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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 36-38

A large vallecular cyst presenting as a tonsillitis mimic


Birmingham Heartlands Hospital, Birmingham, England, UK

Date of Submission24-Jan-2022
Date of Acceptance21-Feb-2022
Date of Web Publication12-Apr-2022

Correspondence Address:
Andrew James Mowat
Heartlands Hospital, Bordesley Green, Birmingham, B9 5SS
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jlv.jlv_1_22

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   Abstract 


We describe a unique case of an 18-year-old man referred to otolaryngology on call, as tonsillitis. He gave a 4-day history of progressive dysphagia, change in voice, and globus. No past medical history was given, and vital observations were stable. On clinical examination, his tonsils were unremarkable. Inflammatory markers were within normal limits. Flexible nasoendoscopy revealed a 5-cm oropharyngeal cyst, arising from the left vallecula. His airway was distorted with no view of the vocal cords. Initial management with antibiotics, steroids, and intravenous fluids stabilized his condition. A computed tomography neck with contrast confirmed the cyst to be an isolated lesion. A magnetic resonance imaging excluded the differential of lingual thyroid tissue. The patient was taken to the theater for marsupialization of the cyst, normalizing his airway. He was discharged the following day symptom-free.

Keywords: Airway, pharyngitis, vallecular cyst


How to cite this article:
Mowat AJ, Sandhar P, Gill C, Kale U. A large vallecular cyst presenting as a tonsillitis mimic. J Laryngol Voice 2021;11:36-8

How to cite this URL:
Mowat AJ, Sandhar P, Gill C, Kale U. A large vallecular cyst presenting as a tonsillitis mimic. J Laryngol Voice [serial online] 2021 [cited 2022 Dec 5];11:36-8. Available from: https://www.laryngologyandvoice.org/text.asp?2021/11/2/36/342860




   Introduction Top


Sore throats are a common referral to the otolaryngology on-call service. Cases are often reviewed by nonspecialist emergency medicine practitioners and rotating junior doctors within the ear, nose, and throat (ENT) team. Noncritical patients are frequently discharged without admission or clinical assessment with nasoendoscopy.

The most common diagnosis is that of acute infection. Viral pharyngitis is commonly seen secondary to adenovirus, influenza, or Ebstein–Barr viruses. Acute bacterial infection can cause tonsillitis, with or without peritonsillar abscess. The most common causative organism is Streptococcus pyogenes. Numerous noninfective conditions can mimic the same presenting symptoms. Common differentials include reflux and sialolithiasis. More serious conditions including supraglottitis, foreign bodies, or laryngotracheobronchitis may threaten the airway if misdiagnosed. Malignancy must be excluded in cases in which infection is not apparent.

We describe a unique case of an adolescent patient referred to the ENT service with a sore throat and dysphagia. This was initially diagnosed as being secondary to inflammation of his tonsils. However, he was found to have a large vallecular cyst which was close to causing critical airway obstruction. The case displays the importance of thinking broadly when managing routine symptomatology.


   Case Report Top


An 18-year-old man presented to the otolaryngology acute on-call service with a sore throat. He reported a 4-day history of voice change, globus, and a progressive dysphagia. The emergency department had made the diagnosis of tonsillitis. At the time of assessment, he could only manage sips of water. On clinical examination, his tonsils and oropharynx were not inflamed. Flexible nasoendoscopy revealed a large cyst in the vallecular, which distorted the view of the glottis [Figure 1]. His airway was stable and he was able to speak in complete sentences throughout.
Figure 1: Flexible nasoendoscopic image of the cystic lesion in the vallecula

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He was initially managed with intravenous antibiotics, fluids, and steroids. A computed tomography scan of the neck with contrast confirmed a 5.0 cm × 2.5 cm × 3.0 cm cystic lesion in the oropharynx with the peduncle emanating from the vallecular [Figure 2]. The possibility of lingual thyroid was queried by the reporting radiologist.
Figure 2: Axial computed tomography neck with contrast showing the cyst in the left vallecular

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A magnetic resonance imaging scan confirmed that the lesion was not in continuity with the thyroid gland [Figure 3]. The lesion was isolated with no evidence of concurrent pathology or lymphadenopathy [Figure 4].
Figure 3: Coronal T2-weighted magnetic resonance imaging scan

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Figure 4: Sagittal T2-weighted magnetic resonance imaging scan

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The patient was taken to the theater for surgical excision of the cyst. The distortion of the laryngeal anatomy caused by the cyst prevented routine intubation. Hence, the patient's airway was secured through awake fiber-optic nasal intubation. A Lindholm scope was used to visualize the lesion. After direct laryngoscopy, the cyst was marsupialized and the contents drained. Following surgery, the patient's airway and swallow normalized. He was discharged the following day.


   Discussion Top


Vallecular cysts are well described as a cause of airway obstruction in neonates. However, their presentation in adults is less well reported.

Such cysts represent mucous retention cysts of the epiglottis or the base of the tongue. They can arise when the duct of a mucous gland or lingual tonsillar crypt becomes obstructed. Typically, they are provoked by inflammation, irritation, or trauma. They can occur at any location lined by mucosa and can be found at any site in the larynx, other than the free edge of the true vocal cords.[1]

In pediatric cases, presenting complaints include respiratory distress, feeding difficulties, or gastroesophageal reflux disease. Failure to thrive has also been reported.[2] Concurrent laryngomalacia is common.[3]

Prenatal identification has been described. In such cases, delivery should be carried out in a tertiary referral center with ventilation and tracheostomy facilities available.[4] Management in the pediatric age group is through a direct transoral approach.[5] Coblation excision has also been trialed.[6] Patient age and surgical technique (marsupialization versus total surgical excision) have been shown to have no statistically significant impact on recurrence rates. Pseudocysts can present in a similar fashion and do show a higher recurrence rate following excision.[3]

Presentation in adults can be subdivided. Some cysts present acutely with a superimposed infection.[7] A critical airway is common in such cases, particularly as progression to acute epiglottitis and abscess formation is likely. Other cysts present without superimposed infection with symptoms of globus, dysphonia, and dysphagia. Adult cysts can be an incidentally noticed by anesthetic teams, when they may cause problematic intubations.[8]

In adults, direct transoral excision is the mainstay of management. Small asymptomatic cysts can be managed conservatively. Recent surgical advances in head-and-neck surgery have been applied to the excision of vallecular cysts. Utilizing the Da Vinci robot[9] and separately the KTP laser[10] have been described.


   Conclusion Top


We describe a rare case of a large cyst presenting in an adolescent patient. The symptoms mimicked acute pharyngitis. The case displays the importance of thorough assessment with nasoendoscopy, and considering a wide differential when managing cases of acute, progressive dysphagia. If missed, the cyst may have represented as acute airway obstruction. Vallecular cysts should be considered in the differential diagnosis of acute dysphagia and voice change in adolescents and adults. Once diagnosed such lesions are managed surgically. Follow-up is suggested to exclude recollection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands 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.
Romak JJ, Olsen SM, Koch CA, Ekbom DC. Bilateral vallecular cysts as a cause of Dysphagia: Case report and literature review. Int J Otolaryngol 2010;2010:697583.  Back to cited text no. 1
    
2.
Tuncer U, Aydoğan LB, Soylu L. Vallecular cyst: A cause of failure to thrive in an infant. Int J Pediatr Otorhinolaryngol 2002;65:133-5.  Back to cited text no. 2
    
3.
Leibowitz JM, Smith LP, Cohen MA, Dunham BP, Guttenberg M, Elden LM. Diagnosis and treatment of pediatric vallecular cysts and pseudocysts. Int J Pediatr Otorhinolaryngol 2011;75:899-904.  Back to cited text no. 3
    
4.
Cuillier F, Samperiz S, Testud R, Fossati P; Department of Obstetrics and Gynecology, Félix Guyon Hospital, Reunion Island, France [email protected] Antenatal diagnosis and management of a vallecular cyst. Ultrasound Obstet Gynecol 2002;20:623-6.  Back to cited text no. 4
    
5.
Chen EY, Lim J, Boss EF, Inglis AF Jr., Ou H, Sie KC, et al. Transoral approach for direct and complete excision of vallecular cysts in children. Int J Pediatr Otorhinolaryngol 2011;75:1147-51.  Back to cited text no. 5
    
6.
Gogia S, Agarwal SK, Agarwal A. Vallecular cyst in neonates: Case series – A clinicosurgical insight. Case Rep Otolaryngol 2014;2014:764860.  Back to cited text no. 6
    
7.
Berger G, Averbuch E, Zilka K, Berger R, Ophir D. Adult vallecular cyst: Thirteen-year experience. Otolaryngol Head Neck Surg 2008;138:321-7.  Back to cited text no. 7
    
8.
Kamble VA, Lilly RB, Gross JB. Unanticipated difficult intubation as a result of an asymptomatic vallecular cyst. Anesthesiology 1999;91:872-3.  Back to cited text no. 8
    
9.
McLeod IK, Melder PC. Da Vinci robot-assisted excision of a vallecular cyst: A case report. Ear Nose Throat J 2005;84:170-2.  Back to cited text no. 9
    
10.
Zalvan CH, Reilly E. Symptomatic vallecular cysts: Diagnosis and management with the KTP laser. Eur Arch Otorhinolaryngol 2016;273:2111-6.  Back to cited text no. 10
    


    Figures

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



 

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