Laryngoceles and saccular cysts in infants and children

Congenital saccular cyst of the larynx: a rare cause of stridor in a newborn infant

Congenital saccular cyst of the larynx is a rare cause of presentation of stridor and respiratory distress in newborns. The clinical presentation of a saccular laryngeal cyst often overlaps with other common causes of stridor, such as laryngomalacia, presenting a diagnostic dilemma for clinicians. We present a case of a term newborn infant referred for evaluation of inspiratory stridor since birth. Microlaryngoscopy and bronchoscopy confirmed the presence of a large cystic mass obstructing the supraglottis. Marsupialisation of the cyst was performed with resolution of stridor, and histopathological examination confirmed the diagnosis of a saccular laryngeal cyst. Our case highlights the importance of considering congenital saccular laryngeal cysts, although rare, in the differential diagnoses of neonatal stridor. Prompt recognition, early endoscopic airway evaluation and surgical intervention are crucial to preventing potentially life-threatening airway obstruction in a newborn presenting with stridor.

Laryngeal Cyst in Children : A Retrospective Analysis

Aim: To study the presentation, management and outcome of laryngeal cysts in children. Materials and methods: This is a retrospective observational study of children with Laryngeal cysts who were managed in the Department of Paediatric Surgery between April 2015 to Jan 2022. Observations and Results: Eight children with laryngeal cysts were included, 5 were girls. Age ranged from 3 days to 10 years (median 5 months). Weight ranged from 3kg to 40kg (median 6.3 kg). All presented with stridor. Three children had co-morbid conditions, one each with Leucocyte adhesion deficiency type -1, atrial septal defect & PHACES syndrome. Two children had severe respiratory distress and required tracheostomy at presentation. All children underwent MLB. The cysts were 2 subglottic cysts (one inflammatory cyst) and 6 vallecular cyst. Five underwent endoscopic excision of cysts, 1 underwent excision with lateral cervical approach, 1 underwent endoscopic de-roofing of cyst and airway reconstruction with anterior costal cartilage graft (associated Sub glottis stenosis). Conclusion: Laryngeal cysts are a rare cause of stridor in children. MLB is the best diagnostic tool. Treatment with excision / deroofing of the cyst endoscopically, is safe and effective in paediatric age group.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03495-w.

Thyroid chondroplastic flap for resection of laryngoceles

PURPOSE

Large and combined laryngoceles usually need an external approach. One difficulty in such approach was the dissection at the paraglottic space. To overcome such difficulty, a thyroid chondroplastic flap approach to the paraglottic space was designed.

METHODS

This study is a case series of thirty consecutive patients (24 men and six women with an average age of 45.6 years), having large combined laryngocele resected externally between January 1995 and December 2019) at the department of ORL_HNS Tanta University, Egypt.

RESULTS

This approach allowed for excellent exposure of the paraglottic space, facilitating complete resection. Complications included perichondrial tearing in five patients, obstructing hematoma in two patient and minimal edema in four patients.

CONCLUSIONS

Thyroid chondroplastic flap is an excellent and safe approach for the paraglottic space facilitating complete resection of large laryngoceles.

Coblation of paediatric cystic laryngeal lymphovascular malformations: a safe and effective alternative to tracheostomy

We describe the case of a 12-hour-old, full-term newborn girl referred to the Ear, Nose and Throat emergency team with increased work of breathing and stridor present at birth. Flexible nasendoscopy revealed a cystic laryngeal lesion obstructing the glottis that prompted securing of the airway with intubation and transfer to a tertiary paediatric centre. On further investigation with MRI and direct visualisation, the lesion was identified as a mixed macro/microcystic laryngeal lymphovascular malformation. The patient successfully underwent a series of microlaryngo-bronchoscopy and coblations of the laryngeal lesion with the aim of avoiding a tracheostomy. We describe the presentation, diagnosis and management of this rare condition in a paediatric case, along with a literature review of the subject.

Clinical Characteristics and Management of Saccular Cysts: A Single Institute Experience

Objectives

A saccular cyst is defined as a dilated saccule of the larynx, filled with mucus, and is located between the false vocal cords and the thyroid cartilage. Although this uncommon laryngeal condition is benign in nature, it could lead to dyspnea, stridor, and airway obstruction, depending on its size and location. Furthermore, some saccular cysts have been associated with laryngeal carcinoma. This study aimed to characterize this rather uncommon laryngeal condition to aid in determining the proper management of this pathology.

Methods

Medical records were retrospectively reviewed of all patients with saccular cysts diagnosed and treated between 2006 and 2017 at a tertiary otolaryngologic care center.

Results

Seven patients with saccular cysts were identified (male:female=2:5; mean age, 34.1 years); two were pediatric patients. Surgical intervention was performed in all patients by laryngo-microsurgery using CO₂ laser. There was no recurrence after the initial surgical treatment.

Conclusion

Saccular cysts can be managed endoscopically using CO₂ laser, without requiring an external approach. Therefore, an endoscopic approach should be actively considered for an optimal treatment outcome.

Laryngoceles: Concepts of diagnosis and management

A laryngocele is an abnormal dilatation of the laryngeal saccule. It is a rare benign lesion of the larynx. Various modalities of treatment have been advocated for its management. We present our treatment results and outcomes of a series of cases of laryngoceles and discuss the concepts of their management. This study included patients with different laryngocele types. Patients with an internal laryngocele underwent endoscopic CO₂ laser resection, while those with a combined laryngocele underwent resection via a V-shaped lateral thyrotomy approach. Seven patients had an internal laryngocele, and 4 patients had a combined laryngocele. Hoarseness and neck swelling were the most common symptoms. The mean follow-up period was 8.5 months. None of the patients needed a tracheostomy either preoperatively or postoperatively, or had recurrence of laryngocele. We advocate the lateral thyrotomy approach for combined laryngoceles as it provides safe, precise, and complete resection under direct visualization via a single approach, while we favor the endoscopic laser approach for the internal ones as it allows resection of the entire lesion with minimal laryngeal trauma, less operative time, and a shorter hospital stay.

The clinical characteristics of congenital laryngeal saccular cysts

CONCLUSION

The first step when treating newborns and infants with hoarseness and dyspnea is to consider the possibility of CLSCs. The appropriate operation can then be chosen based on the cyst sub-type. Complete resection of the cyst wall is the key to preventing recurrence.

BACKGROUND

A laryngeal saccular cyst is an unusual congenital lesion that appears clinically during the neonatal period or early infancy. Because few reports on congenital laryngeal saccular cysts (CLSCs) exist, this study investigated the clinical features of patients with a history of CLSCs to determine the clinical characteristics of this disease.

METHODS

The data from 28 CLSC patients admitted to Beijing Tongren Hospital from July 2004 to September 2014 were reviewed. Gender, age at onset of symptoms, number of surgical procedures performed, effect of the operation, and CLSC classification were analyzed.

RESULTS

CLSCs accounted for 0.79% of laryngeal operations during the study period. Of the cases examined, 35.7% (10/28) had first been treated as laryngomalacia. With respect to cyst type, 17.9% (5/28) were anterior laryngeal saccular cysts, and 82.1% (23/28) were lateral saccular cysts. The patients underwent a total of 53 surgeries, including 21 procedures performed at other hospitals. The time to recurrence of the cysts following needle aspiration ranged from 5-10 days. The time to recurrence after the roof of the cyst was excised ranged from 1-10 months. There were no recurrences after the complete resection of the cyst wall using a CO2 laser and microsuturing of the wound surfaces via an endoscopic procedure, which is much better than the 41% of endoscopic de-roofing cases which recurred reported by Mitchell et al.

A new case of pediatric laryngeal foraminal cyst: diagnostic challenges and association with hemi-facial microsomia

Laryngeal cysts are heterogeneous in their clinical presentation and several classifications have been proposed. Here, we report the case of a foraminal laryngeal cyst in a 6 year-old child who also has hemi facial microsomia (HFM). The cyst was treated surgically with laryngotracheal endoscopy followed by cervicotomy. Histological analysis revealed different types of cystic wall epithelium. This case is the first report of a laryngeal cyst associated with HFM in the literature. We discuss the diagnostic challenges of these specific cystic pathologies, and their pathogenesis as part of an oculo-auriculo-vertebral spectrum. Several hypotheses are proposed, based mainly on characterization of their embryological origin.

Flexible Carbon Dioxide Laser-Assisted Endoscopic Marsupialization and Ablation of a Laryngeal Saccular Cyst in a Neonate

Objective:

To report the occurrence of a neonate with a lateral saccular cyst that was successfully managed by flexible, carbon dioxide laser-assisted endoscopic marsupialization and ablation.

Case Summary:

A full-term, 14-day-old girl presented to the clinic for progressively worsening stridor since birth. On fiber optic laryngoscopy, she was found to have a large, right saccular cyst obstructing the laryngeal inlet. The patient was admitted and underwent microlaryngeal endoscopic CO2 laser marsupialization and ablation of the saccular cyst. She was observed overnight and was discharged without complication the next day. At that time, stridor was no longer present and she remained symptom free at both her 2-week and 3-month follow-up.

Discussion:

The congenital saccular cyst is a rare, abnormal dilation of the laryngeal saccule that is known to be a cause of airway obstruction. A variety of contrasting treatment strategies for laryngeal saccular cysts in children have been reported in the literature. Determining the definitive treatment modality thus remains a challenge that is compounded further by the rarity of the lesion.

Conclusion:

We introduce a new surgical technique that employs a 30-degree angled telescope with a flexible laser fiber system that provides excellent visualization of saccular cysts, in particular, lateral lesions that are less visible using line-of-sight technology.

Laryngeal cysts in infants and children--a pathologist's perspective (with review of literature)

OBJECTIVES

To expose the rarity of the phenomena of congenital laryngeal cysts. Additionally, a discussion is presented in support of the basic similarities between laryngeal duplication cyst and bronchogenic cyst and a proposal to use the term 'bronchogenic cyst' (appended by the location) is put forth.

MATERIALS AND METHODS

Three cases of cysts of the larynx, two in the neonate and one, in a child were discovered in the pediatric age group from the archives of the Department of Pathology, Kasturba Medical College, Mangalore.

OBSERVATIONS

Laryngeal duplication cyst/bronchogenic cyst in a 6-day-old male infant was lined by predominantly respiratory with focal squamous epithelium. The wall contained fibromuscular bundles within a myxoid stroma studded with seromucinous glands. The fibromuscular bundles were positive for smooth muscle actin (SMA) and negative with desmin. A 3-year-old male child diagnosed of laryngocele had the cyst lined by respiratory epithelium and the wall densely infiltrated with lymphoid cells. A 20-day-old male neonate with laryngomalacia had a small arytenoid cyst lined by squamous epithelium.

CONCLUSION

On morphological grounds, a laryngeal duplication cyst may be called a bronchogenic cyst and published reports do not deny that both these entities are cognate. Hence, pathologists should enjoy the freedom to write 'bronchogenic cyst' as the final impression if the histological features should so indicate. Otolaryngologtists however might term the congenital cyst as Type 1, 2a or 2b (according to Forte's classification) taking into account the laryngoscopic, radiologic, intraoperative and pathological findings.

[Congenital saccular cyst of the larynx: a rare cause of stridor in neonates and infants]

Stridor is a noise caused by the passage of turbulent air through a diminished airway caliber. Laryngomalacia is the most common congenital anomaly of the larynx and the principal cause of stridor in children under 6 months. A less common etiology of stridor and respiratory distress in newborns and infants is congenital laryngeal saccular cyst. This entity should be considered in the differential diagnosis of stridor. Early recognition and proper treatment are essential because it can cause life-threatening airway obstruction. We describe our experience with 4 patients with this disease, 3 of them successfully treated with microsurgical resection of the cyst, and we emphasize the importance of considering the endoscopic evaluation of the airway in every child exhibiting stridor with an unexpected evolution to determine the causal lesion.

Congenital cysts of the infant larynx

OBJECTIVES

Congenital laryngeal cysts are a rare cause of neonatal airway obstruction. Two varieties can be distinguished, ductal cysts and saccular cysts. Treatment remains controversial, particularly with regard to saccular cysts, with some believing that endoscopic procedures leave cysts more prone to recurrence. We reviewed our management of congenital laryngeal cysts to determine the most effective intervention.

METHODS

A review of all children treated by our unit for congenital laryngeal cysts between 2001 and 2011. Demographic data, age at and mode of presentation were noted. Operation notes were reviewed to determine the nature of each laryngeal cyst and treatment methodology.

RESULTS

Ten children were identified, six with a ductal cyst of the vallecula and four with a saccular cyst, giving an overall incidence of 3.49 cases per 100,000 live births. Children of Pakistani ancestry were disproportionately represented, accounting for 40% of cases. Saccular cysts presented earlier with symptoms of more severe airway compromise, whilst vallecular cysts tended to present later with feeding difficulties and failure to thrive. Two-thirds of children with vallecular cysts had co-existing laryngomalacia. Treatment by single-stage endoscopic marsupialisation was effective in all cases at a mean follow-up of thirteen months.

CONCLUSIONS

Congenital laryngeal cysts are rare, although they appear to be more common in the British-Pakistani population. Presentation depends on cyst size and proximity to the glottis and can be associated with laryngomalacia. Endoscopic marsupialisation is an effective means of treatment for ductal cysts and saccular cysts confined to the larynx.

Saccular cysts: a current review of characteristics and management

OBJECTIVES/HYPOTHESIS

To review a large cohort of adult saccular cyst patients and update current management of saccular cysts.

STUDY DESIGN

Retrospective review of treatment of adult patients with saccular cysts.

METHODS

Medical records were reviewed of all adult patients with saccular cysts identified between July 1, 2005 and August 31, 2009 at a tertiary care voice center.

RESULTS

Sixteen patients were identified. All complained of dysphonia. Saccular cysts were predominantly left-sided (62.5%). The majority were anterior (85.7%); 14.3% were combined anterior/lateral. There were no isolated lateral saccular cysts. Surgical intervention was performed in 13 patients (81%); 100% were endoscopic. No patient required an external approach. Two patients recurred (15%), both within 2 months, and were managed conservatively.

CONCLUSIONS

Saccular cyst is uncommonly encountered but can cause debilitating or even life-threatening symptoms. Over time, management of these lesions has changed dramatically. With current, improved endoscopic techniques, most saccular cysts can be managed endoscopically with great success rates, often without the need for an external approach.

Rare laryngeal anomaly or spontaneously drained bilateral saccular cyst?

Laryngeal malformations are usually present at birth. Common anomalies include laryngomalacia, vocal fold paralysis, and subglottic stenosis; less common are congenital saccular cysts, laryngeal webs and atresias, and laryngeal lymphangiomas. Symptoms may range from stridor and hoarseness to respiratory distress. In some cases, patients are asymptomatic. Here, we present a case with abnormal laryngeal ventricles.

Laryngoceles - presentations and management

INTRODUCTION

Laryngoceles usually present as cervical masses with or without hoarseness of voice. They are mostly unilateral and may be symptomatic or asymptomatic. They are classified as internal, external or combined. They have been described to be an occupational hazard among wind instrument players or glass blowers. They also occur in association with neoplasms of the larynx.

MATERIALS AND METHODS

Here we report five patients with laryngoceles of whom two had bilateral laryngoceles, which are very rare. One patient had associated laryngeal malignancy for which total laryngectomy was performed. Two cases underwent excision via cervical approach. The rest were managed conservatively.

CONCLUSION

Symptomatic cases have to be managed surgically while asymptomatic ones may be managed conservatively.

Foregut duplication cyst of the hypopharynx: a rare cause of upper airway obstruction

Foregut duplication cysts of the hypopharynx are extremely rare, and only 6 cases, all of which have been described as solid lesions and contained heterotopic gastric epithelium, could be found during our literature review. We present a unique case of a hypopharyngeal foregut duplication cyst that was grossly cystic and had no heterotopic epithelium microscopically. The present case required intubation for stridor and airway obstruction shortly after birth. Congenital laryngeal cysts can appear similar to this lesion. However, the hypopharyngeal location of a cyst is a clue for the diagnosis of duplication on endoscopic examination.

Therapeutic concepts in upper airway obstruction

In children, congenital or acquired upper airway obstruction can present as an acute, potentially life-threatening condition or a chronic process. The latter may be progressive and lead to chronic respiratory failure or episodes of acute airway obstruction. Therapeutic options have been greatly expanded recently, and the single approach of tracheotomy has been replaced by a complex and invidualised approach in many cases. Conservative treatment ranges from topical application or local injection to systemic administration of pharmacological substances such as steroids, adrenalin and antibiotics. Interventions available for children, even for the very young, include non-invasive or invasive ventilation, endoscopic or open surgical interventions. Such interventions can carry considerable risks and have to be performed cautiously by experienced personnel but offer great promise for the individual patient. Non-invasive approaches will not always be inherently safer than timely surgery.

Congenital laryngeal cyst: one or two cysts

The case presented is of a neonate with extreme respiratory distress immediately after birth, caused by a large laryngeal cyst. The vertical diameter of the cyst was larger than the height of the neonatal larynx. First excision of the cyst was performed in the region of the prominent aryepiglottic fold. Three weeks later, because of a recurrence of dyspnea, excision of the prominent wall of an obstructing cystic lesion was performed in the ventriculus Morgagni.

Endoscopic CO2 laser management of laryngocele

OBJECTIVE

To report on the management of laryngoceles by CO2 laser-assisted endoscopic excision.

STUDY DESIGN

A 15-year retrospective study of 12 adult patients (7 men and 5 women) who presented with a laryngocele. Nine patients had an internal laryngocele, one patient had an external laryngocele, and two patients had combined internal-external components. Two laryngoceles were right-sided, six were left-sided, and four were bilateral.

METHODS

An endoscopic examination of the laryngocele was carried out for both diagnostic and therapeutic purposes. Once identified the air- or mucus-filled cyst (extending from the laryngeal ventricle into the paraglottic space and beyond the thyrohyoid membrane in some cases), the laryngocele was excised in toto, with its surrounding capsule, via endoscopic approach using the CO2 laser.

RESULTS

The main presenting symptom was dysphonia in seven patients, visible or palpable mass in the neck in three, and upper airway obstruction in the remaining two. All laryngoceles were treated with endoscopic laser excision of the internal and external components when required. The average postoperative stay in hospital was 1.8 days. Only two of the patients treated had a tracheotomy; both cases presented elsewhere with an emergency airway obstruction, which necessitated tracheotomy. In these two cases, decannulation was subsequently performed. There were no significant complications. The follow-up ranged from 6 months to 5 years.

CONCLUSION

CO2 laser-assisted endoscopic excision of a laryngocele is a quick, precise, and safe alternative to an external approach excision (lateral thyroidotomy, laryngofissure) with fewer complications than its external counterparts, resulting in speedier rehabilitation of both the patient and his or her voice.

Congenital anomalies of the larynx and trachea

A variety of congenital anomalies arise within the laryngeal or tracheal airway. Symptoms primarily include airway obstruction, hoarseness, and difficulty feeding. The diagnosis is typically made by a combination of clinical presentation, physical examination, and endoscopic evaluation. Definitive intervention may be necessary requiring endoscopic or open laryngeal surgery. Some of the more common congenital laryngeal and tracheal anomalies are discussed with respect to their diagnostic evaluation, clinical presentation, and management.

Laryngopyocele: signs on computed tomography

A laryngocele is an air-filled dilation of the saccule of the larynx. An infected laryngocele is called a laryngopyocele. Our experience with a case of laryngopyocele with signs on computed tomography before and after antibiotic therapy is presented since laryngopyocele is more unusual.

Endoscopic CO2 laser excision of large or recurrent laryngeal saccular cysts in adults

Saccular cysts are uncommon disorders that represent cystic dilatation of the laryngeal saccule. They are distinguished from laryngoceles by their lack of lumenal continuity with the endolarynx, and the fact that they are not air filled. Voice change is the most common clinical presentation in adults, whereas airway compromise is more common in infants. Management recommendations range from observation of asymptomatic lesions, to endoscopic marsupialization or excision, to excision through a laryngotomy or the thyrohyoid membrane. The literature states that large or recurrent saccular cysts require the exposure afforded by a transcervical approach. This report describes complete endoscopic laser excision of large, symptomatic saccular cysts in seven adults. Four of the seven patients were referred with recurrent cysts after the failure of endoscopic marsupialization procedures. None required tracheotomy, and only three of seven were observed overnight in the hospital. Surgical technique with emphasis on complete excision, pre- and postoperative radiographic and surgical anatomy, and treatment outcome are discussed.

Stridor in neonates

Stridor in neonates and infants is a symptom that indicates partial obstruction of the large diameter airways. Its presence should prompt a thorough examination and workup. Steps in evaluating stridor include a careful history and physical examination and rapid assessment of the severity of the clinical situation. Infants with respiratory distress and severe stridor should be safely and urgently transported to a tertiary care center, and colleagues from the departments of otolaryngology and anesthesia-critical care should be alerted. An essential component of the physical examination is auscultation. The phase of respiration in which the stridor is heard best provides important clues to help localize its cause. Radiographs, including plain films, dynamic fluoroscopic airway films, contrast esophagography, CT, and MR imaging are useful in specific clinical situations, based on the likely differential diagnosis. The anatomic causes for stridor in infants and neonates are vast. Successful management depends on expert consultation, proper equipment, and a staff that is experienced in the management of pediatric airway problems. The trend over the past decade has been to significantly decrease morbidity and mortality and also to decrease the number of tracheotomies necessary to stabilize pediatric airways. The best treatment outcomes result when there is good cooperation and communication among pediatricians, otolaryngologists, pulmonologists, and anesthesiologists.

Surgical management of congenital saccular cysts of the larynx

Congenital saccular cysts of the larynx are unusual lesions that commonly present with respiratory obstruction in infants and children. The saccular cyst may result from an atresia of the laryngeal saccule orifice or may represent the retention of mucus in the collecting ducts of submucosal glands located around the ventricle. Traditionally, the treatment of the lesions has been endoscopic unroofing or marsupialization. Frequently, this modality requires multiple procedures as well as concomitant tracheotomy. There also have been reports of acquired subglottic stenosis. We have found that removal of the recurrent saccular cyst can be achieved relatively safely and effectively via a lateral cervical approach to the thyrohyoid membrane. We review our experience with four patients with congenital saccular cysts and detail the evaluation and surgical management of these lesions.

Histopathologic fundamentals of acquired laryngeal stenosis

Acquired laryngeal stenosis is the most serious long-term complication of endotracheal intubation in children. Employing the whole-organ serial section technique, the sequence of histopathologic changes leading to stenosis was studied. Ulceration occurs when an endotracheal tube causes mechanical abrasion and/or induces pressure necrosis on the laryngeal mucosa. Secondary healing of ulceration produces granulation tissue and subsequent fibrous scar tissue. Most exuberant granulation tissue resolves without sequelae, but some becomes firm, almost avascular fibrous scar tissue. The accumulation of submucosal fibrous tissue may decrease the size of the glottic or subglottic lumen. Contraction of scar tissue causes a distortion of glottic and subglottic laryngeal complex, leaving a reduced and irregularly shaped glottic and subglottic lumen. Submucosal mucous gland hyperplasia directly reduces the inner diameter of the airway. Finally, compromise of the laryngeal lumen may occur when the duct of a mucous gland is obstructed by scarring resulting from intubation: mucus accumulates in the dilated duct, producing a ductal cyst.