What is the management approach for a cystic swelling in the nasopharynx (nasal pharynx) discovered after bilateral tonsillectomy (b/l tonsillectomy) for a tonsillar cyst?

Management of Cystic Swelling in the Nasopharynx After Bilateral Tonsillectomy

Endoscopic surgical removal is the treatment of choice for a cystic swelling in the nasopharynx discovered after bilateral tonsillectomy. 1

Diagnosis and Assessment

• The cystic swelling in the nasopharynx likely represents a retention cyst of peritubal mucoserous glands that may have undergone oncocytic metaplasia, classified as a lateral acquired cyst of the nasopharynx 1
• Magnetic Resonance Imaging (MRI) should be performed to:
  • Determine the exact location and extent of the cyst 2
  • Confirm the absence of fistulous ducts connected to the cyst 2
  • Rule out other nasopharyngeal pathologies 3
• Cytologic examination of fluid aspirated from the cyst can help establish the correct diagnosis 2

Surgical Management

• Endoscopic surgical approach is preferred due to:
  • Less invasiveness compared to external approaches 2
  • Better visualization of the surgical field 1
  • Lower morbidity and faster recovery 2
• Complete removal of the cyst is recommended to prevent recurrence 1, 2
• The surgical technique typically involves:
  • Blunt dissection to remove the cyst intact when possible 2
  • Care to avoid injury to nearby structures, including the Eustachian tube 1

Perioperative Considerations

• A single intraoperative dose of intravenous dexamethasone should be administered to reduce postoperative pain and inflammation 4, 5
• Multimodal pain management should be implemented with:
  • Paracetamol (acetaminophen) and NSAIDs as baseline therapy 4, 5
  • Opioids only as rescue medication if needed 5
• Adequate hydration should be maintained throughout the perioperative period 5

Postoperative Care

• Regular follow-up should be scheduled to:
  • Ensure complete removal of the cyst 2
  • Monitor for potential complications such as synechia formation 2
  • Assess for recurrence 1
• Post-operative MRI at 6 months is recommended to confirm complete removal 2

Potential Complications and Management

• Bleeding: Monitor for signs of hemorrhage, which may require intervention 4
• Pain: Implement multimodal analgesia with scheduled paracetamol and NSAIDs 5
• Eustachian tube dysfunction: May occur due to proximity of the cyst to the Eustachian tube 1
• Synechia formation: May not require treatment if asymptomatic 2

Important Considerations

• These cysts are benign but may cause symptoms related to their location in the airway and proximity to the Eustachian tube 1
• The prevalence of nasopharyngeal cysts is higher than previously described in literature (Tornwaldt cysts 6%, mucous retention cysts 10%) 3
• Younger and older patients have the lowest prevalence of nasopharyngeal cysts, suggesting these lesions are acquired and subsequently involute with time 3
• Inadequate examination and incomplete removal are the main reasons for recurrence 2

By following this management approach, the cystic swelling in the nasopharynx can be effectively treated with minimal morbidity and low risk of recurrence.