What is a Tornwaldt cyst?

What is a Tornwaldt Cyst?

A Tornwaldt cyst is a benign congenital cyst located in the midline of the nasopharynx, formed from embryonic remnants of the notochord and pharyngeal endoderm that becomes obstructed. 1, 2

Embryologic Origin and Pathophysiology

• The cyst develops around the 10th week of embryonic development when the pharyngeal ectoderm adheres to the notochord at its most cranial end 3
• The pharyngeal bursa—an embryological remnant—occurs in approximately 3% of healthy adults 4
• When the orifice of this nasopharyngeal bursa becomes mechanically obstructed, inflamed, or develops an abscess, a Tornwaldt cyst forms 2, 4
• The cyst is located superficial to the superior constrictor muscle and is covered by nasopharyngeal mucous membrane 2

Clinical Presentation

Most Tornwaldt cysts are asymptomatic and discovered incidentally during routine ENT examination or imaging studies. 1, 2

When symptomatic, patients may present with:

• Unexplained sinonasal symptoms including nasal obstruction and post-nasal drip 1
• Occipital headache (often obstinate) 1, 3
• Foreign body sensation in the nasopharynx 2
• Hearing loss or feeling of ear fullness (as seen with serous otitis media) 2, 5, 3
• Periodic halitosis 2, 3
• Purulent choanal discharge 3
• Throat clearing 3

Diagnostic Evaluation

• MRI is superior to CT for detection and characterization of Tornwaldt cysts 4
• Nasopharyngeal fiberscopy/endoscopy allows direct visualization 1, 3
• On imaging, the cyst appears as a well-rounded, smooth-walled cystic formation in the midline of the upper nasopharynx, often showing adhesion to the cervical vertebrae 5, 3
• Posterior rhinoscopy and simple lateral view X-ray tomography can also be useful 3

Management Algorithm

Asymptomatic cysts require no treatment, while symptomatic cysts necessitate surgical intervention. 2, 4

For Asymptomatic Patients:

• No surgical treatment is required 2, 4
• Observation is appropriate as these are benign lesions 1

For Symptomatic Patients:

• Endoscopic transnasal marsupialization is the procedure of choice to prevent recurrence 2, 5, 4
• Alternative approaches include transoral access, though transnasal is preferred 2, 4
• Complete excision or incision of the cyst can be performed 3
• The procedure is safe and effective with minimal complications 1, 5

Clinical Outcomes

• Endoscopic surgical excision results in complete symptom resolution with no cyst recurrence when marsupialization is performed 1, 5
• Histopathology confirms benign cystic nature with walls infiltrated by lymphocytes and absent lymph follicles 4
• Patients remain disease-free at follow-up after appropriate surgical management 1, 5

Key Clinical Pitfall

Tornwaldt cyst should be suspected in any patient with unexplained chronic sinonasal symptoms, particularly when accompanied by occipital headache or recurrent serous otitis media. 1 The diagnosis is often missed because symptoms can be attributed to more common upper respiratory conditions, and the cyst may only be discovered incidentally on imaging performed for other indications 2, 4.