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Endoscopic resection of a vallecular cyst in a pediatric patient

Base of tongue masses are rare in the pediatric population, when present they can be remain asymptomatic for years or can cause acute respiratory distress.  The differential diagnosis includes dermoid, vallecular cyst, thyroglossal duct cyst, lingual thyroid, lymphangioma, hemangioma, and teratoma (1). Vallecular cysts consist of mucus filled cysts or pseudocysts arising either from the mucosa on the lingual surface of the epiglottis or on the base of tongue (2). These benign mucous retention cysts most commonly present as stridor, difficulty feeding, respiratory distress but they can also remain asymptomatic and can be found incidentally (3,4).

Vallecular cysts may occur in isolation, but they can be associated with laryngomalacia and GERD in a significant number of patients(5). Initial screening of the airway is done using flexible fiberoptic laryngoscopy which provides a quick assessment of the larynx and visualization of the cyst(6). Imaging (ultrasonography, CT, MRI) can also be useful for evaluation of the mass and more detailed visualization of the mass and surrounding structures(6).

Conservative medical treatment is not adequate for the management of vallecular cysts. Several surgical options have been described, these include aspiration, transoral endoscopic excision, marsupialization and deroofing with CO2 laser or microdebrider (6). There is a high recurrence rate when simple aspiration is performed (7), and there is reported risk of recurrence with marsupialization techniques. Excision using transoral endoscopic technique ensures complete resection with adequate visualization and preservation of surrounding structures and mucosa with low risk of recurrence (4).

Here, we describe transoral endoscopic approach for excision of base of tongue cyst in a 3 year-old female. The patient presented with the diagnosis of PFAPA and she was seen to discuss tonsillectomy and adenoidectomy.  On physical exam, a 1.5 cm midline base of tongue cyst was seen when she protruded her tongue. The cyst had been increasing in size. Plan was to proceed with tonsillectomy & adenoidectomy and excision of base of tongue cyst.

After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating table. Correct patient and procedure were identified and general anesthesia by mask was induced. A laryngeal mask airway was placed first.

A red rubber catheter was placed through the left nostril  after the Davis mouth gag was inserted with a small tongue blade.  The soft palate and uvula were palpated to be normal.  The adenoid was mildly enlarged and was cauterized completely with suction cautery. Following that, Afrin was placed in the nasal cavity.  The child was intubated with a nasotracheal tube through her left nostril that allowed for exposure.  A red rubber catheter was left in her right nostril.   The side-biting mouth gag was used.  Two separate 2-0 silk sutures were placed in the midline to retract her tongue.

A 30-degree telescope was used for visualization of the base of tongue cyst.  With the Hurd elevator and other means of retraction, an extended Colorado needle tip with a 45 degree bend at the distal portion, was used to completely remove the base of tongue cyst which was quite deep.  At the distal part, there  was mucus seen, but the cyst was completely excised.  The wound was irrigated thoroughly.  There was no bleeding.  The side-biting mouth gag was removed and the Davis mouth gag reinserted.

A complete tonsillectomy was then performed. She was then extubated without difficulty in the OR and transferred to PACU.

Patient was discharged on oxycodone and amoxicillin. On her follow up visits, the oral cavity and tongue were healing well with no evidence of recurrence.

Pathology result: consistent with extravasation mucocele. Mucin filled cystic space rimmed by a lympho-histiocytic reaction and granulation tissue. Minor salivary glands w/ dilated ducts focally surrounded by chronic inflammation are present in the surrounding fibromuscular tissue.

1) General anesthesia by mask was induced, laryngeal mask airway was placed. 2) Davis mouth gag was inserted, the soft palate and uvula were normal. 3) A red rubber catheter was placed through the left nostril. 4) The adenoid was mildly enlarged and was cauterized completely with suction cautery. 5) Nasotracheal tube was inserted through her left nostril. 6) A red rubber catheter was placed through her right nostril. 7) A side-biting mouth gag was used. Two separate 2-0 silk sutures were placed midline to retract the tongue. 8) A 30 degree telescope was used for visualization, a 1.5 cm base of tongue cyst was identified. 9) A Hurd elevator was used for retraction and a Colorado needle tip extended and bent tip was used to completely dissect and remove the base of tongue cyst. 10) The cyst was found to be deep. At the distal part, there was mucus seen, but the cyst was completely excised. 11) The wound was irrigated thoroughly. There was no bleeding. The side-biting mouth gag was removed.
Base of tongue had been increasing in size. These cysts can cause respiratory and feeding difficulties due to upper airway obstruction.
Presence of other compromising airway anomalies Bleeding disorders
30 degree telescope Side-biting mouth gag 2-0 silk sutures Red rubber catheters Hurd elevator Colorado needle tip cautery
Thorough physical exam
Base of tongue Epiglottis Vallecula Lingual tonsils Glossoepiglottic ligament
Transoral endoscopic approach with retraction using silk sutures provides adequate visualization of base of tongue cyst and surrounding structures. The advantage of this technique over the more common procedure with a suspension laryngoscopy setup, is that there is improved visualization, exposure and access to the whole cyst, especially the deep portion. The use of a laser would necessitate multiple different precautions to avoid an airway fire that are not necessary with an electrocautery. Complete excisions and low morbidity can be achieved using this technique.
Bleeding Airway edema/obstruction Pain Infection Recurrence
The authors have no conflicts to disclosed
Pediatric Otolaryngology Department at NYU Langone Health
REFERENCES: 1- Sun JY, Mitchell RB, Ulualp SO. Tongue base cyst in a 6-week-old boy. Ear Nose Throat J. 2012 Oct;91(10):426-7. 2- Leibowitz JM, Smith LP, Cohen MA, et al. Diagnosis and treatment of pediatric vallecular cysts and pseudocysts. Int J Pediatr Otorhinolaryngol. 2011 Jul;75(7):899-904. 3- Lahiri AK, Somashekar KK, Wittkop B, et al. Large Vallecular Masses; Differential Diagnosis and Imaging Features. J Clin Imaging Sci. 2018 Jun 28;8:26. 4- Chen EY Lim J, Boss EF, Inglis AF Jr, et al. Transoral approach for direct and complete excision of vallecular cysts in children. Int J Pediatr Otorhinolaryngol. 2011 Sep;75(9):1147-51. 5- Yao TC, Chiu CY, Wu KC, Wu LJ, Huang JL. Failure to thrive caused by the coexistence of vallecular cyst, laryngomalacia and gastroesophageal reflux in an infant. Int J Pediatr Otorhinolaryngol. 2004 Nov;68(11):1459-64. 6- Li Y, Irace AL, Dombrowski ND, et al. Vallecular cyst in the pediatric population: Evaluation and management. Int J Pediatr Otorhinolaryngol. 2018 Oct;113:198-203. 7- Tsai YT, Lee LA, Fang TJ, et al. Treatment of vallecular cysts in infants with and without coexisting laryngomalacia using endoscopic laser marsupialization: Fifteen-year experience at a single-center. Int J Pediatr Otorhinolaryngol. 2013 Mar;77(3):424-8

Review Endoscopic resection of a vallecular cyst in a pediatric patient.

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