Diagnosis and treatment of pediatric vallecular cysts and pseudocysts
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.
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2018, Journal of Pediatric Surgery Case ReportsCitation Excerpt :Firstly, all stridor in neonates and infants is not laryngomalacia, especially if worsening. Secondly, laryngomalacia, especially when causing marked increases in work of breathing, can cause failure to thrive, weight loss, or symptoms of airway obstruction—however, progression of these symptoms should prompt further laryngoscopic investigation and may implicate a growing cyst of the upper airway [8]. Lastly, the growth of vallecular cysts is often associated with concomitant infection with organisms such as pneumococci, streptococci, staphylococci, Haemophilus influenza, Bacteroides sp., herpes simplex virus, and Candida sp.—once identified, definitive antimicrobial therapy must be implemented [11−13].
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