A Case Report of Epiglottic Cyst Mimicking A Laryngocele: A Diagnostic Dilemma

Laryngeal cyst account for 5% of non malignant laryngeal lesions. They are more common in men but increasingly symptomatic in women. Supraglottic cyst are common among the laryngeal cyst of which the epiglottic cyst is the commonest. Here we report a rare case of epiglottic cyst which was mimicking an internal laryngocele in radiological images.

A 54 year old man presented to our hospital with recent history of change in voice and excessive snoring. He also had associated increased daytime sleepiness and lethargy. He had history of obstructive sleep apnoea and previously mandibular surgery was done to relieve his obstructive symptoms but still after that also he has symptoms suggestive of obstruction with episodes of sudden choking on supine position and dysphonia. Nose and throat examination was normal. Fibreoptic laryngoscopy was done and a benign pedunculated smooth swelling was noticed in the supraglottis arising from the right lateral margin of epiglottis completely occluding the laryngeal inlet (Figures 1, 2). Mass moves up and down while coughing and vocal cords were visualized and was found to be normal and mobile.

Computed tomography of the neck was requested prior to surgery to know the extent of mass and to assess the airway. Preop CT was reported as evidence of 2.8x1.2,2.5cm cystic lesion with few pockets of air noted arising from right pyriform sinus. Another similar cystic lesion with air noted anterior to the above mentioned lesion measuring 1.4x0.8x1.7cm. A 0.7x0.6x1.2cm purely air containing lesion is noted on the left side. All of the lesion was found confined in the paralaryngeal space confined by thyrohyoid membrane. Findings suggestive of internal laryngocele (Figure 3).

He was taken for microlaryngoscopy and excision of cyst under general anesthesia. Cystic lesion was excised in toto, it was found arising from the right lateral margin of epiglottis and right pharyngoepiglottic fold. Specimen sent for histopathological examination. He was extubated uneventfully with no postoperative complications.

Histopathology reported as cyst consistent with laryngeal cyst.

Postoperative CT neck done after 2 months reported as edema with nonspecific air/fluid seen along both aryepiglottic folds suggesting postoperative changes. Laryngoscopy done after 1 month and 3 months showed complete healing of the slough and normal adequate laryngeal inlet (Figure 4).

His obstructive symptoms markedly reduced after surgery and he had no signs of recurrences noted.

Laryngeal cysts are benign fluid filled non infected sacs that can appear in different anatomical parts of the larynx. Large epiglottic cyst are reportedly rarer (0.02%) as per literature. The classification by Desantoet al is most commonly utilized as either ductal or saccular ductal cyst also called as mucus retention cyst and is limited to the mucus membrane. Saccular cyst is submucosal and subdivided to anterior and lateral cyst. A large saccule is termed as laryngocele when it is symptomatic. (It must be air filled and openly communicating with the airway.)

These cysts are usually asymptomatic and are incidental finding in laryngoscopic examination. Supraglottic cyst may present as foreign body sensation, snoring , obstructive sleep apnoea, dysphagia with progression to stridor and dyspnoea reported for all location of cysts.

Videolaryngoscopy is the initial diagnostic modality for most laryngeal disorders. There is significant overlap among cysts of varying location with alternative differential diagnosis. Infrequently cysts lesion which appear benign have been later diagnosed as carcinoid tumor, lymphoma and spindle cell carcinoma. Prior CT is ideal to assess the airway, plan the management and look for malignant changes.

The differential diagnosis include laryngocele, saccular cyst, mucus retention cyst of epiglottis, glottis, vallecula tonsillar cyst oncocytic cyst etc.

Various form of treatment have been advocated which include needle aspiration which has high rate of recurrences, marsupilization which also leaves a nidus of cyst tissue for recurrence, endoscopic excision. Microlaryngoscopy and exicision with laser has replaced cold instruments since it offers superior precision and enhanced depth perception and its intrinsic hemostatic properties allow for ablation of remanent epithelial lining. In our secondary care set up, resources are limited hence we offered this patient microlaryngoscopy and excision of cyst [1-9].

An epiglottic cyst in an adult rarely causes obstructive symptoms. But our patient presented to us with obstructive symptoms and laryngoscopy showed supraglottic cyst which explains his symptoms. CT neck can give false information and can be confused with laryngocele as it happened in this case. Microlaryngoscopy and excision of cyst is the management modality.

None.

No conflict of interest.

1. Journal of Medical Sciences (2022)10(2) Electronic-ISSN: 2345-0592.
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