Diagnosis and treatment of pediatric vallecular cysts and pseudocysts

Vallecular cyst causing sleep-disordered breathing in an older child

Consensus-based recommendations are needed to better guide paediatric otolaryngologists in providing standardised care to children with sleep-disordered breathing (SDB). Here we present a unique case of vallecular cyst found during SDB workup in a patient in their middle childhood (6-12 years old). While the patient underwent successful cyst resection, he was noted to have a suspected recurrence 6 months later. Immediately prior to revision excision, repeat awake flexible fibre-optic laryngoscopy revealed complete resolution of the suspected recurrence. This case underscores the significance of performing a complete upper airway examination, including endoscopic examination, to identify structural and anatomical lesions in older children with SDB.

New approach to establish a surgical planning in infantile vallecular cyst synchronous with laryngomalacia based on aerodynamic analysis

BACKGROUND AND OBJECTIVES

A large proportion of infants with vallecular cyst (VC) have coexisting laryngomalacia (LM). Feeding difficulties, regurgitation, occasional cough, and sleep-disordered breathing are the common symptoms in moderate to severe cases. The surgical management of these cases is more challenging and remains controversial. The purpose of this study is to help surgeons select the effective surgical strategies by computer-aided design (CAD) and computational fluid dynamics (CFD) simulations of the upper airway flow characteristics.

METHODS

The three dimensional (3D) geometric model of the upper airway was reconstructed based on two dimensional (2D) medical images of the patient with VC accompanied with LM. Virtual surgeries were carried out preoperatively to simulate three possible post-operative states in silico. The different outcomes of virtual surgical strategies were predicted based on computational evaluations of airway fluid dynamics including pressure, resistance, velocity, and wall shear stress (WSS).

RESULTS

The CFD results of this study suggested the importance of the angle between the rim of epiglottis and arytenoid epiglottic (AE) fold. There was a small impact on the upper airway flow field while the VC was removed and the angle of epiglottis was unchanged. The partial lifting of epiglottis can further improve the flow field. With performing supraglottoplasty (SGP) and the marsupialization of VC, epiglottis was completely recovered, and the flow field was significantly improved. The clinical symptoms of this patient improved greatly after surgeries and no recurrence or growth retardation were noted during 1-year follow-up. The clinical prognosis was consistent with the prediction of the CFD results.

CONCLUSIONS

The state of epiglottis needs to be carefully checked to evaluate the necessity of performing further SGP in the patients with VC accompanied with LM. CFD and CAD could be developed as a new approach to help surgeons predict the post-operative outcomes through quantification of the airflow dynamics, and make the optimal and individualized surgical approaches for patients with airway obstruction.

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.

Vallecular Cyst: Reminder of a Rare Cause of Stridor and Failure to Thrive in Infants

The vallecular cyst is a rare cause of stridor, respiratory distress, and failure to thrive in infants. Large vallecular cysts may present with serious complications such as life-threatening airway obstruction. This report is of an infant who presented with stridor and failure to thrive. The patient’s condition was diagnosed as the presence of a vallecular cyst using flexible laryngoscopy. The vallecular cyst was successfully managed using endoscopic marsupialization. After the procedure, the patient was asymptomatic and dramatically gained weight within a few months. This case report serves as a reminder for clinicians to consider vallecular cysts as a differential diagnosis of stridor and failure to thrive in infants. It also emphasizes that early diagnosis and management lead to favorable clinical outcomes.

Tongue Cyst in a Neonate: Unusual Presentation

Congenital cysts of the tongue base are an uncommon cause of airway obstruction. The diagnosis of upper airway cysts requires a high index of clinical suspicion. We report a case of a vallecular cyst that uniquely extended to the dorsum of the tongue, and the patient presented with airway distress. We found that this presentation may facilitate an early diagnosis, as asymmetry of the tongue can be picked up easily during proper clinical examination.Therefore, inspection and palpation of the dorsal surface of the tongue is crucial for the approach of pediatric patients with airway obstruction.

Minimally invasive procedure for diagnosis and treatment of vallecular cysts in children: review of 156 cases

PURPOSE

Vallecular cyst is an uncommon but potentially life-threatening disease. The aim of this study was to review the presentation, evaluation, and treatment of vallecular cysts in children.

METHODS

Medical records of 156 patients treated for vallecular cysts between 2013 and 2016 were retrospectively reviewed. The patients were divided into four age groups for comparison of clinical data: A, < 1 month; B, 1-6 months; C, 7-12 months; and D, > 1 year.

RESULTS

The median age of all patients (98 males and 58 females) was 12.1 months (range 1 day-11 years), including 21, 86, 21, and 28 patients in group A, B, C, and D, respectively. A diagnosis of vallecular cysts was made for 135 patients using a combination of flexible laryngoscopy and ultrasound, and ten patients (all in group A) required pre-surgery ventilation support. The most common symptoms were wheezing (59.6%) and stridor (36.5%). Ten patients experienced difficulty with intubation. Endoscopic-assisted transoral coblation marsupialization was performed for all patients, combined with supraglottoplasty for 41 out of 68 patients with concurrent laryngomalacia. Patients in group D had a longer operation time and higher incidence of intraoperative bleeding, two of whom experienced post-operation recurrence, and symptoms resolved after a second operation in both cases.

CONCLUSIONS

Flexible laryngoscopy and ultrasound are recommended for a diagnosis in suspected cases of vallecular cysts. Coblation marsupialization has advantages of minor damage, low recurrence rate, and suitability for all age groups.

Vallecular cyst in the pediatric population: Evaluation and management

OBJECTIVE

To review the presentation of pediatric vallecular cysts and outline an approach for evaluation and management.

METHODS

Medical records of patients diagnosed with vallecular cyst between 2005 and 2017 were reviewed. Data on demographics, clinical characteristics, diagnostic methods, surgical procedures, and outcomes were collected and analyzed. A comprehensive literature search for pediatric cases of vallecular cyst was conducted for comparative analysis.

RESULTS

Twenty patients underwent surgery for congenital vallecular cysts during the study period. Age at diagnosis ranged from birth to 8 years (median age = 1.1 years). The most common preoperative symptom was inspiratory stridor (45%) followed by feeding difficulties (40%). Eight patients (40%) initially presented with laryngomalacia and 7 (35%) with feeding difficulties. Imaging was obtained in 16 patients and consisted of plain films, ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI). Marsupialization of the cyst was performed in all 20 patients. Three patients (15%) presented with recurrence.

CONCLUSION

Vallecular cysts can cause feeding difficulties due to upper airway obstruction and pressure at the laryngeal inlet. Diagnostic work-up for vallecular cysts should include a detailed medical history, complete head and neck examination including endoscopic examination, and appropriate imaging, as each of these components complements the histopathologic findings. Our findings indicate that performing marsupialization is associated with low rate of recurrence or complication.

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.

Neonatal stridor and laryngeal cyst: Which comes first?

Neonatal stridor is a rare condition usually caused by laryngomalacia. Congenital laryngeal cyst represents an uncommon cause of stridor in the neonatal population and may be misinterpreted as laryngomalacia, leading to serious morbidity and mortality if diagnosis and treatment are delayed. Herein we report the case of a full-term infant with stridor, feeding problems and failure to thrive. Initially, direct laryngoscopy diagnosed only laryngomalacia. As stridor worsened, however, and respiratory distress appeared, repeat laryngoscopy showed vallecular laryngeal cyst, visible macroscopically. The patient was successfully treated with endoscopic marsupialization. There was no evidence of recurrence at follow up after 3 months. This case highlights the importance of laryngoscopic assessment for suspected laryngeal abnormalities in infants with stridor. If symptoms worsen, endoscopy should be repeated, because congenital laryngeal cysts may not be immediately visible macroscopically.

Endoscopic surgical management of inspiratory stridor in newborns and infants

OBJECTIVE

Compare the incidence of endoscopic surgical treatment of patients with laryngomalacia to other aerodigestive pathology who may present with similar symptoms.

METHODS

Consecutive case series with chart review of endoscopic surgical intervention in infants, aged 12 months or less, presenting with inspiratory stridor, in the absence of syndromic condition or prior history of intubation.

RESULTS

A total of 30 patients were identified. The average age at the time of surgical intervention was 2.7 months. Endoscopic surgical management was directed at laryngomalacia (70%), vallecular cysts (23.3%), and anterior glottic webs (6.7%). All patients had nearly immediate resolution of the stridor and feeding difficulties. None required revision surgery, modified diets, or alternative means of enteric nutrition.

CONCLUSIONS

Laryngomalacia was the most commonly encountered surgical indication for stridulous newborns and infants with severe symptoms. Like most previous descriptions, patients responded well to supraglottoplasty. Vallecular cysts accounted for about one-quarter of the infants treated. Clinicians should carefully consider the presence of other airway pathology, which may mimic laryngomalacia, in non-syndromic infants without a previous history of intubation. Endoscopic surgical management may be safe and effective.

Congenital Vallecular Cyst Causing Airway Compromise in a 2-Month-Old Girl

Congenital vallecular cyst is a rare entity and may present with acute airway obstruction. This is a case of congenital vallecular cyst presenting with airway compromise requiring immediate management. The epidemiology, pathogenesis, and clinical presentation of vallecular cysts are discussed as well as the diagnosis and management.

A Case Report of a Vallecular Cyst and Literature Review

Cysts in the vallecula are rare entities and seldom have been reported in the literature. However, these masses can have very important clinical implications. When they are small, they are usually asymptomatic. When they reach a large enough size, they can cause dysphagia, odynophagia, and acute airway complications. With the expanded scope of oral and maxillofacial surgery, the proper diagnosis and management of vallecular lesions could become a routine part of oral and maxillofacial surgical practice and aid in further development of the specialty. This report describes the case of a benign lymphoepithelial cyst of the vallecula.

The outcomes of infantile vallecular cyst post CO₂ laser treatment

OBJECTIVES

Vallecular cyst is not a common disease of neonate and infant. However, it may cause severe airway obstruction and even death. Its clinical symptoms are similar to laryngomalacia, including stridor, suprasternal retraction, substernal retraction, feeding difficulties, vomiting, failure to thrive, feeding choking and desaturation. This study is aimed to evaluate the surgical outcomes of infantile vallecular cyst post CO₂ laser treatment and to explore the appropriate time point of surgery for infantile vallecular cyst.

METHODS

In a retrospective review, thirty three patients diagnosed as vellecular cyst were enrolled in this study. All the patients received awake fiberoptic videobronchoscopic examination in order to prove the diagnosis. Pre-operative and post-operative eight symptom items were both recorded for comparison of the surgical outcomes. The age of diagnosis, gender, operation, body weight at surgery, co-morbidities, dates of postoperative endotracheal intubation, ICU stays and admission days were all recorded for analysis.

RESULTS

Total 33 cases of vallecular cyst were diagnosed by fiberoptic videobrochoscopy at our department. Most infants were diagnosed at 2-3 months-old. Stridor was the most common pre-operative symptom (100%). Additionally, feeding choking was the most common post-operative one (29.41%). Two patients (6.06%) with newly onset postoperative feeding choking recovered spontaneously within 2 weeks. Failure to thrive got worse as age increased before the operation. Eighty-eight percent of patients had good or excellent improvement of symptoms after surgery. There was neither recurrence nor surgical complication in our study.

CONCLUSION

Vallecular cyst often combined with laryngomalacia. Different from laryngomalacia, it had excellent outcomes after CO₂ laser treatment. Failure to thrive got worse if delay diagnosis. Therefore, if definite diagnosis is made, early laser excision of cyst is a good method and the surgical outcomes are excellent.

Treatment of vallecular cysts in infants with and without coexisting laryngomalacia using endoscopic laser marsupialization: fifteen-year experience at a single-center

OBJECTIVE

To share our experience in treating a large cohort of infants with congenital vallecular cysts using endoscopic laser marsupialization. We describe the clinical characteristics of infants with pediatric vallecular cysts and compare these characteristics between infants with and without concurrent laryngomalacia and those who did or did not require preoperative airway support.

METHODS

Medical records of infants treated for vallecular cyst at Chang Gung Memorial Hospital between March 1994 and July 2008 were reviewed. Demographic and clinical characteristics and outcomes were recorded and compared.

RESULTS

Twenty-eight infants were included in our study: 11 (39.3%) males and 17 (60.7%) females. The incidence of vallecular cyst was 5.3 cases/100,000 live births. Median ages at symptom onset and diagnosis were 3.0 and 40.0 days, respectively. Mean symptom onset to diagnosis interval was 42.4 days. Eighteen (64.3%) infants had coexisting laryngomalacia and 11 (39.3%) required ventilatory support. The number of symptoms decreased in all patients after surgery (median no. symptoms before=4.5, after=0.5) and most symptoms were completely resolved within 3 months of surgery. Compared with infants who did not have laryngomalacia, infants with laryngomalacia: were younger at symptom onset (2 vs 10 days); had more symptoms before (5.0 vs 3.5) and after treatment (1.0 vs 0.0); had a longer length of hospital (14.6 vs 9.4 days) stay; and more commonly required airway intervention compared with infants without laryngomalacia (55.6% vs 10.0%: all P<0.05). Compared with infants who did not require ventilatory support, those that did: had a shorter interval between symptom onset and diagnosis (31.8 vs 49.3 days); were younger at the age of diagnosis (38.0 vs 49.0 days); had more symptoms before surgery (5.0 vs 4.0); had a higher prevalence of laryngomalacia (90.9% vs 47.1%); had a longer length of hospital (16.4 vs 10.4 days) stay (all P<0.05).

CONCLUSIONS

Our study included a large number of infants with vallecular cyst who were treated with endoscopic laser marsupialization. Of note, we found that a large proportion of infants had coexisting laryngomalacia, which appears to complicate the clinical presentation and management of vallecular cyst.

Radiofrequency ablation of pediatric vallecular cysts

OBJECTIVE

Pediatric congenital vallecular cysts are an infrequent cause of infantile airway obstruction that can cause difficulty breathing or feeding, and lead to failure to thrive or death. There have been many different techniques proposed for effective treatment. We present three cases of congenital vallecular cyst, all excised utilizing a bipolar radiofrequency plasma ablation (RFA) device. The bipolar RFA device provides excellent hemostasis without the risk of airway fire. We offer a review of literature and a discussion of the potential advantages of this modality in treating neonatal/infantile vallecular cysts.

METHODS

Retrospective case series of three infants all between 2 and 3 months old who presented with failure to thrive due to partially obstructive vallecular cysts. The cysts were removed surgically utilizing a bipolar RFA device. Patients were followed by complications and signs of recurrence for periods ranging from 9 to 20months.

RESULTS

All cysts were excised completely in a single operation. All children are feeding well and without stridor or evidence of recurrence between 9 and 20 months postoperatively.

CONCLUSIONS

RFA appears to be an effective and safe modality for removing vallecular cysts. We were able to demonstrate complete removal of lesions in our patients. This provides an alternative to other ablative modalities in treating cystic lesions of the vallecula and larynx.

Vallecular cyst in an infant: does your specimen show D2-40 immunoreactivity?

Vallecular cysts are infrequent causes of supraglottic obstruction causing stridor and swallowing difficulty in infants. When detected early in life, the management consists of marsupialization or resection. Supraglottic lymphangiomas of the tongue base and vallecula present with similar symptoms and time of presentation. Endoscopic visualization is traditionally considered to be sufficient in identifying and differentiating these. When a vallecular cyst is visually diagnosed by the surgeon during endoscopy, surgical treatment is provided at the same time. Obtaining a specimen is rarely considered for histopathologic diagnostic verification. However, the natural presentation of a cystic lymphangioma may be indistinguishable from a solitary vallecular cyst by endoscopy alone. This case presentation argues in favor of histopathologic diagnosis in vallecular cysts because the 2 may represent a continuum of disease. A vallecular mass with a single large mucus-filled cyst and adjoining edematous soft tissue extension into the tongue base and piriform sinus diagnosed as lymphangioma through D2-40 immunoreactivity is presented.

Transoral approach for direct and complete excision of vallecular cysts in children

OBJECTIVE

To review the presentation, evaluation, and treatment of children with vallecular cysts and introduce a new technique of transoral excision for this entity.

METHODS

Retrospective case series of children diagnosed with vallecular cyst between 2001 and 2008 at a single tertiary care children's hospital. Data collected, including age at diagnosis, presenting symptoms, additional diagnoses, diagnostic modality, prior and subsequent surgical therapy, length of hospital stay, length of follow-up, and recurrence were analyzed with descriptive statistics.

RESULTS

Seven children (mean age 198 days, range 2 days to 2.9 years) were included in this series. Five children presented with respiratory distress and/or swallowing difficulties. Vallecular cyst was diagnosed by initial flexible fiberoptic laryngoscopy (5/7), MRI (1/7), and intubating laryngoscopy (1/7). All children underwent complete cyst excision via transoral surgical approach. Two children underwent additional supraglottoplasty for concomitant laryngomalacia, one of whom underwent tracheotomy for persistent respiratory distress and vocal cord immobility. The average length of hospital stay postoperatively was 9.5 days, and four patients stayed less than 2 days. No patients experienced recurrence of the vallecular cyst at last follow-up (range 4-755 days, mean 233 days).

CONCLUSIONS

Vallecular cysts are rare but should be considered in children with respiratory distress and dysphagia. Awake, flexible fiberoptic laryngoscopy with particular attention to the vallecular region should be performed on any child presenting with these symptoms. Direct, transoral approach for excision of the vallecular cyst is our preferred method of treatment with no recurrences to date.