What is a Vallecular Cyst?
A vallecular cyst is a benign, mucus-retention cyst arising from the vallecula (the depression between the base of the tongue and epiglottis), typically originating from obstruction of minor salivary glands or representing a base-of-tongue variant of thyroglossal duct cysts. 1, 2
Clinical Presentation and Symptoms
Asymptomatic Presentation
- Most adult vallecular cysts are minimally symptomatic or completely asymptomatic at diagnosis, often discovered incidentally during laryngoscopy for unrelated procedures 1, 3, 4
- The noninfected type follows a relatively prolonged, mild clinical course with minimal symptoms 5
Symptomatic Presentation
- Infected vallecular cysts present dramatically with acute epiglottitis (91.7% of infected cases), abrupt onset of symptoms, and potential abscess formation (79.2% of infected cases) 5
- Airway compromise occurs in 37.5% of infected cases, representing a life-threatening emergency 5
- Symptomatic patients may present with breathing difficulties, dysphagia (swallowing problems), foreign body sensation, or voice changes 1, 2
- Recurrent acute epiglottitis can occur, with some patients experiencing multiple episodes before the underlying cyst is identified 5
Diagnosis
Fiberoptic laryngoscopy is the definitive diagnostic tool, confirming the presence of a vallecular cyst in all cases. 1
- In infected cases, the origin of the cyst may only become evident after acute symptoms subside, requiring follow-up endoscopy 5
- Imaging studies are recommended for patients with recurrent episodes of acute epiglottitis to identify underlying vallecular cysts 5
Management Strategy for Asymptomatic Adults
Recommendation: Transoral Complete Excision
For asymptomatic adult vallecular cysts, transoral complete excision is the ideal treatment to prevent life-threatening acute airway obstruction and disease recurrence, even in the absence of current symptoms. 1
Rationale for Surgical Intervention in Asymptomatic Patients
- Risk of acute airway obstruction: Vallecular cysts pose significant risk during anesthesia induction for any future surgical procedure, as they can cause difficult bag-mask ventilation and laryngoscopy, with documented cases requiring ICU admission after cyst rupture 4
- Prevention of infection: Asymptomatic cysts can become infected, leading to acute epiglottitis and abscess formation with rapid airway compromise 5
- Low surgical morbidity: Transoral excision has minimal complications and excellent outcomes 1
Surgical Technique
- Transoral approach using suspension laryngoscopy with the operating microscope and cold instruments is the standard technique 1, 2
- Complete excision (not marsupialization) is required to achieve long-lasting cure and prevent recurrence 2
- No major complications have been reported from this surgical intervention 1
Recurrence Rates
- Recurrence occurs in approximately 22% of cases after transoral excision 1
- Patients who undergo marsupialization (incomplete removal) have higher recurrence rates and may require observation or repeat surgery 1
- Complete excision significantly reduces recurrence compared to partial removal 2
Critical Pitfalls to Avoid
- Do not defer treatment based on lack of symptoms—the risk of future airway emergency during anesthesia or spontaneous infection justifies prophylactic removal 4, 5
- Avoid marsupialization as the primary treatment, as it leads to higher recurrence rates; complete excision is necessary 1, 2
- Do not miss the diagnosis in patients with recurrent acute epiglottitis—always perform follow-up endoscopy after symptoms resolve to identify underlying cysts 5
- Ensure proper airway planning if surgery is deferred and the patient requires anesthesia for other procedures, as incidental vallecular cysts are associated with difficult airway management 4