OJHAS: 2003-3-2 Sathish Bhandary, Innovative Surgical Technique in the Management of Vallecular Cyst

Among the benign lesions in the larynx and laryngopharynx, cystic lesions are common entities. Vallecular Cysts are usually retention cysts of the minor salivary glands. An innovative method of surgical treatment of one such case is presented here.

A 30 years old man presented with the history of foreign body sensation in the throat since one month and change in voice since 1 week. Preliminary examination and indirect laryngoscopy revealed a 5x4cm transluscent swelling in the region of the vallecula, obscuring the view of the larynx and laryngopharynx. Under endotracheal general anaesthesia, direct laryngoscopy was done in the Boyce’s position, which showed the cystic mass arising from the vallecula. (Fig.- 1) Keeping in mind the conventional modalities of treatment like marsupialisation, de-roofing etc., we decided to opt for an innovative technique for removal of the cyst, i.e. snaring.
Figure 2: Line diagram illustrating vallecular cyst excision using snare		Figure1: Intra-operative photograph of the vallecular cyst
	Procedure: The Boyle-Davis mouth gag, used for exposure of the oropharynx for tonsillectomy, was engaged and the cyst was adequately visualized. The eve’s tonsillar snare was engaged around the base of the cyst and with its characteristic crushing action, the cyst was removed. (Fig 2)Minimal bleeding from the wound was controlled with direct pressure for a few minutes. The post-operative period was uneventful and the patient was discharged on the 2nd post-operative day. On review one week later, the wound was found to have healed completely and after 6 months, no recurrence was noted.

Vallecular cysts are retention cysts of the minor salivary glands in the vallecula and base of the tongue. Obstruction of the mucous glands leads to cyst formation and continued secretion leads to a corresponding increase in size of the cyst. They are asymptomatic when small in size, but large cysts may cause dysphagia and voice change. Majority of patients presenting with vallecular cysts are in the paediatric age group, most of them being infants;(1-3) in infants and children it may also present with upper aero-digestive tract obstruction and stridor. The differential diagnoses include internal thyroglossal duct cysts, dermoid cysts, lingual thyroid, teratomas, lymphangio-mas and haemangiomas. The conventional modalities of management of vallecular cyst include marsupialisation, de-roofing or excision.(4) These are done with either the CO2 laser or by electrocautery. Repeated aspiration invariably leads to recurrence of the cysts.

The technique adopted by us i.e., snaring of the cyst, is a quick and effective way of surgical removal. This procedure can be done with a set of tonsillectomy instruments. This method is safe, cost effective and the result obtained is comparable with that by the conventional techniques. Age does not restrict the method of excision and snaring is a relatively simple and in-expensive method of excision of vallecular cysts.