data Sources

PubMed/Medline.

Review Methods

A primary literature search of the entire Medline database was performed for all titles of publications pertaining to laryngeal cysts and reviewed for relevance. Full manuscripts were reviewed per the relevance of their titles and abstracts, and selection into this review was according to their clinical and scientific relevance.

Conclusion

Laryngeal cysts have been associated with rapid-onset epiglottitis, dyspnea, stridor, and death; therefore, they should not be considered of little significance. Symptoms are varied and nonspecific. Laryngoscopy is the primary initial diagnostic tool. Cross-sectional imaging may be required, and future use of endolaryngeal ultrasound and optical coherence tomography may revolutionize practice. Where possible, cysts should be completely excised, and there is growing evidence that a transoral approach is superior to transcervical excision for nearly all cysts. Histology provides definitive diagnosis, and oncocytic cysts require close follow-up.

Implications for Practice

A new classification system is proposed that increases clarity in terminology, with the aim of better preparing surgeons and authors for future advances in the understanding and management of laryngeal cysts.

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.