RESUMO
El enfrentamiento de estridor en el Servicio de Urgencias puede ser un desafío para el clínico. La mayoría de los pacientes responderán a medidas estándar de anafilaxia, no obstante, ante pacientes refractarios a tratamiento se deben sospechar otras patologías. Presentamos el caso clínico de una paciente refractaria a manejo de anafilaxia. Se realiza videolaringoscopía que identifica quiste de vallécula y se maneja mediante protección de vía aérea con intubación orotraqueal. Se decide escisión quirúrgica, en la cual se identifica estenosis subglótica que requiere instalación de traqueostomía. La paciente evoluciona favorablemente y es dada de alta.
Coping with stridor in the Emergency Department can challenge the clinician. Most patients respond to standard anaphylaxis measures. The clinician should suspect other differential diagnoses when patients are refractory to treatment. We present the clinical case of a patient refractory to standard anaphylaxis management. A video laryngoscopy was performed, identifying a vallecula cyst. We secured the airway through orotracheal intubation. The surgical team of our hospital performed a surgical excision of the cyst and identified subglottic stenosis, which required the installation of a tracheostomy. The patient evolved favorably in the postoperative period and was discharged.
RESUMO
Resumen Los quistes laríngeos, y en particular los quistes de vallécula, son una entidad infrecuente en la práctica clínica habitual. Sin embargo, su localización y aparición en neonatos y lactantes, pueden suponer una causa reconocida de estridor y obstrucción de vía aérea superior que, si no es diagnosticada y tratada de forma precoz, puede tener consecuencias fatales. Presentamos el caso de un lactante que presenta estridor inspiratorio. Se realiza una nasofibrolaringoscopía observándose una formación quística en la vallécula, y una ecografía cervical que muestra dicha formación quística sugerente de un quiste del conducto tirogloso como primera posibilidad etiológica. Ante estos hallazgos, se solicitan pruebas tiroideas y una gammagrafía que son normales, por lo que se decide intervenir al paciente bajo laringoscopia en suspensión, realizando una marsupialización del quiste, sin complicaciones posteriores. El análisis histopatológico posterior confirmó el diagnóstico de un quiste de vallécula. Se debe considerar esta patología en los casos de estridor inspiratorio en lactantes ya que, aunque es infrecuente, su diagnóstico precoz y tratamiento adecuado son determinantes.
Abstract Laryngeal cysts, and especially vallecular cysts, are a rare entity in everyday clinical practice. Nevertheless, their location and the fact that they appear in newborns and infants, must be recognized as a cause of stridor and upper airway obstruction, since their misdiagnosis and late treatment can have fatal consequences. We present the case of an infant with inspiratory stridor. We performed a nasofibrolaryngoscopy where a vallecular cystic lesion was observed, and a neck ultrasound showed a cyst, described as a thyroglossal duct cyst, as the main etiology. Thyroid function tests and a gammagraphy, were both normal, hence the patient underwent a suspension microlaryngoscopy and marsupialization of the cyst, without further complications. The histopathology confirmed the diagnosis of a vallecular cyst. This entity must be considered in infants with inspiratory stridor. Although it is a rare lesion, its early diagnosis and adequate management is crucial.
RESUMO
Difficult airway management is one of the most important challenges an anesthesiologist faces. It is due to the high morbidity and mortality that it entails. The challenge is even greater if the patient is a newborn. For this reason, we should have different strategies that allow us to anticipate and treat possible complications derived from the procedure. In this case, we present a newborn with vallecular cyst and respiratory distress who is admitted for cyst resection. The gold-standard in anticipated difficult airway management is the fibrobronchoscope. We decided to perform an alternative management by means of orotracheal intubation with videolaryngoscope (Glydescope®) in spontaneous ventilation
El manejo de una vía aérea difícil es uno de los retos más importantes a los que puede enfrentarse un anestesiólogo debido a la elevada morbimortalidad que conlleva. El reto aún es mayor si el paciente es un neonato. Por este motivo, debemos contar con diferentes estrategias que permitan anticipar y poder tratar las posibles complicaciones derivadas del procedimiento. En este caso, presentamos un neonato con quiste de vallécula con clínica de trabajo respiratorio que es admitido para cirugía de exéresis del quiste. El gold standard en el manejo de una vía aérea difícil conocida es el fibrobroncoscopio. Nosotros decidimos realizar un manejo anestésico alternativo mediante intubación orotraqueal con videolaringoscopio (Glydescope®) en ventilación espontánea.
Assuntos
Humanos , Feminino , Recém-Nascido , Doenças da Laringe/cirurgia , Cistos/cirurgia , Intubação Intratraqueal/métodos , Anestésicos/administração & dosagem , Laringoscopia/métodos , Doenças da Laringe/complicações , Cirurgia Vídeoassistida , Cistos/complicações , Obstrução das Vias Respiratórias/etiologiaRESUMO
Background and Objectives: Vallecular cysts are rare and generally asymptomatic. In infants and children they present with stridor, feeding difficulties, failure to thrive. Treatment is surgical excision with cautery or laser.Presentation of Case: We discuss the clinical, radiological presentation of a 7 months old child with vallecular cyst which was surgically treated with deroofing and marsupialisation with elecrocautery. There was no recurrence even up 2 years of follow-up.Discussion: Flexible nasopharyngolaryngoscopic examination was done which showed present of swelling in the left vallecula pushing the epiglottis posteriorly and to the right with narrowed normal endolarynx. Radiological investigations with CT scan showed cystic lesion noted in left side of neck with no septation and solid component. The lesion was extending to ipsilateral vallecula and paraglottic region with narrowing of endolarynx.Conclusion: Vallecular cyst is rare cause of noisy breathing in infants and children. In adults it is usually asymptomatic. Treatment of choice is marsupialization with electrocautery or laser.
RESUMO
Los quistes de la valécula son un trastorno raro en los niños; el estridor es el síntoma más frecuente y la alteración del crecimiento, el más infrecuente. Se presenta el caso de un niño de 2 meses referido por la escasa ganancia ponderal desde su nacimiento, con antecedentes de atragantamiento al alimentarse. No presentaba dificultad respiratoria, pero llamaba la atención la respiración bucal y la hiperextensión del cuello con lateralización hacia la derecha. El esofagograma mostró una masa hipofaríngea que desplazaba la laringe y reflujo del medio de contraste hacia el árbol bronquial. Por laringoscopia directa se resecó un quiste con técnica de marsupialización. La evolución fue favorable, sin recidivas, hasta el cuarto mes de seguimiento.
Vallecula cysts are a rare condition in children, with stridor being the most common symptom and growth alterations the more uncommon. We present a 2 months-old child referred by low weight gain from birth, with a history of choking when feeding. He had no respiratory distress but struck mouth breathing and neck hyperextension with lateralization to the right. The esophagogram showed a mass displacing hypopharynx and larynx reflux of contrast into the bronchial tree. The cyst was resected by direct laryngoscopy with marsupialization technique. The outcome was favorable, without recurrence until the fourth month of monitoring.
Assuntos
Humanos , Lactente , Masculino , Cistos/complicações , Cistos/congênito , Epiglote , Insuficiência de Crescimento/etiologia , Língua , Peso CorporalRESUMO
Large symptomatic vallecular cyst is rare, but may cause difficulty or inability in conventional tracheal intubation during induction of general anesthesia. A flexible fiberoptic bronchoscope is the most useful general purpose aid to awake intubation in the patient with a known difficult airway. We experienced a case of flexible video image fiberoptic bronchoscopic awake orotracheal intubation in a patient with the large symptomatic vallecular cyst. A 35-year-old male suffered from foreign body sensation, voice change and dyspnea one month after upper respiratory tract infection. The two step flexible fiberoptic bronchoscopic approach was performed in the management of a known difficult intubation due to a vallecular cyst. We had an uneventful general anesthesia for removal of large symptomatic vallecular cyst because we anticipated difficult intubation.
Assuntos
Adulto , Humanos , Masculino , Anestesia Geral , Broncoscópios , Dispneia , Corpos Estranhos , Intubação , Infecções Respiratórias , Sensação , VozRESUMO
Large symptomatic vallecular cyst is rare, but may cause difficulty or inability in conventional tracheal intubation during induction of general anesthesia. A flexible fiberoptic bronchoscope is the most useful general purpose aid to awake intubation in the patient with a known difficult airway. We experienced a case of flexible video image fiberoptic bronchoscopic awake orotracheal intubation in a patient with the large symptomatic vallecular cyst. A 35-year-old male suffered from foreign body sensation, voice change and dyspnea one month after upper respiratory tract infection. The two step flexible fiberoptic bronchoscopic approach was performed in the management of a known difficult intubation due to a vallecular cyst. We had an uneventful general anesthesia for removal of large symptomatic vallecular cyst because we anticipated difficult intubation.
Assuntos
Adulto , Humanos , Masculino , Anestesia Geral , Broncoscópios , Dispneia , Corpos Estranhos , Intubação , Infecções Respiratórias , Sensação , VozRESUMO
Congenital vallecular cyst (VC) is a rare cause of stridor and respiratory distress in neonates and infants. Due to the anatomical location of the cyst, an infant with a VC is at risk of life-threatening upper airway obstruction and eventual death. The cyst sits in the vallecular space and can cause significant retroflexion of the epiglottis. It may also present with feeding problems resulting in failure to grow. Endoscopic laryngoscopy is necessary to visualize it and mar-supialization of the cyst is the preferred treatment. We present 2 successfully treated cases of congenital VC in young infants with symptoms of upper respiratory obstruction and feeding problems.
Assuntos
Humanos , Lactente , Recém-Nascido , Ácido 4-Acetamido-4'-isotiocianatostilbeno-2,2'-dissulfônico , Obstrução das Vias Respiratórias , Epiglote , Laringoscopia , Sons RespiratóriosRESUMO
Vallecular cyst is an uncommon but potentially dangerous condition causing stridor and has been associated with sudden airway obstruction resulting in death due to its anatomical location in neonates. It may also present with various degrees of feeding problems resulting in failure to thrive. When a vallecular cyst is suspected clinically, endoscopic laryngoscopy is necessary to visualize it. Other conditions leading to neonatal stridor such as laryngomalacia and other laryngotracheal abnormalities should be ruled out. Marsupialization with a CO2 laser is the most effective and safest treatment to prevent recurrence. We report a case of a 1-month-old male infant with a vallecular cyst synchronous with gastroesophageal reflux, and failure to thrive. He was referred to our hospital because of hoarseness, inspiratory stridor, feeding-cyanosis, chest retraction and failure to thrive. Diagnostic workup revealed a cyst at the tongue base, suggesting a vallecular cyst. The cyst was removed by laryngomicrosurgery with CO2 laser. After the surgery, the symptoms improved and the body weight increased steadily. We report a successfully treated case of neonatal vallecular cyst with symptoms of upper respiratory obstruction, gastroesophageal reflux, and failure to thrive.