Surgical approach to congenital vallecular cyst with concomitant laryngomalacia

A 10-day-old girl, brought with stridor, feeding difficulties, and persistent cough, tachypnea along with suprasternal and subcostal retractions. Airway assessment revealed a left vallecular cyst pressing on the lingual surface of the epiglottis leading to Type 3 laryngomalacia (posteriorly displaced floppy epiglottis) in addition to bilateral short ary-epiglottic folds (Type 2 Laryngomalacia), further narrowing the upper airway [Figure 1a]. The vallecular cyst was marsupialised with cauterization of the base [Figure 1b]. The short aryepiglottic folds were cut on both sides using microlaryngoscopy scissors and epiglottopexy was performed using 16G needles and 2-0 prolene sutures that were buried beneath the anterior neck skin crease above the level of thyroid cartilage to further widen the supraglottic airway [Figure 1a-d]. The baby recovered well and was completely weaned off oxygen by the 4^th postoperative day. Vallecular cyst is a rare cause of neonatal airway obstruction (1.87–3.49 cases per 100,000 live births).^[1] In addition to cyst marsupialization, supraglottoplasty with epiglottopexy is the mainstay of treatment of vallecular cyst with concomitant severe type 3 laryngomalacia.^[2]

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Figure 1:

(a) Vallecular cyst causing posterior displacement of epiglottis (Type 3 Laryngomalacia); (b) Appearance after marsupialisation and cauterisation of base of cyst; Bilateral aryepiglottic folds lysed (Supraglottoplasty); (c) Epiglottopexy done with 16G needles; (d) Final result with an open larynx.

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