Clinical Review & Education
Clinical Problem Solving | RADIOLOGY
Unusual Presentation of a Laryngeal Mass Oscar Trujillo, MD, MS; Justin Cohen, MD; Marc Cohen, MD; C. Douglas Phillips, MD
A
B
C
D
Figure. Sagittal views of a patient with a neck mass. A, Computed tomographic scan of the neck with intravenous contrast. B, Magnetic resonance imaging examination demonstrating the mass compressed by the endotracheal catheter. C, Intraoperative image. D, Resection in a submucosal plane with scissors under microlaryngoscopy.
A woman in her 50s with a history of hypertension and chronic back pain presented to the emergency department. She had been discovered unresponsive in bed, was apneic, and was intubated in the field. She had experienced multiple episodes of emesis. At presentation, a computed tomographic (CT) scan demonstrated diffuse subarachnoid hemorrhage, intraventricular hemorrhage, and communicating hydrocephalus with tonsillar and central herniation. She received mannitol and an emergent extraventricular drain. During her hospital stay, a cerebral aneurysm was successfully treated by an endovascular route. She required a tracheostomy and percutaneous gastrostomy tube placement. Twenty-eight days after her tracheostomy, a flexible endoscopic evaluation of swallowing with sensory testing (FEESST) revealed a submucosal mass. The mass did not fully obstruct the airway, and the patient tolerated a Passy-Muir valve with
jamaotolaryngology.com
no respiratory distress. The primary team administered dexamethasone sodium phosphate and consulted the otolaryngology service. On examination, her vital signs were within normal limits, she was nonverbal but in no acute distress, her breathing unlabored and silent, with no stridor or stertor. Passing a flexible fiber-optic laryngoscope confirmed the presence of an apparent submucosal mass that either originated from the epiglottis or deep to a severely edematous right aryepiglottic (AE) fold or arytenoid, or completely obstructed the vocal cords from view. The mass did not respond to steroids. A CT scan of the neck with intravenous contrast was performed (Figure, A). The mass was nonenhancing. Subsequently, a retrospective review of a magnetic resonance imaging (MRI) examination demonstrated the mass compressed by the endotracheal catheter (Figure, B). What is your diagnosis?
JAMA Otolaryngology–Head & Neck Surgery August 2014 Volume 140, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Nanyang Technological University User on 06/10/2015
781
Clinical Review & Education Clinical Problem Solving
Diagnosis Benign laryngeal cyst, consistent with saccular cyst
Discussion The broad categories of laryngeal cysts are laryngoceles (containing air), saccular cysts (containing mucous), and laryngopyocele (containing pus).1 DeSanto et al2 further classified laryngeal cysts into 3 main categories based on anatomic location: saccular cysts, ductal cysts, and the rarer thyroid-cartilage foraminal cysts. Laryngeal saccular cysts form on dilation of a blind sac with mucous, typically between the false vocal cord and the thyroid cartilage.3 Laryngeal saccular cysts are further classified based on anatomic location of dissection: anterior, lateral internal, and lateral internal and external. Anterior saccular cysts typically occur between the true and false vocal cords and may protrude from the anterior ventricle toward the laryngeal vestibule.1 Lateral internal cysts dissect superiorly and laterally into the false vocal cords and aryepiglottic folds but may extend to the medial wall of the pyriform sinus, and may even, on occasion, fill the vallecula.1 The lateral internal/external saccular cysts dissect as lateral internal cysts but also involve thyrohyoid membrane and may cause an outward bulge in the neck. In this case, the laryngeal cyst was located at the level of the glottis, contiguous with the epiglottis and the right AE fold, and measured 2.5 × 1.6 × 2.0 cm. It was likely resting dependently on the arytenoid while making broad contact with the posterior pharyngeal wall. The primary team believed that this cyst was responsible for the patient’s repeated episodes of emesis, and the family was concerned about the nature of the mass, so a direct laryngoscopy with excision of the mass was scheduled in the operating room. Intraoperatively, the mass was very bulky, and it was difficult to assess where it was pedicled, as seen in Figure, C. The mass was resected in a submucosal plane with scissors under microlaryngoscopy (Figure, D), and it was determined that it mostly likely was pedicled to the right AE fold. After resection, ARTICLE INFORMATION Author Affiliations: Department of Otolaryngology–Head and Neck Surgery, New York Presbyterian Columbia and Cornell, New York (Trujillo); Joint Residency Program, New York Presbyterian and Cornell, New York (J. Cohen, M. Cohen, Phillips). Corresponding Author: Oscar Trujillo, MD, MS, Department of Otolaryngology–Head and Neck Surgery, New York Presbyterian Columbia and Cornell, 1330 First Ave, Apt 628, New York, NY 10021 ([email protected]).
pathologic characteristics of the mass were found to be consistent with a benign laryngeal saccular cyst. In a current review3 of saccular cysts, the most common presenting symptom was hoarseness with a choking sensation and, more rarely, dysphagia. In this case, the patient’s airway was already secured by a tracheostomy, and the only symptoms she experienced at the time of discovery were repeated episodes of emesis. It is important to note that while the patient’s episodes of emesis ended on removal of the mass, it is unclear whether the mass either directly or indirectly caused those symptoms. Standard treatment of glottic cysts is surgical removal, commonly performed with either laryngomicrosurgery or carbon bicarbonate laser under microscopy.4 Complete removal of the cyst through marsupialization is recommended by most studies because attempting simple aspiration is likely to result in recurrence.4 Diagnosis of glottis or supraglottic cysts depends on an accurate history of symptoms, flexible fiber-optic laryngoscopy, and crosssectional imaging such as CT or MRI. Differential diagnosis for a submucosal glottic or supraglottic mass is not limited to saccular and ductal laryngeal cysts but may include thyroglossal duct cysts, lymphatic malformation, hemangioma, amyloid, chondroma, lingual thyroid, paraganglioma, and papilloma.5 The presence or absence of enhancement is an important clue: nonenhancing lesions are more likely cysts or amyloid, and enhancing lesions more likely to be soft-tissue or vascular tumors such as hemangioma, paraganglioma, chondroma, ectopic thyroid tissue, and others. In this case, the patient had a stable airway and was nonverbal; the primary team noticed the cyst incidentally during FEESST, which prompted an investigation by laryngoscopic examination and CT imaging of the neck. Cysts may form as a result of intubation subsequent to the patient’s arrival in the emergency department but in this case was likely congenital and asymptomatic, most likely classified as a lateral internal cyst originating from the right AE fold.
Conflict of Interest Disclosures: None reported.
3. Young VN, Smith LJ. Saccular cysts: a current review of characteristics and management. Laryngoscope. 2012;122(3):595-599.
REFERENCES
4. Su CY, Hsu JL. Transoral laser marsupialization of epiglottic cysts. Laryngoscope. 2007;117(7):1153-1154.
Published Online: July 17, 2014. doi:10.1001/jamaoto.2014.1204.
1. Messner AH. Congenital disorders of larynx. In: Cummings CW, Flint PW, Haughey BH, et al, eds. Cummings Otolaryngology: Head and Neck Surgery. 5th ed. Philadelphia, PA: Mosby; 2010:2866-2876.
5. Luo CM, Yang SW, Chen TA. Treatment of wide-based epiglottic cyst by microdebrider. Med Devices (Auckl). 2009;2:41-45.
2. DeSanto LW, Devine KD, Weiland LH. Cysts of the larynx: classification. Laryngoscope. 1970;80(1): 145-176.
Section Editor: C. Douglas Phillips, MD.
782
JAMA Otolaryngology–Head & Neck Surgery August 2014 Volume 140, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Nanyang Technological University User on 06/10/2015
jamaotolaryngology.com
Clinical Problem Solving | RADIOLOGY
Unusual Presentation of a Laryngeal Mass Oscar Trujillo, MD, MS; Justin Cohen, MD; Marc Cohen, MD; C. Douglas Phillips, MD
A
B
C
D
Figure. Sagittal views of a patient with a neck mass. A, Computed tomographic scan of the neck with intravenous contrast. B, Magnetic resonance imaging examination demonstrating the mass compressed by the endotracheal catheter. C, Intraoperative image. D, Resection in a submucosal plane with scissors under microlaryngoscopy.
A woman in her 50s with a history of hypertension and chronic back pain presented to the emergency department. She had been discovered unresponsive in bed, was apneic, and was intubated in the field. She had experienced multiple episodes of emesis. At presentation, a computed tomographic (CT) scan demonstrated diffuse subarachnoid hemorrhage, intraventricular hemorrhage, and communicating hydrocephalus with tonsillar and central herniation. She received mannitol and an emergent extraventricular drain. During her hospital stay, a cerebral aneurysm was successfully treated by an endovascular route. She required a tracheostomy and percutaneous gastrostomy tube placement. Twenty-eight days after her tracheostomy, a flexible endoscopic evaluation of swallowing with sensory testing (FEESST) revealed a submucosal mass. The mass did not fully obstruct the airway, and the patient tolerated a Passy-Muir valve with
jamaotolaryngology.com
no respiratory distress. The primary team administered dexamethasone sodium phosphate and consulted the otolaryngology service. On examination, her vital signs were within normal limits, she was nonverbal but in no acute distress, her breathing unlabored and silent, with no stridor or stertor. Passing a flexible fiber-optic laryngoscope confirmed the presence of an apparent submucosal mass that either originated from the epiglottis or deep to a severely edematous right aryepiglottic (AE) fold or arytenoid, or completely obstructed the vocal cords from view. The mass did not respond to steroids. A CT scan of the neck with intravenous contrast was performed (Figure, A). The mass was nonenhancing. Subsequently, a retrospective review of a magnetic resonance imaging (MRI) examination demonstrated the mass compressed by the endotracheal catheter (Figure, B). What is your diagnosis?
JAMA Otolaryngology–Head & Neck Surgery August 2014 Volume 140, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Nanyang Technological University User on 06/10/2015
781
Clinical Review & Education Clinical Problem Solving
Diagnosis Benign laryngeal cyst, consistent with saccular cyst
Discussion The broad categories of laryngeal cysts are laryngoceles (containing air), saccular cysts (containing mucous), and laryngopyocele (containing pus).1 DeSanto et al2 further classified laryngeal cysts into 3 main categories based on anatomic location: saccular cysts, ductal cysts, and the rarer thyroid-cartilage foraminal cysts. Laryngeal saccular cysts form on dilation of a blind sac with mucous, typically between the false vocal cord and the thyroid cartilage.3 Laryngeal saccular cysts are further classified based on anatomic location of dissection: anterior, lateral internal, and lateral internal and external. Anterior saccular cysts typically occur between the true and false vocal cords and may protrude from the anterior ventricle toward the laryngeal vestibule.1 Lateral internal cysts dissect superiorly and laterally into the false vocal cords and aryepiglottic folds but may extend to the medial wall of the pyriform sinus, and may even, on occasion, fill the vallecula.1 The lateral internal/external saccular cysts dissect as lateral internal cysts but also involve thyrohyoid membrane and may cause an outward bulge in the neck. In this case, the laryngeal cyst was located at the level of the glottis, contiguous with the epiglottis and the right AE fold, and measured 2.5 × 1.6 × 2.0 cm. It was likely resting dependently on the arytenoid while making broad contact with the posterior pharyngeal wall. The primary team believed that this cyst was responsible for the patient’s repeated episodes of emesis, and the family was concerned about the nature of the mass, so a direct laryngoscopy with excision of the mass was scheduled in the operating room. Intraoperatively, the mass was very bulky, and it was difficult to assess where it was pedicled, as seen in Figure, C. The mass was resected in a submucosal plane with scissors under microlaryngoscopy (Figure, D), and it was determined that it mostly likely was pedicled to the right AE fold. After resection, ARTICLE INFORMATION Author Affiliations: Department of Otolaryngology–Head and Neck Surgery, New York Presbyterian Columbia and Cornell, New York (Trujillo); Joint Residency Program, New York Presbyterian and Cornell, New York (J. Cohen, M. Cohen, Phillips). Corresponding Author: Oscar Trujillo, MD, MS, Department of Otolaryngology–Head and Neck Surgery, New York Presbyterian Columbia and Cornell, 1330 First Ave, Apt 628, New York, NY 10021 ([email protected]).
pathologic characteristics of the mass were found to be consistent with a benign laryngeal saccular cyst. In a current review3 of saccular cysts, the most common presenting symptom was hoarseness with a choking sensation and, more rarely, dysphagia. In this case, the patient’s airway was already secured by a tracheostomy, and the only symptoms she experienced at the time of discovery were repeated episodes of emesis. It is important to note that while the patient’s episodes of emesis ended on removal of the mass, it is unclear whether the mass either directly or indirectly caused those symptoms. Standard treatment of glottic cysts is surgical removal, commonly performed with either laryngomicrosurgery or carbon bicarbonate laser under microscopy.4 Complete removal of the cyst through marsupialization is recommended by most studies because attempting simple aspiration is likely to result in recurrence.4 Diagnosis of glottis or supraglottic cysts depends on an accurate history of symptoms, flexible fiber-optic laryngoscopy, and crosssectional imaging such as CT or MRI. Differential diagnosis for a submucosal glottic or supraglottic mass is not limited to saccular and ductal laryngeal cysts but may include thyroglossal duct cysts, lymphatic malformation, hemangioma, amyloid, chondroma, lingual thyroid, paraganglioma, and papilloma.5 The presence or absence of enhancement is an important clue: nonenhancing lesions are more likely cysts or amyloid, and enhancing lesions more likely to be soft-tissue or vascular tumors such as hemangioma, paraganglioma, chondroma, ectopic thyroid tissue, and others. In this case, the patient had a stable airway and was nonverbal; the primary team noticed the cyst incidentally during FEESST, which prompted an investigation by laryngoscopic examination and CT imaging of the neck. Cysts may form as a result of intubation subsequent to the patient’s arrival in the emergency department but in this case was likely congenital and asymptomatic, most likely classified as a lateral internal cyst originating from the right AE fold.
Conflict of Interest Disclosures: None reported.
3. Young VN, Smith LJ. Saccular cysts: a current review of characteristics and management. Laryngoscope. 2012;122(3):595-599.
REFERENCES
4. Su CY, Hsu JL. Transoral laser marsupialization of epiglottic cysts. Laryngoscope. 2007;117(7):1153-1154.
Published Online: July 17, 2014. doi:10.1001/jamaoto.2014.1204.
1. Messner AH. Congenital disorders of larynx. In: Cummings CW, Flint PW, Haughey BH, et al, eds. Cummings Otolaryngology: Head and Neck Surgery. 5th ed. Philadelphia, PA: Mosby; 2010:2866-2876.
5. Luo CM, Yang SW, Chen TA. Treatment of wide-based epiglottic cyst by microdebrider. Med Devices (Auckl). 2009;2:41-45.
2. DeSanto LW, Devine KD, Weiland LH. Cysts of the larynx: classification. Laryngoscope. 1970;80(1): 145-176.
Section Editor: C. Douglas Phillips, MD.
782
JAMA Otolaryngology–Head & Neck Surgery August 2014 Volume 140, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Nanyang Technological University User on 06/10/2015
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