Abstract
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A 50-year-old man had a perforated peptic ulcer and peritonitis. At emergency laparotomy, the anesthetist noted a large mass at the tongue base and had difficulty with oropharyngeal intubation. Nasotracheal fiberoptic intubation was successful.
Direct laryngoscopy revealed a 3-cm cystic mass on the lingual surface of the epiglottis occupying both valleculae. The laryngeal surfaces of the epiglottis, false cords, and true cords were normal. Despite its size, the patient had remained asymptomatic. The epiglottic cyst (Fig 1) was excised under microscopic laryngoscopy, and he made a full recovery.
Laryngeal cysts, particularly epiglottic cysts, are usually benign. They are uncommon and constitute approximately 5% of benign laryngeal lesions. Laryngeal or epiglottic cysts can occur at any age but are most common in the sixth decade of life.
Verneuril 1 reported the first laryngeal cyst in 1852. The exact origin and cause of laryngeal cysts remain uncertain, but they are thought to originate from the obstruction and subsequent dilatation of laryngeal glands. Laryngeal cysts are most commonly located on the lingual surface of the epiglottis and on the true cords. 2 Lesions in the subglottic region are extremely rare.
Histologically, most cysts are lined by squamous or respiratory epithelium and less commonly oncocytic epithelium. Laryngeal cysts may be classified into ductal and saccular types. 2 For the clinical setting, the modified working classification is more useful. 3 , 4 This classification divides laryngeal cysts into epithelial, tonsillar, and oncocytic cysts. Epithelial cysts are the most common and are predominantly located in the region of the epiglottis and the laryngeal ventricles. Tonsillar cysts are lined by squamous epithelium with underlying lymphoid follicles, which resemble tonsillar crypts. They occur almost exclusively in the valleculae, epiglottis, and pyriform fossa. Oncocytic cysts, characterized by oxyphilic epithelium, typically affect the older population and are located at the laryngeal ventricles. They are thought to represent a generalized hyperplastic or metaplastic process but not a neoplastic one.
The presenting symptoms may vary according to the age of the patient and the size and location of the cysts. Infants with small airways may have stridor and dyspnea or poor feeding. Adults are usually asymptomatic but may have hoarseness, foreign-body sensation, pain, or dysphagia. Most epiglottic cysts are asymptomatic, although acute epiglottitis associated with an infected epiglottic cyst, epiglottic abscess, and unexpected intubation difficulty have been reported.
Most laryngeal cysts can be managed by deroofing or excision under direct laryngoscopy. Recurrence is uncommon after adequate marsupialization or complete excision.
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Endoscopic view of an epiglottic cyst located at the valleculae and lingual surface of the epiglottis at suspension laryngoscopy with an endotracheal tube in situ.