David J. Kim, MD, MS
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts
Epiglottic cysts are rare and constitute only 5% of all benign laryngeal lesions.1 However, the true incidence of epiglottic cysts is unknown as many can be asymptomatic and discovered incidentally during workup of other comorbidities or induction of general anesthesia. Asherson reported an incidence of larger epiglottic cysts of 1 in 4,200 laryngoscopies and Padfield reported a personal incidence of 4 in 5,000 laryngoscopies.2,3
Epiglottic cysts are potentially dangerous and can present at any stage in life. They can cause obstruction of the airway, unexpected difficulty with mask ventilation and intubation, asphyxiation, and sudden death.4-7 The most common symptoms of epiglottic cysts are nonspecific and include voice changes, stridor, dysphagia, and hoarseness. We present a case of an unanticipated difficult intubation due to an epiglottic cyst that was found incidentally during the induction of general anesthesia.
Case Description
A 59-year-old man with a past medical history significant for hypertension, hyperlipidemia, type 2 diabetes, coronary artery disease with a prior myocardial infarction, obstructive sleep apnea (OSA), and chronic diverticulitis of the sigmoid colon presented for laparoscopic sigmoid colectomy. His previous surgeries included a tonsillectomy in childhood and right knee surgery at a different institution. His daily medications included aspirin 81 mg, gemfibrozil 600 mg, lisinopril 20 mg, simvastatin 20 mg, and metformin 500 mg twice daily. He used a continuous positive airway pressure (CPAP) machine nightly for OSA. He denied alcohol use but admitted an extensive tobacco history (smoking two packs daily for 46 years).
The airway examination was notable for a Mallampati class I airway. The patient had full range of motion of the neck, good jaw protrusion, thyromental distance of greater than 6 cm, and mouth opening of 4 cm. His voice was hoarse, but he stated it was chronic and attributed it to his smoking history. The remainder of his physical exam was unremarkable.
After premedication with midazolam 2 mg, general anesthesia was induced using propofol 2 mg/kg. The patient was initially a difficult mask ventilation but significantly improved with an size 5 oral airway (100 mm). After confirmation of adequate mask ventilation, rocuronium 0.6 mg/kg was administered for neuromuscular blockade. Direct laryngoscopy with a MAC 3 laryngoscope resulted in a Cormack-Lehane grade 4 view (neither epiglottis nor glottis seen). Mask ventilation was reinitiated with 100% oxygen while a video laryngoscope (VL) was brought into the room.
Visualization via a GlideScope (size 3 Stat; Verathon) showed a pink, cystic mass measuring approximately 2 cm × 1.5 cm, slightly left of midline on the lingual surface of the suprahyoid epiglottis. The mass was broad-based, pedunculated, and ball-valving into the endolarynx (Figure 1). However, we were unable to obtain a view of the larynx even with the VL. Under visualization of the VL, we then advanced an endotracheal tube (ETT) introducer (Portex, Smiths Medical) under the epiglottis with the coudé tip pointing anteriorly. Tactile “clicking” sensations were noted as the tip of the introducer was advanced over the tracheal rings. We also encountered the familiar “resistance to further insertion” after advancing approximately 8 cm. At this point, a 7.5 mm ETT was advanced over the introducer without difficulty using a Seldinger-like technique, while maintaining visualization with the VL (Figures 2 and 3). Tracheal intubation was confirmed with bilateral chest rise, auscultation of breath sounds, and the presence of sustained end-tidal carbon dioxide (CO2). The surgical procedure was completed without complication. The patient was extubated at the conclusion of the case and recovered uneventfully in the postanesthesia care unit.
Three months later, the patient underwent suspension microlaryngoscopy, CO2 laser and cold steel simple excision, and decompression of the epiglottic cyst. Final pathology showed a benign squamous-lined cyst and microscopic component consistent with squamous papilloma (benign epithelial neoplasm). The patient was doing well at follow-up at 10 months, and denied hoarseness, dyspnea, dysphonia, dysphagia, and reflux. Evaluation using a flexible video nasolaryngoscope showed a small left posterior vocal fold granuloma. There was normal arytenoid mobility and otherwise smooth vocal edges bilaterally. There were no masses or ulcerations in the oropharynx, hypopharynx, or larynx.
Discussion
Although each of the airway tests (eg, Mallampati classification, thyromental distance, and mouth opening) has limited value on its own, together they can create a more comprehensive picture of expected difficulty with mask ventilation and tracheal intubation in patients presenting for preoperative evaluation.8 It has been reported that a history of previous airway difficulty is the best predictor of subsequent difficult airway.9 Unfortunately, we did not have records of previous anesthetics for our patient. Furthermore, our patient had a relatively reassuring airway exam that was only notable for hoarseness, which could have been attributed to many other causes. It is also possible that his OSA may have been partly due to obstruction secondary to the mass effect of the cyst. He did confirm improved OSA symptoms at follow-up after removal of the epiglottic cyst, although he continued to use CPAP nightly. This case report illustrates the limitations of the airway assessment and the importance of being prepared for the management of an unanticipated difficult airway for any patient.
References
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Henderson LT, Denneny JC 3rd, Teichgraeber J. Airway-obstructing epiglottic cyst. Ann Otol Rhinol Laryngol. 1985;94(5 Pt 1):473-476.
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el-Ganzouri AR, McCarthy RJ, Tuman KJ, et al. Preoperative airway assessment: predictive value of a multivariate risk index. Anesth Analg. 1996;82(6):1197-1204.
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