Transoral approach for direct and complete excision of vallecular cysts in children

Abstract

Objective: To review the presentation, evaluation, and treatment of children with vallecular cysts and introduce a new technique of transoral excision for this entity.

Methods: Retrospective case series of children diagnosed with vallecular cyst between 2001 and 2008 at a single tertiary care children's hospital. Data collected, including age at diagnosis, presenting symptoms, additional diagnoses, diagnostic modality, prior and subsequent surgical therapy, length of hospital stay, length of follow-up, and recurrence were analyzed with descriptive statistics.

Results: Seven children (mean age 198 days, range 2 days to 2.9 years) were included in this series. Five children presented with respiratory distress and/or swallowing difficulties. Vallecular cyst was diagnosed by initial flexible fiberoptic laryngoscopy (5/7), MRI (1/7), and intubating laryngoscopy (1/7). All children underwent complete cyst excision via transoral surgical approach. Two children underwent additional supraglottoplasty for concomitant laryngomalacia, one of whom underwent tracheotomy for persistent respiratory distress and vocal cord immobility. The average length of hospital stay postoperatively was 9.5 days, and four patients stayed less than 2 days. No patients experienced recurrence of the vallecular cyst at last follow-up (range 4-755 days, mean 233 days).

Conclusions: Vallecular cysts are rare but should be considered in children with respiratory distress and dysphagia. Awake, flexible fiberoptic laryngoscopy with particular attention to the vallecular region should be performed on any child presenting with these symptoms. Direct, transoral approach for excision of the vallecular cyst is our preferred method of treatment with no recurrences to date.

Fig. 1

Endoscopic view of vallecular cyst of patient 3 after nasotracheal intubation.

Fig. 2

Patient 4 after nasotracheal intubation, placement of Jennings retractor, and placement of retraction sutures. (A) Direct view of vallecular cyst with retractors in place. (B) Side view of setup. White arrow, vallecular cyst. Short black arrow, retraction sutures. Long black arrow, Jennings retractor.

Fig. 3

Endoscopic view of vallecular cyst with palate retracted with red rubber catheter sutured to the uvula which is pulled toward the nasopharynx as is done during sphincter pharyngoplasty and placement of throat pack posteriorly to improve visualization and exposure of cyst in patient 7. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.)

Fig. 4

(A–D) Direct, complete excision of vallecular cyst from patient 5, using angled Colorado tip electrocautery. White arrow, retraction sutures. Black arrow, epiglottis. Star, vallecular cyst.