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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 21-23

Concomittant epiglottic and multiple vallecular cyst: An exceptioally rare case report


1 Department of ENT, AFMC, Pune, Maharashtra, India
2 ACMS and Base Hospital, Delhi Cantt, New Delhi, India
3 Department of PSM, AFMC, Pune, Maharashtra, India
4 Department of Psychiatry, AFMC, Pune, Maharashtra, India

Date of Submission03-Oct-2020
Date of Acceptance09-May-2021
Date of Web Publication5-Jul-2021

Correspondence Address:
Kamalpreet Singh
AFMC, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jlv.jlv_13_20

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   Abstract 


Laryngeal cysts are rare and are often diagnosed incidently as majority of the patients are symptom free or have nonspecific complaints. Here, we describe single large epidermoid inclusion epiglottic cyst and multiple small mucosal retention vallecular cysts presenting concomitantly which has not been described previously in literature.

Keywords: Epidermoid inclusion cyst, epiglottic cyst, laryngeal cyst, vallecular cyst


How to cite this article:
Singh K, Mishra AK, Gupta A, Kour A. Concomittant epiglottic and multiple vallecular cyst: An exceptioally rare case report. J Laryngol Voice 2021;11:21-3

How to cite this URL:
Singh K, Mishra AK, Gupta A, Kour A. Concomittant epiglottic and multiple vallecular cyst: An exceptioally rare case report. J Laryngol Voice [serial online] 2021 [cited 2021 Dec 4];11:21-3. Available from: https://www.laryngologyandvoice.org/text.asp?2021/11/1/21/320559




   Introduction Top


Larynx contains numerous mucosal and serous glands which can lead to formation of laryngeal cysts. They account for 5%–10% of all benign lesions of larynx.[1] De Santo et al. classified the laryngeal cysts into ductal and saccular cysts.[2] Ductal cysts are simple mucosal retention cysts, and saccular cysts are submucosal lying in plane of saccule of larynx. He also stated that vallecular cysts if found are often multiple.[2] Arens et al. classified the laryngeal cysts into congenital, inclusion, and retention cysts.[3] Congenital cysts are formed due to aberration in embryogenesis in third and fifth branchial arches, leading to the formation of saccular cysts. Inclusion cysts are epidermoid cysts found mainly in true vocal folds. Retention cysts are ductal cysts of mucosal origin. Newman et al. classified laryngeal cysts into epithelial (ductal and saccular), tonsillar, and oncocytic cysts.[4] Laryngeal cysts thus can be classified into mucous retention cysts (ductal, saccular, and epithelial), epidermoid inclusion cysts, and oncocytic cysts. The common location of these cysts is true vocal folds (58%), ventricle (18%), epiglottis (10%), and vallecula (10%).[3] Epiglottic and vallecular cysts are formed mostly due to obstruction of duct of mucous glands and sometimes as epidermoid inclusion cysts and have been found to present alone. Here, we report a case where the epidermoid inclusion cyst of epiglottis presented concomitantly with multiple mucosal retention cysts of vallecula.


   Case Report Top


A 46-year-old male presented with complaints of foreign-body sensation throat, muffled voice, and difficulty in swallowing of 10-month duration. The patient had no addictions and no associated systemic illness. Fiber-optic laryngoscopy revealed 2 cm × 2 cm cystic lesion arising from lingual surface of epiglottis having smooth surface, creamish yellow in color with a leash of blood vessels over it [Figure 1]. Rest of larynx and hypopharynx was normal with mobile vocal cords bilaterally. With diagnosis of concomitant epiglottic and vallecular cysts, the patient was taken up for microlaryngeal surgery under general anesthesia. Insertion of endotracheal tube was challenging due to multiple cysts obscuring the view of glottis. Preoperatively, the case was thoroughly discussed with the anesthesiologist for the intubation difficulty and possible requirement of tracheostomy. Hence, finally, the decision of intubation using awake fiber-optic technique under vision was taken. Under general anesthesia, direct laryngoscope was positioned and microscope adjusted to visualize the cysts. The epiglottic cyst was then decompressed using 18G needle. Three to four milliliter creamish aspirate was removed allowing better inspection of the larynx and attachment of cysts. Following complete excision of epiglottic cyst, multiple vallecular cysts were visualized which were also excised in toto using microlaryngeal instruments [Figure 2] and sent for histopathological examination. Postoperative period was uneventful. The patient was discharged next day with advice of voice hygiene and proton pump inhibitors for 2 weeks. Fiber-optic laryngoscopy done after 2 weeks was essentially normal [Figure 3]. The histopathological examination showed epiglottic cyst as epidermoid inclusion cyst [Figure 4] and vallecular cyst as mucosal retention cyst [Figure 4].
Figure 1: Preoperative images of cysts

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Figure 2: Intraoperative images of cysts

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Figure 3: Postoperative image of larynx

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Figure 4: Histopathological staining of cysts

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   Discussion Top


Epiglottic cysts are benign cysts which can either be mucous retention cyst or epidermoid inclusion cysts and generally arise from anterior surface of the epiglottis. Mucous retention cyst of epiglottis occurs due to obstruction of mucous and lymphatic glands. The epidermoid inclusion cysts can be developmental or acquired and occur due to the implantation of epidermal tissue into the dermis.[5] The wall of cyst is lined by thin keratinized stratified squamous epithelium with lymphocyte infiltration. The lumen is filled with keratinaceous material and no skin appendages.[6] The vallecular cysts are generally mucous retention cysts which arise when ducts of seromucinous glands (ductal cysts), crypts of tonsil (epithelial cysts) gets obstructed and are often multiple in number. The patients with laryngeal cysts are generally asymptomatic and often diagnosed incidentally by anesthesiologists during intubation or by otolaryngologists during fiber-optic laryngoscopy. If the cysts are symptomatic, then the patients have nonspecific complaints such as foreign-body sensation throat or specific complaints such as change in voice, dysphagia when the cysts are large or multiple in number. Voluminous cysts discovered incidentally in patients requiring general anesthesia pose a challenge to intubation and increase the risk of airway obstruction. Epiglottic cysts are also discovered in patients with acute epiglottis or when the acute infection has subsided.[7] Sometimes, it can lead to fatal outcomes and sudden death.[8] Rarely epidermoid cysts can turn malignant.[9] There are different various modalities to treat laryngeal cysts. Initially, few surgeons used to do needle aspiration or marsupialization of cysts, but it leads to recurrences.[7] Now, complete excision of cyst wall is the preferred treatment of choice which can be done with various modalities such as microlaryngeal instruments, microdebrider, or CO2 laser.[10] Mucosal retention cyst of vallecula is uncommon, accounting for around 10%–20% of all laryngeal cysts. There are few case reports of epidermoid inclusion cysts of preepiglottic region or vallecula,[11],[12] vocal folds, and sublingual region.[13] However, only one case report of epidermoid inclusion cyst of epiglottis was found on Medline/PubMed database of literature.[14] Coexistence of both epidermoid inclusion cyst of epiglottis and multiple mucosal retention cysts of vallecula is rare.


   Conclusion Top


Epiglottic cysts and vallecular cysts are rarely found, and their concomitant presence is not reported till date. Management principles include complete removal of cyst wall and meticulous joint efforts by otorhinolaryngologists and anesthesiologists as airway concerns are primary apart from achieving best results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Berke GS. Historical classics: Editorial. Laryngoscope 2015;125:2627-8.  Back to cited text no. 1
    
2.
Santo JK, Aqel NM, McEwen J, Bleach NR. Cysts of the larynx classification. Laryngoscope 1970;80:145-76.  Back to cited text no. 2
    
3.
Arens C, Glanz H, Kleinsasser O. Clinical and morphological aspects of laryngeal cysts. Eur Arch Otorhinolaryngol 1997;254:430-6.  Back to cited text no. 3
    
4.
Yoon TM, Choi JO, Lim SC, Lee JK. The incidence of epiglottic cysts in a cohort of adults with acute epiglottitis. Clin Otolaryngol 2010;35:18-24.  Back to cited text no. 4
    
5.
Wollina U, Langner D, Tchernev G, França K, Lotti T. Epidermoid cysts - A wide spectrum of clinical presentation and successful treatment by surgery: A retrospective 10-year analysis and literature review. Open Access Maced J Med Sci 2018;6:28-30.  Back to cited text no. 5
    
6.
Hoang VT, Trinh CT, Nguyen CH, Chansomphou V, Chansomphou V, Tran TT. Overview of epidermoid cyst. Eur J Radiol Open 2019;6:291-301.  Back to cited text no. 6
    
7.
Leibowitz JM, Smith LP, Cohen MA, Dunham BP, Guttenberg M, Elden LM. Diagnosis and treatment of pediatric vallecular cysts and pseudocysts. Int J Pediatric Otorhinolaryngol 2011;75:899-904.  Back to cited text no. 7
    
8.
Dada MA. Laryngeal cyst and sudden death. Med Sci Law 1995;35:72-4.  Back to cited text no. 8
    
9.
Zito PM, Scharf R. StatPearls. Cyst, Epidermoid (Sebaceous Cyst). Treasure Island (FL): StatPearls Publishing; 2020.  Back to cited text no. 9
    
10.
Heyes R, Lott DG. Laryngeal cysts in adults: Simplifying classification and management. Otolaryngol Head Neck Surg 2017;157:928-39.  Back to cited text no. 10
    
11.
Kaur A, Kini U, Alva SK. Cysts of the larynx: A clinicopathologic study of nine cases. Indian J Otolaryngol Head Neck Surg 1998;50:250-6.  Back to cited text no. 11
    
12.
Keenleyside HB, Greenway RE. Management of pre-epiglottic cysts: A report of nine cases. Can Med Assoc J 1968;99:645-9.  Back to cited text no. 12
    
13.
Nishar CC, Ambulgekar VK, Gujrathi AB, Chavan PT. Unusually giant sublingual epidermoid cyst: A case report. Iran J Otorhinolaryngol 2016;28:291-6.  Back to cited text no. 13
    
14.
Bobrov VM. Epidermoid cysts of the epiglottis. Vestn Otorinolaringol 1998;(5):51.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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