Neonatal Endoscopic Cold Steel Vallecular Cyst Marsupialization

Educational/Technical Point(s): Endoscopic marsupialization of vallecular cysts is a safe and effective treatment method with improved visibility, minimal recovery and acceptably low recurrence rate.1

Introduction:

Vallecular cysts are rare but important causes of neonatal stridor and dysphagia. When present, they can cause aspiration and dyspnea or apnea. They are readily identified on flexible fiberoptic laryngoscopy, and treatment is solely surgical though multiple techniques exist.

Case Presentation:

We present a 6-week old infant with coughing, choking, and gasping spells with feeds admitted for further workup. Flexible laryngoscopy demonstrated a large, well circumscribed vallecular cyst. Endoscopic marsupialization was recommended.

The decision to excise versus marsupialize is based on surgeon preference, however, we propose that cold steel marsupialization results in less tongue base dissection and lower opportunity for inadvertent iatrogenic injury.2,3

Technique:

Following intubation, the cyst was needle decompressed using an 18-gauge needle. It is our institutional preference to have on hand for every vallecular cyst induction in the event of inability to ventilate and the need to immediately decompress the cyst to secure the airway.

Following decompression, a three handed endoscopic technique was used to allow improved visualization and for educational purposes. Using a microlayngeal grasper to apply tension, the microlaryngeal scissors were used to sharply excise the redundant cyst lining.

Dissection was continued across the lingual surface of the epiglottis. This was continued circumferentially until the entirety of the cyst was excised. Hemostasis was achieved using Afrin soaked pledgets.

After ensuring adequate excision, silver nitrate was then used on the exposed mucosal surfaces for hemostasis. At the conclusion of the procedure, the patient’s prior grade 4 view was improved to grade 1.

Post operatively, the patient was admitted to the floor for observation overnight and given two doses of Decadron for post operative pain control. She was allowed to nurse with immediate improvement in symptoms and was discharged home post operative day 1. Flexible in-office laryngoscopy 3 weeks later demonstrated re-mucosalization of the tongue base, no evidence of recurrence, and resolution of symptoms.

Conclusion:

Endoscopic cold steel marsupialization of vallecular cysts is a safe and effective treatment method with improved visibility, minimal recovery and acceptably low recurrence rate.