Vallecular cyst causing a difficult intubation

Abstract

Editor-Vallecular cysts are a rare cause of difficulty in intubating the trachea. We describe a case of difficult intubation in a patient, after inhalation induction, for examination under anaesthesia of an infected vallecular cyst. A 31-yr-old male presented with a year-long history of dysphagia, anorexia, and 13 kg weight loss. He had a 3 week history of shortness of breath on exertion and associated dysphonia. There was no evidence of stridor or hoarseness. He was apryexial, haemodynamically stable with oxygen saturation of 98% on room air. His medical history was significant for a 6 yr history of i.v. drug usage and heavy smoking. On examination, there were no palpable masses on his neck or visible abnormalities in his oral cavity. He was Mallampati score 1, and had good mouth opening and neck movement. Flexible fibreoptic nasolaryngoscopy revealed a well-circumscribed pedunculated mass arising from the vallecula. He was taken to the theatre for examination under anaesthesia, pharyngoscopy, and oesphagoscopy. Inhalation induction was carried out with upward titration of 1-8% sevoflurane in 100% oxygen. Anaesthesia was maintained with bolus doses of propofol, in addition to sevoflurane in oxygen via face mask. Spontaneous respiration was maintained. Three attempts at laryngoscopy using Mackintosh blade 3, McCoy blade 3, and Miller laryngoscope were all unsuccessful. Oxygen saturations throughout remained stable and the patient was easy to bag-mask ventilate. Endotracheal intubation was finally obtained by the ENT surgeon using the ENT rigid laryngoscope. Being longer than anaesthetic laryngoscopes, it was possible to pass distal to the cyst, displacing it to one side allowing visualization of the vocal cords. The remainder of the anaesthetic was uneventful. Definitive treatment included aspiration of thick pus followed by excision. IV dexamethasone was administered to limit airway oedema. At the end of the procedure, the patient was extubated uneventfully. Microbiology culture grew Staphylococcus aureus. Histological examination revealed that of a benign cyst. He was treated with i.v. antibiotics and discharged home on the fifth postoperative day. Most laryngeal cysts are asymptomatic. However, all have the potential to present with airway compromise. Non-infected cysts usually present with mild symptoms related to pressure effect on surrounding tissues. Infection of cysts can cause acute epiglottitis or abscess formation and subsequent acute airway obstruction. A review published in 2008 describes an increased incidence of airway obstruction in infected compared with non-infected cysts. 1 There are case reports of patients with vallecular cysts proving difficult to intubate. 2 3 Several describe complications encountered during intubation attempts: bleeding requiring abandonment of the procedure 4 and laryngospasm. 2

Difficult intubation in a patient with vallecular cyst

“…As was the case in Walshe et al's report, (3) we were aware of the potentially difficult airway in our patient and thus employed intubation techniques that maintained spontaneous respiration in order to safely secure the airway. Possible options, whether asleep or awake, include direct laryngoscopy, video laryngoscopy, rigid laryngoscopy (by an otolaryngologist) and flexible scopes.…”

“…If the cyst obscures the laryngeal view, these approaches may be successful if the cyst can be displaced to one side using either the scope or the tube. (1)(2)(3) The rigid laryngoscope, for example, is longer than the anaesthetic laryngoscope, and is thus able to pass beyond and displace the cyst to visualise the vocal cords. …”

“…(6,9) Symptoms may manifest after the vallecular cyst has become infected and an abscess has formed. (3,4) The incidence of vallecular cysts on laryngoscopy is estimated to be between 1 in 1250 to 1 in 4200. with pedunculated cysts that can result in a 'ball-valve' effect. (2) Surgical management of a symptomatic vallecular cyst is complete removal by marsupialisation, deroofing or excision with CO2 laser or electrocautery.…”

“…Although rare, cases of unanticipated difficult intubation from asymptomatic vallecular cysts have been well documented in the literature. (1)(2)(3)(4) Meticulous airway assessment and planning is mandatory in the anaesthetisation of patients with vallecular cysts. We describe a case of difficult intubation in a patient with a vallecular cyst and discuss the airway management options following a review of the current literature.…”

Airway Management in an Adult Patient With a Large Vallecular Cyst

“…These cysts might be asymptomatic or might be associated with airway obstruction, feeding difficulties and failure to thrive during infancy, and even with death due to severe laryngeal obstruction [3][4][5]. In cases with laryngeal inlet obstruction due to a vallecular cyst, the airway management sometimes might be a challenge [5][6][7]. In this case report, the airway management of an adult patient with difficult airway due to a large vallecular cyst completely obstructing the pharynx was presented.…”