Transventricular subtotal excision of laryngeal saccular cyst (with partial excision of false vocal cord) with COMET (Combined Microscopic and Endoscopic Technique)

Laryngeal saccular cysts are rare anomalies that typically present as supraglottic swellings, most often managed via a supraglottic approach. Diagnosis is aided by MRI, which demonstrates the lesion arising from the laryngeal ventricle.

We opted for a transventricular approach because the initial supraglottic decompression had failed. Given that the base of the swelling lies in a dependent area, simple reroofing can occasionally result in fluid recollection within the cyst. In this context, excising the cyst base and creating a wide opening of the ventricle ensures optimal drainage and minimizes the risk of recurrence.

For cysts with an inaccessible wall via endolaryngeal approach through ventricle, the transventricular route should be avoided to prevent blind dissection and potential injury to the vocal cords and thyroarytenoid muscle.

We used a Lindholm laryngoscope for suspension, and dissection was performed with cold steel instruments. Microscopic dissection was carried out using a 400 mm focal length microscope, while endoscopic dissection was performed with a 0° 4 mm Hopkins Rod telescope.

The procedure was performed under general anesthesia with orotracheal intubation and suspension using a pediatric Lindholm laryngoscope.

Routine preoperative workup to assess fitness for general anesthesia was carried out. MRI was preferred as it provided superior soft tissue detail. Additionally, bedside flexible endoscopy was performed, as the child had been intubated since the first day of life.

The pharyngoepiglottic (PE) fold can serve as a useful landmark to distinguish saccular cysts from vallecular cysts. Vallecular cysts are generally located anterior to the PE fold, while saccular cysts arise over or just behind it. Saccular cysts can be categorized as anterior or lateral types. An anterior cyst tends to expand medially and posteriorly between the true and false vocal cords, whereas a lateral cyst grows in a posterosuperior direction, between the false cords and the aryepiglottic folds. Lateral cysts, in particular, may extend through the thyrohyoid membrane without obstruction.

Cyst fluid can trickle into the airway and cause infectious complications, so securing the lower airway with a cuffed endotracheal tube is essential. Excessive excision carries a risk of damaging the true vocal cords, potentially resulting in permanent voice changes. Lateral dissection should therefore be performed under direct vision to avoid injury to the vocal cords/ thyroarytenoid muscle.

The authors have no conflict of interest to declare.

Kim JH, Kim MH, Ahn HG, Choi HS, Byeon HK. Clinical characteristics and management of saccular cysts: a single institute experience. Clin Exp Otorhinolaryngol. 2019;12(2):212-216. doi:10.21053/ceo.2018.00808