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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 205-208

Unanticipated difficult intubation caused by vallecular cyst managed in an unconventional yet easy way


Department of Anaesthesiology, Maharaja Agrasen Medical College, Hisar, Haryana, India

Date of Submission05-Sep-2021
Date of Acceptance27-Sep-2021
Date of Web Publication13-Nov-2021

Correspondence Address:
Dr. Rishabh Agarwal
Department of Anaesthesiology, Maharaja Agrasen Medical College, Hisar - 125 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/arwy.arwy_52_21

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  Abstract 


Vallecular cysts are rare entities in adults and are often asymptomatic. Although rarely life-threatening, they pose an airway challenge when discovered incidentally. There is no technique that has been described in literature that is absolutely conclusive regarding the airway management in cases of vallecular cysts. We report a case of an asymptomatic vallecular cyst encountered in an adult male scheduled for laparoscopic cholecystectomy under general anaesthesia using ProSeal laryngeal mask airway (LMA). Despite selecting the proper size of ProSeal LMA and its correct placement, the patient could not be ventilated. Hence, endotracheal intubation was performed to maintain a patent airway. Direct laryngoscopy revealed a cyst measuring 2 cm × 2 cm at the base of the tongue completely obscuring the glottis. Fibreoptic bronchoscope-guided intubation was planned. The operating table was tilted to the left and direct laryngoscopy repeated after applying rightward external laryngeal manipulation. Cormack-Lehane Grade 3a was obtained allowing the passage of a bougie over which a 7.0 mm ID endotracheal tube was railroaded. The rest of the perioperative period was uneventful, and the patient was extubated without any problem.

Keywords: Airway, difficult intubation, vallecular cyst


How to cite this article:
Kumar S, Agarwal R, Sharma J, Gajraj A. Unanticipated difficult intubation caused by vallecular cyst managed in an unconventional yet easy way. Airway 2021;4:205-8

How to cite this URL:
Kumar S, Agarwal R, Sharma J, Gajraj A. Unanticipated difficult intubation caused by vallecular cyst managed in an unconventional yet easy way. Airway [serial online] 2021 [cited 2022 Jan 27];4:205-8. Available from: https://www.arwy.org/text.asp?2021/4/3/205/330385




  Introduction Top


Vallecular cysts are benign in nature, occurring because of obstruction of the duct of mucous glands. These small-sized cysts usually range about 1–5 mm in diameter and are seldom symptomatic. Although rare, possible symptoms include “lump in throat,” dysphagia, hoarseness of voice and airway obstruction.[1] Vallecular cysts can get infected leading to acute epiglottitis with or without abscess formation and may give rise to life-threatening airway obstruction. Although vallecular cysts are often asymptomatic and harmless to the patient, discovery of a large vallecular cyst after induction of anaesthesia is a potentially life-threatening problem for the patient and presents a challenge in the airway management to the anaesthesiologist. There are a few case reports of giant vallecular cysts encountered at the time of direct laryngoscopy after induction of general anaesthesia leading to an unanticipated difficult intubation.[2] We report our management of a patient with an asymptomatic huge vallecular cyst encountered during direct laryngoscopy after induction of general anaesthesia for incidental laparoscopic surgery. Airway management strategies for such a situation have been reviewed.


  Case Report Top


A 50-year-old male presenting with dyspepsia and recurrent right upper quadrant pain was scheduled for laparoscopic cholecystectomy under general anaesthesia. Preanaesthetic evaluation revealed no significant past medical or surgical history. He had no complaints of difficulty in breathing or swallowing and there was no evidence of stridor or hoarseness of voice. On general physical examination, the patient had a body mass index of 24 kg/m2. Vital signs and systemic examination were essentially normal. Airway examination revealed a mouth opening > 4 cm, modified Mallampati Class 1 with normal neck movements, no visible distortion of the oral cavity or abnormal facial features.

On the day of the planned procedure, the fasting status of the patient was confirmed and written informed consent was obtained. On arrival in the operating room, standard monitors including electrocardiogram, noninvasive blood pressure and pulse oximeter were attached and baseline vitals were recorded. An 18 SWG intravenous (IV) line was secured, and the patient preoxygenated for 3 min. General anaesthesia was induced with IV fentanyl 2 μg/kg and propofol titrated to produce unconsciousness. After check ventilation, IV vecuronium 0.1 mg/kg was given and the patient ventilated for 3 min using face mask. A # 4 ProSeal laryngeal mask airway (LMA) was placed using an introducer and inflated with the recommended volume of air. An attempt at manual ventilation was met with high resistance. The ProSeal LMA was repositioned, and the head-and-neck position optimised but in vain. Even after replacing with a # 5 ProSeal LMA, ventilation was not possible.

We reverted to face mask ventilation while planning the subsequent course of action for securing the airway. Direct laryngoscopy revealed a large cyst approximately 2 cm × 2 cm in size at the base of the tongue [Figure 1]. The cyst was pedunculated with a small stalk and seemed to arise from the left side of the vallecula. Cormack-Lehane grade 4 view was obtained and the cyst was noted to be completely obscuring the glottic opening and the epiglottis. Fibreoptic bronchoscope-guided intubation was planned, and the otorhinolaryngologist was requested to stand by for performing a tracheostomy if needed. Meanwhile, as the fibreoptic bronchoscope cart was being mobilised, we provided a 30° left lateral tilt to the operating table as the cyst seemed to arise from the left side and seemed to possess limited mobility during the first laryngoscopy. On repeating direct laryngoscopy in this position and applying rightward external laryngeal manipulation, Cormack-Lehane grade 3a was obtained, allowing us to pass a gum-elastic bougie over which a 7.0 mm ID endotracheal tube was railroaded. Tilting the operating table appeared to have displaced the cyst to the left, thereby improving the glottic view and allowing us to pass a bougie. An otorhinolaryngologist was consulted, the cyst was aspirated and the cyst wall excised. Dexamethasone 8 mg IV was given, anaesthesia was discontinued and 100% oxygen was administered. As the patient awakened, the pharynx was carefully suctioned and the patient was extubated. During retrospective interrogation in the postanaesthesia care unit, the patient admitted to a several year history of dysphagia. The pathology report confirmed a vallecular cyst measuring 2.1 cm × 1.9 cm × 0.5 cm with a membranous wall that was 1 mm thick.
Figure 1: Endoscopic view of the oropharynx showing base of the tongue (BOT), vallecular cyst (VC) and endotracheal tube (ETT)

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  Discussion Top


Vallecular cysts are a rare entity, accounting for about 10.5%–20.1% of all the laryngeal cysts.[3] These cysts arise due to the obstruction and retention of mucous in the ducts of submucosal glands or due to dilated and obstructed lingual tonsillar crypts. These cysts are variably described in literature as epiglottic cyst, mucous retention cyst, base-of-the-tongue cyst and more recently as ductal cysts.[4] In adults, vallecular cysts are more prevalent in males with a peak incidence in the fifth decade. Nearly two-thirds of vallecular cysts are asymptomatic and are incidental findings on indirect laryngeal examination.[5] When symptomatic, these cysts cause a change in voice, dysphagia, pain or a foreign-body sensation in the throat. The incidence of vallecular cysts on direct laryngoscopy has been reported as 1 in 1250–1 in 4200, but the exact incidence is difficult to evaluate.[6]

In our case, a pedunculated cyst became apparent on direct laryngoscopy after induction of general anaesthesia for incidental laparoscopic surgery and posed difficulty in intubation. The patient was asymptomatic, and the clinical airway examination was essentially within the normal limits. Thus, we had no reason to anticipate difficulty in airway management. We successfully managed the case by intubating the patient after tilting the table to the left and applying rightward external laryngeal manipulation, resulting in the displacement of the cyst and improvement in the glottic view.

Literature does not describe any specific airway management technique for such a scenario. Several techniques described include displacing the cyst using a gum elastic bougie, use of a tongue depressor to displace the cyst, railroading an endotracheal tube over a suction catheter, and using a rigid ENT laryngoscope which is larger than a conventional anaesthetic laryngoscope.[7],[8],[9],[10] As is evident from our experience, an easily performed manoeuvre of tilting the table to the same side as the suspected origin of cyst can improve the laryngeal view by displacing the cyst and can be utilised for the successful management of these cases.

However, patients in whom existence of these laryngeal cysts are anticipated or confirmed, fibreoptic bronchoscope-guided tracheal intubation should be the method of choice. Although the diagnosis of this pathology can be easily missed on routine clinical airway examination (as it was in our case), airway examination using point-of-care airway ultrasonography can easily rule out airway pathologies such as these allowing the attending anaesthesiologists to plan and prepare accordingly.[11]

Depending upon the availability of resources and expertise, indirect laryngoscopy by an otorhinolaryngologist and point-of-care ultrasonography along with a focused preanaesthetic evaluation by an anaesthesiologist should be recommended. These examinations will not only add to the information gleaned from the clinical examination but will make patient care even more effective and safe. We believe that these suggestions need to become the focus of further discussion and research.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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2.
Berger G, Averbuch E, Zilka K, Berger R, Ophir D. Adult vallecular cyst: Thirteen-year experience. Otolaryngol Head Neck Surg 2008;138:321-7.  Back to cited text no. 2
    
3.
Romak JJ, Olsen SM, Koch CA, Ekbom DC. Bilateral vallecular cysts as a cause of dysphagia: Case report and literature review. Int J Otolaryngol 2010;2010:697583.  Back to cited text no. 3
    
4.
Gutiérrez JP, Berkowitz RG, Robertson CF. Vallecular cysts in newborns and young infants. Pediatr Pulmonol 1999;27:282-5.  Back to cited text no. 4
    
5.
Arens C, Glanz H, Kleinsasser O. Clinical and morphological aspects of laryngeal cysts. Eur Arch Otorhinolaryngol 1997;254:430-6.  Back to cited text no. 5
    
6.
Mason DG, Wark KJ. Unexpected difficult intubation. Asymptomatic epiglottic cysts as a cause of upper airway obstruction during anaesthesia. Anaesthesia 1987;42:407-10.  Back to cited text no. 6
    
7.
Riaz MR, Priya V, Patro A, Sahu S. A novel use of gum elastic bougie to manage an unanticipated difficult airway due to vallecular cyst. Anesth Essays Res 2017;11:802-3.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Monem A, Khan FA, Awan S. Tongue depressor as an intubation aid in a patient with vallecular cyst: A case report. J Anaesth Crit Care Case Rep 2018;4:16-8.  Back to cited text no. 8
    
9.
Jahagirdar SM, Karthikeyan P, Ravishankar M. Acute airway obstruction, an unusual presentation of vallecular cyst. Indian J Anaesth 2011;55:524-7.  Back to cited text no. 9
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10.
Kothandan H, Ho VK, Chan YM, Wong T. Difficult intubation in a patient with vallecular cyst. Singapore Med J 2013;54:e62-5.  Back to cited text no. 10
    
11.
Agarwal R, Jain G, Agarwal A, Govil N. Effectiveness of four ultrasonographic parameters as predictors of difficult intubation in patients without anticipated difficult airway. Korean J Anesthesiol 2021;74:134-41.  Back to cited text no. 11
    


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