A Huge Epiglottic Cyst Causing Airway Obstruction in An Adult

Case Report
275
A Huge Epiglottic Cyst Causing Airway Obstruction in an Adult

Tuan-Jen Fang, MD; Ka-Shun Cheng1, MD; Hsueh-Yu Li, MD
An epiglottic cyst causing airway obstruction is rare in an adult. Early definitive diagnosis and management obviate an unnecessary tracheostomy. We report a case of a 64-yearold woman who arrived at our hospital with progressive stridor and foreign body sensation when swallowing for 6 weeks. A hot potato voice and biphasic stridor were remarkable upon physical examination. Indirect mirror and fibroscopic examination revealed a huge epiglottic cyst. The neck lateral X-ray and computed tomography scan demonstrated a huge cystic mass over the epiglottis. A 2.5 3.0 cm cystic mass was removed with endoscopic CO2 laser after needle decompression. The patient was discharged on the third day after surgery without complications. An epiglottic cyst in an adult seldom causes upper airway obstruction and is easily ignored by clinicians. We emphasize that complete airway evaluation including routine check-up of the larynx is mandatory for patients with intractable obstructive airway disease. Endoscopic laser surgery is effective in the surgical removal of an epiglottic cyst. (Chang Gung Med J 2002;25:275-8) Key words: epiglottic cyst, airway obstruction.
aryngeal cysts constitute approximate 5% of benign laryngeal lesions.(1) The majority of cysts originate from the epiglottis.(2) A congenital epiglottic cyst almost always causes neonatal respiratory distress or even sudden death (3,4) but this rarely occurrs in adults. Herein we report on a 64-year-old woman with an epiglottic cyst presenting with stridor; the cyst was successfully removed using CO2 laser therapy.
to voice and biphasic stridor. Otherwise, her vital signs and general condition were stable. Fibroscopic
CASE REPORT
The patient was a 64-year-old woman who presented with a lump in her throat and progressive stridor for 6 weeks. She denied having any other systemic disease and had previously been treated with a bronchodilator for obstructive airway disease. Physical examination revealed a significant hot pota-
Fig. 1 A huge epiglottic cyst as revealed by fibroscopic examination.
From the Department of Otolaryngology Head and Neck Surgery; 1Department of Anesthesiology, Chang Gung Memorial Hospital, Taipei; Chang Gung University, Taoyuan. Received: Jun. 1, 2001; Accepted: Sep. 7, 2001 Address for reprints: Dr. Hsueh-Yu Li, Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital. 5, Fu-Shin Street, Kweishan, Taoyuan, 333, Taiwan, R.O.C. Tel.: 886-3-3281200 ext.3967; Fax: 886-3-3979361; E-mail: [email protected]
276
Tuan-Jen Fang, et al Epiglottic cyst
intubation with general anesthesia, direct laryngoscopy and decompression of the mass with a long laryngeal needle were performed. Then, the cyst base which was attached to the lingual surface of the epiglottis was exposed. A 2.5 3.0 cm cystic mass was removed with CO2 laser. The symptoms were relieved after surgery, and she was discharged 3 days later with no complications. The cyst had not recurred after a 6-month follow-up.
DISCUSSION
From a 10-year review of Mayo Clinic experience, DeSanto et al.(5) reported that 52% of laryngeal cysts originate from the epiglottis, with most coming from the lingual surface. They divided laryngeal cysts into ductal and saccular types. Epiglottic cysts and vallecular cysts were attributed to the ductal type and are caused by obstruction of the submucous duct. Laryngeal cysts confined to the vallecular space are known as vallecular cysts. Because the vallecular space is full of lymphoid and glandular tissue which is easily obstructed, vallecular cysts in adults are not rare.(5) Epiglottic cysts are specifically defined as cysts occurring at the lingual and dorsal surfaces of the epiglottis. Most adult epiglottic cysts are detected in the 6th decade.(6) Presenting symptoms of epiglottic cysts vary with cyst size, age of the patient, as well as extension into the airway. Epiglottic cysts in neonates often cause sudden infant death.(3,4) Adult epiglottic cysts often cause a lumpy sensation in the throat but seldom produce respiratory distress. Secondary infection of an epiglottic cyst may progress to epiglottitis or epiglottic abscess. (2,7) Heeneman and Ward (8) reviewed 26 such cases in 40 years, most of which were adults. The major organisms identified were pneumococci, beta-hemolytic streptococci, and staphylococci. A mortality rate of up to 30% has been reported.(8) So, early diagnosis and appropriate therapy of epiglottic cysts are of utmost importance. Indirect mirror or fibroscopy may provide the first clue of an epiglottic cyst, and further imaging studies may be needed. Neck lateral X-ray may mimic acute epiglottitis with a thumb sign. CT scan can demonstrate a low-density mass at the tongue base. Ring-shaped contrast enhancement may occur in an infected cyst. Air bubbles in a cyst are some-
Fig. 2 Neck lateral X-ray showing a soft-tissue shadow in the

epiglottic area (arrowhead) mimicking acute epiglottitis.
Fig. 3 CT scan demonstrating a huge cystic lesion (arrowhead)

measuring 2.5 1.8 cm in the epiglottic area.
examination showed a huge epiglottic cyst (Fig. 1). A lateral X-ray of the neck revealed a soft-tissue shadow in the epiglottic area (Fig. 2). A computed tomographic (CT) scan of the neck demonstrated a huge low-density mass at epiglottis and vallecula measuring 2.5 1.8 cm (Fig. 3). Under endotracheal
Chang Gung Med J Vol. 25 No. 4 April 2002
Tuan-Jen Fang, et al Epiglottic cyst
277
times found, but should be differentiated from an epiglottic abscess.(7) Treatment of epiglottic cysts depends on their size and on the clinical symptoms. Surgery is necessary for large ones. Various modalities of therapy include endoscopic excision, marsupialization, and deroofing with or without a CO2 laser.(9,10) A lateral pharyngotomy approach to remove the cyst is preserved for recurrent cases.(10,11) An endoscopic technique with a CO2 laser can be successfully applied in nearly all cases due to the laser's good hemostatic effect.(8) To avoid local recurrence, the cyst wall has to be completely resected.(8) Surgery can usually be done under oral intubation, but is difficult in a patient with a huge cyst. Aspiration of the contents to reduce the cyst size helps and can avoid a tracheostomy. Prophylactic antibiotics and adequate hydration after surgery are always utilized to avoid acute epiglottitis.(11) In summary, a huge epiglottic cyst may simulate other obstructive airway disease, but it can easily be ignored by clinicians. Secondary infection of an epiglottic cyst can cause catastrophic acute airway obstruction and requires an emergent tracheostomy. Early definitive diagnosis and management obviate an unnecessary tracheostomy. Resection with an endoscopic CO2 laser is recommended as the treatment of choice.
REFERENCES
1. Lam HCK, Abdullah VJ, Soo G. Epiglottic cyst. Otolayngol Head Neck Surg 2000;122:311. 2. Henderson LT, Denny JC 3rd, Teichgraeber J. Airwayobstructing epiglottic cyst. Ann Otol Rhinol Laryngol 1985;94:473-6. 3. Lee WS, Tsai CSS, Lin CH, Lee CC, Hsu HT. Airway obstruction caused by a congenital epiglottic cyst. Int J Pediatr Otorhinolayngol 2000;53:229-33. 4. Dahm MC, Panning B, Lenarz T. Acute apnea caused by an epiglottic cyst. Int J Pediatr Otorhinolayngol 1998;42:271-6. 5. DeSanto LW, Devine KD, Weiland LH. Cyst of the larynx-classification. Laryngoscope 1970;80:145-76 6. Reichard KG,Weingarten-Arams J. Radiological case of the month: epiglottic cyst. Arch Pediatr Adolesc Med 1998;152:1237-8. 7. Casselman J, Oyen R, Baert A, Jorissen M. Computed tomography of infected epiglottic cyst. J Comput Assist Tomogra 1986;10:694-5. 8. Heeneman H, Ward KM. Epiglottic abscess: its occurrence and management. J Otolaryngol 1977;6:31-6. 9. Macneil A, Campbell AM, Clark LJ. Adult acute epiglottitis in association with infection of an epiglottic cyst. Anaesth Intensive Care 1989;17:211-2. 10. Arens C, Glanz H, Kleinsasser O. Clinical and morphological aspects of laryngeal cysts. Eur Arch Otorhinolaryngol 1997;254:430-6. 11. Ward RF, Jones J, Arnold J. Surgical management of congenital saccular cysts of the larynx. Ann Otol Laryngol 1995;104:707-10.
Chang Gung Med J Vol. 25 No.4 April 2002
278
64 X 2.5 3.0
2002;25:275-8)
1 '' | x _| KF ' j 90~ 6 1 F 90~ 7 9 `G` Z G` C `' LBG vA' ' | C (03)3979361; E-mail: [email protected]
333 t s m _
5 Tel.: (03)3281200 3967; Fax: C

A Huge Epiglottic Cyst Causing Airway Obstruction in An Adult

Uploaded by

Copyright:

Available Formats

A Huge Epiglottic Cyst Causing Airway Obstruction in An Adult

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

A Huge Epiglottic Cyst Causing Airway Obstruction in An Adult

Uploaded by

Copyright:

Available Formats

Case Report

A Huge Epiglottic Cyst Causing Airway Obstruction in an Adult

Fig. 1 A huge epiglottic cyst as revealed by fibroscopic examination.

Tuan-Jen Fang, et al Epiglottic cyst

Fig. 2 Neck lateral X-ray showing a soft-tissue shadow in the

Fig. 3 CT scan demonstrating a huge cystic lesion (arrowhead)

Chang Gung Med J Vol. 25 No. 4 April 2002

Tuan-Jen Fang, et al Epiglottic cyst

Chang Gung Med J Vol. 25 No.4 April 2002

5 Tel.: (03)3281200 3967; Fax: C

You might also like