What is the procedure for removing a growth on the vallecula?

Surgical Removal of Vallecular Growths

Vallecular growths are typically removed using transoral surgical approaches, with the specific technique depending on the size and nature of the lesion—small benign cysts can be excised transorally under direct or indirect laryngoscopy, while larger or malignant lesions may require transoral robotic surgery (TORS) or open approaches such as mandibular swing procedures. 1

Preoperative Assessment

Before proceeding with surgery, you need:

• Flexible laryngoscopy or videofluoroscopy to visualize the exact location, size, and attachment of the vallecular mass 2
• Cross-sectional imaging (CT or MRI) to determine the extent of the lesion and rule out malignancy or extension into adjacent structures 3
• Biopsy consideration if imaging suggests malignancy, though many benign cysts are diagnosed definitively only after excision 4, 5

The vallecula is bordered by the epiglottis posteriorly, the base of tongue anteriorly, and the hyoepiglottic membrane inferiorly—understanding these anatomical relationships is critical for surgical planning 6

Surgical Approaches Based on Lesion Characteristics

For Small Benign Cysts (<2-3 cm)

Direct transoral excision under general anesthesia with endotracheal intubation is the standard approach 4, 5:

• The patient is positioned supine with neck extension
• A laryngoscope (Miller straight blade or Macintosh curved blade) is inserted into the vallecula to expose the lesion 1
• The cyst is grasped with forceps and excised at its base using cold steel instruments or electrocautery
• Complete excision is typically achievable given the pedunculated or well-circumscribed nature of most vallecular cysts 4, 5

For Larger Lesions or Those Requiring Better Exposure

Transoral robotic surgery (TORS) provides superior visualization and precision for larger vallecular masses 1:

• This minimally invasive approach allows three-dimensional magnified views
• Particularly useful for lesions extending to the tongue base or lateral pharyngeal walls
• Offers excellent functional outcomes with minimal morbidity compared to open approaches 1

For Extensive or Malignant Lesions

Open surgical approaches may be necessary 1, 6:

• Mandibular swing approach: Provides wide exposure for large malignant lesions involving the vallecula and tongue base 1
• This involves a lip-splitting incision, mandibulotomy, and lateral retraction of the mandible
• Allows en bloc resection with adequate margins for malignancy 1
• Reconstruction with free tissue transfer may be required depending on the extent of resection 1

Anesthesia Considerations

Airway management is critical given the vallecular location 7:

• Large vallecular masses can cause acute airway obstruction, particularly during induction of anesthesia 7
• Have equipment ready for emergency cricothyrotomy or tracheostomy 7
• Consider awake fiberoptic intubation for very large lesions that significantly narrow the airway 1

Postoperative Management

After excision:

• Monitor for airway edema in the immediate postoperative period, as manipulation of vallecular structures can cause significant swelling 7
• Assess swallowing function before resuming oral intake, as the vallecula plays a critical role in bolus control during swallowing 1
• Most patients with small benign cysts resume normal diet within 24-48 hours 4, 5
• Larger resections may require temporary diet modifications or swallowing therapy 2

Common Pitfalls to Avoid

• Incomplete excision: Ensure the entire cyst wall is removed to prevent recurrence, which is rare but possible if remnants remain 4
• Airway compromise: Never underestimate the potential for acute obstruction, especially with large pedunculated lesions that can "ball-valve" the airway 7
• Assuming benignity: While most vallecular masses are benign cysts, malignancies (including adenocarcinoma and squamous cell carcinoma) can present as vallecular masses and require oncologic resection 3

Prognosis

Complete surgical excision of benign vallecular cysts is curative with excellent outcomes 4, 5. Recurrence after complete excision is exceptionally rare 4. For malignant lesions, prognosis depends on stage and histology, with treatment following standard head and neck cancer protocols including possible adjuvant radiation or chemoradiation 1.