VALECULAR CYST IN A CHILD WITH STRIDOR

Dr Anakha V Ajay   DrMadumitha (ENT) Dr.CJayakumar 
AIMS, Kochi
A two month old child presented with complaints of noisy breathing since birth which used to resolve in lateral postilion. There is history of poor weight gain also due probably due to poor feeding. There is no history of regurgitation of feeds or boyishness . She is the first child  of a non consanguinous couple with uneventful antenatal history born term via normal vaginal delivery with a birth weight of 2.8Kg  and no significant post natal  history.
On Examination child was alert with stable vitals and maintaining saturation at room air. Child had normal cry with suprasternal and intercostal retractions and  inspiratory stridor . Respiratory examination revealed air entry equal on both sides.
Differentials considered:
1. Haemangioma 
2. Lymphangioma
3. Teratomas 
4. Vallecular cyst.
5Congenital laryngeal stridor 
Lab Normal counts with normal RFT/LFT/Electrolytes.Flexiblescopy 
Deviated Nasal Septum to right,
Cystic lesion noted at the base of tongue: suggestive of Vallecular cyst and Tubular epiglottis collapsing into the supraglottic space with Short Aryepiglottic folds.
Ultrasound Neck revealed, a well defined midline cystic lesion measuring 8 x 6 mm compatible with a vallecular cyst at the region of floor of mouth. 
Thyroid gland is normal in size and echotexture and is seen at its expected location. 
ECHO normal.
Child was planned for surgery, Micro laryngeal surgery under GA was done. Histopathological examination showed tissues lined hyperplastic stratified squamous epithelium with underlying mucous glands and the skeletal muscle fibres. Focally a cyst lined flattened and focally columnar epithelium seen. Findings suggestive of vallecular cyst consistent with epithelial cyst
Post-operatively child was intubated and shifted to PICU. She was extubated on Post operative day 1 (POD)and was found to have inspiratory stridor with suprasternal and chest retractions. Flexible nasopharyngolaryngoscopy was done on POD 2 which showed oedematous glottis and I V steroids were continued. She was started on NG feeds which she tolerated well. She was then changed to CPAP but the stridor and retractions persisted while saturation was maintained. Repeat flexible nasopharyngolaryngoscopy on POD 4 showed epiglottis in upright position with arytenoid mucosa being sucked into the glottic space. Nasopharyngeal airway was placed which reduced the intensity of inspiratory stridor but the retractions remained same. Hence she underwent Aryepiglottoplasty.Post surgery child was symptomatically better with reduced chest and suprasternal retractions with reduced intensity of stridor,hence was extubated on POD1, feed were started on POD 2 and she was tolerating well. Child was discharged on antireflux medications and advised to be under regular follow up.
Vallecular cyst is a unilocular cystic mass which contains clear and  non infected fluid. They are rare anomalies presenting with respiratory distress, dysphagia & failure to thrive, and they can lead to potentially life threatening conditions and sudden airway obstruction. Clinical presentation include stridor,chest retraction, apneic/cyanotic episodes,choking, postprandial vomiting,coughing & hoarse cry. It may also cause supraglottic obstruction due to their mass effect. Increased size of the cyst progressively interferes with swallowing, subsequently leading to poor weight gain & failure to thrive. Nasopharyngoscopy, Direct laryngoscopy & imaging like CT, MRI,USG are required to confirm the diagnosis and to observe the extension of cyst. Treatment options include cyst aspiration, marsupialisation deroofing of cyst wall & complete excision.
Prognosis: Generally depends on several factors including the size of cyst, degree of airway obstruction,it causes, the age and overall health of the patient and the timeliness of intervention.Early detection and surgical repair, smaller size of cyst favour good prognosis. 
TAKE HOME MESSAGE: The management of vallecular cyst requires a multidisciplinary approach involving careful diagnosis often aided imaging such as MRI/CT Scan followed appropriate surgical intervention.Earlydetection and intervention are crucial to prevent potential airway compromise and ensure favourable patient outcomes.