Diagnosis and treatment of pediatric vallecular cysts and pseudocysts

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Abstract

Objective

To review the experience at a children's hospital diagnosing and treating vallecular cysts.

Secondary objectives

To determine if cyst type, operative mode, or ages are risk factor(s) for recurrence.

Methods

Chart review of eleven children with vallecular cysts and pseudocysts from 1997 to 2009.

Results

The most common presenting symptoms were stridor (8/12, 67%), respiratory distress (7/12, 58%), and feeding difficulties (4/12, 33%). Symptoms of gastroesophageal reflux disease were present in 67% of patients and 17% carried a concurrent diagnosis of laryngomalacia. Eleven of twelve patients required operative intervention, the majority of which were transoral endoscopic procedures. Three patients (3/11, 27%) had recurrences. Two of these patients required only a second procedure, but one patient required multiple procedures. Fifty percent (2/4) of the patients 2 years or older experienced a recurrence, whereas only 14% (1/7) of the patients less than 2 years old had a recurrence, a difference which was not statistically significant (p = 0.49). Pseudocysts tended to recur more frequently than vallecular cysts. (p = 0.13). Surgical approach (marsupialization versus total excision) did not affect recurrence rate. One patient with a small, asymptomatic cyst was observed and continues to be symptom-free. There were no surgical complications.

Conclusions

Vallecular cysts and pseudocysts are rare congenital lesions of the upper aerodigestive tract. Vallecular pseudocysts tended to recur more than vallecular cysts in our series. Surgery is the treatment of choice for symptomatic patients; smaller cysts may be followed closely.

Introduction

Vallecular cysts (VC) (including true vallecular cysts (TVC) and vallecular pseudocysts (VPC)) are rare, but well known causes of upper airway obstruction and death in newborns and infants. They consist of a cyst or pseudocyst arising beneath the mucosa of the vallecula, either on the lingual surface of the epiglottis or the base of tongue (Fig. 1A and B). Clinical presentation may include feeding difficulties and/or respiratory distress. Given the rarity of these lesions, the methods used to evaluate and to manage these patients varies in the literature. While most authors recommend flexible nasopharyngolaryngoscopy (NPL) for initial diagnostic evaluation [1], [2] others have utilized lateral X-ray [1], [3] and barium esophagram [4]. Treatment options include conservative medical management [2], cyst aspiration, marsupialization, surgical debulking, and laser excision [1], [2], [3].

In this study we review our experience with the diagnosis and treatment of VC.

Section snippets

Methods

The primary outcome was surgical success, defined as no recurrence of symptoms or lesion requiring further surgery (except office NPL for follow-up evaluation). Secondary outcomes included whether recurrence rates were affected by type of pathology, surgical technique, penetration of the cyst during the procedure, or age at presentation. We also evaluated the impact of concurrent laryngomalacia (LM) or gastrointestinal reflux disease (GERD) in patients with feeding difficulties and respiratory

Results

Twelve children were identified who met the inclusion criteria. Eight were male and four were female. Age at diagnosis ranged from 3 days to 13 years with a median age of 3.4 months.

Discussion

VC is rare, but can cause significant airway obstruction in children and infants. Structurally these cysts present as mucus-filled masses in the vallecula, but they may differ in their histology. A TVC is lined by epithelium, possibly arising from obstructed ducts of submucosal glands in the vallecula, whereas, VPC lack an epithelium lining. Clinically they present similarly and may rapidly enlarge if inflamed or infected. Only a small number of retrospective case series are found in the

Conclusion

In reviewing our results, most VCs can be successfully treated using a transoral endoscopic approach. Recurrence rate did not appear to depend on whether the cyst was excised completely or marsupialized. There was a trend towards higher rate of recurrence if the child was older or if the pathology was consistent with a pseudocyst. Inflammation or infection seemed to trigger recurrence in one of our patients who required multiple procedures. This has been reported in the adult literature as

Funding

None.

Disclosure

None.

Conflict of interest

None.

Acknowledgement

None.

References (11)

There are more references available in the full text version of this article.

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