Anesthetic and Surgical Management of Mucoid Retention Cyst in the Vallecular Region: An Airway Challenge.

Growth of any kind in the oropharynx poses a threat to the airway especially during anaesthesia. Being aware of the challenges and adequately equipped to handle the situation is the duty of the anesthesiologist. METHODS AND MATERIAL: An eight year old girl diagnosed case of multiple mucous cysts presented to the outpatient department for excision of a lower lip mucous cyst. So an ultrasound was done which revealed a large intramural mucous cyst. After a preanaesthetic checkup she was posted for the excision of the cyst.
RESULTS: The girl was posted for Elective surgery and was induced without prior premedication as she had revealed a history of snoring in supine position. After preoxygenating with 100% oxygen, she was induced with Injection Ketamine and Sevoflurane. She started desaturated abruptly so nasal airway and finally # 2.5 LMA was inserted but SpO2 didn't improve. With backup of Ent and paediatric surgeons direct larngoscopy was attempted and #5 ETT was inserted successfully. Following which the huge vallecular cyst was removed.

INTRODUCTION

Mucus retention cysts have been known to occur in different parts of the body; however, when they unanticipatedly present in the airway, they pose an airway challenge. The present anesthetic and surgical case is a learning lesson for anesthesiologists and surgeons to be prepared for preventable catastrophes if we work vigilantly as a team.

CASE REPORT

The anesthetic and surgical management were carried out in an 8-year-old female child weighing 38 kg. After a preanesthetic checkup where a history of snoring and preferable sleeping in lateral position was revealed, she was brought with no premedication to the operation theater.

After preoxygenating the child with 100% oxygen, incremental doses of injection ketamine were given after injection glycopyrrolate 0.2 mg intravenous (iv) maintaining spontaneous respiration. However, on giving inhalational anesthetics, i.e., sevoflurane with O2, she started to desaturate abruptly. Continuous positive pressure ventilation was given, but SpO2 declined steadily. #3 oral and #6 nasal airways were inserted to ventilate her. As SpO2 became 38%, #2.5 laryngeal mask airway was inserted, but it failed to increase the SpO2. Finally, it was removed and again ventilated with #3 oral airway, and all gases were stopped temporarily till SpO2 rose to 100%. This took at least 2 min. With the ENT and pediatric surgeons to backup, direct laryngoscopy was done, and using #3 Macintosh blade, a #5 endotracheal tube was inserted and airway secured. After confirming correct tube placement, injection atracurium 15 mg and injection fentanyl 40 μg were given. The ENT surgeon excised the growth [Figure 1] which was enveloping the vallecular region using rigid video laryngoscopy. After the bleeding was secured, the child was shifted unreversed to electively ventilate to lessen cord edema. After 2 days, the child was successfully extubated and shifted to the ward. On the next day, she was discharged and called for follow-up after a week. The child was found to sleep better after the cyst excision, so her snoring also reduced gradually.

Figure 1

Mucous cyst in the vallecula with multiple cystic extensions

The mucoid retention cyst in the oropharynx was successfully removed, and the child is now able to have a better sleep pattern as her snoring has reduced considerably from before.

DISCUSSION

Vallecular cysts have been encountered in the past as an airway challenge. It becomes more chaotic if we have an unanticipated and unprepared situation to manage.[1]

Vallecular cysts are generally benign and asymptomatic. Giant vallecular cysts can present with pressure symptoms such as dyspnea and dysphagia.[2] Vallecular cysts form when the mucous glands in the lingual tonsils become dilated secondary to trauma or inflammation.[3] A team approach by both the anesthesiologist and the surgeon is required for successful results.

The major challenge is the failure to mask ventilate the patient which arises because a ball-valve obstruction can result, especially seen in vallecular cysts and pedunculated glottis tumors,[4] while giving positive pressure ventilation. The experts have little consensus over the definitive method of airway control in these patients with upper airway obstruction. Inhalational induction or iv inductions using awake fibreoptic intubation (AFOI) are the choices available. The NAP4 report showed 14 failed intubations of 23 planned AFOI in patients with head and neck pathologies which needed a surgical pathway finally.[5]

The surgical procedure for cyst removal includes deroofing, excision with a snare, marsupialization, and CO2 laser.[6] In our patient, endoscopic excision of the cyst was done which was uneventful. Hence, to conclude, one should always remember vallecular cysts as rare entities which can present to us as airway challenges both in adults and in pediatric populations.

CONCLUSIONS

Airway growths are real-time dilemmas and pose a threat to both the anesthesiologist and the surgeons, and it is necessary to be well equipped and vigilant while managing them.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.