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Previously undiagnosed or asymptomatic epiglottic cysts may be coincidentally detected during intubation. This retrospective case series identified undiagnosed epiglottic cysts that were discovered during intubation in 4 patients who underwent oral surgery under general anesthesia at our hospital during a 6-year period. Including 2 additional cases, 1 previously diagnosed and 1 detected during preoperative imaging, epiglottic cysts were observed in 6 of 1112 cases (0.54%) total. Among the undiagnosed epiglottic cyst cases, mild dyspnea on effort or snoring was reported in 2 patients, but all others were asymptomatic. Upon discovering previously undiagnosed epiglottic cysts during intubation, it is essential to proceed cautiously, remain alert for potential airway management difficulties, and avoid injuring or rupturing the cysts. In addition, any available preoperative imaging should be reviewed as information pertinent to the airway and any abnormalities may be useful. This report discusses the anesthetic care of 6 patients with epiglottic cysts that were previously known or initially discovered during intubation.
Case 1—Laryngeal endoscopic and CT images. Multiple bilateral epiglottic cysts, previously undiagnosed and discovered during intubation, that obstructed the glottic view while using a conventional laryngoscope. (A) A larger epiglottic cyst on the left side of the anterior surface of the epiglottis and 2 smaller epiglottic cysts on the right side were detected (black arrows). (B) Axial, (C) sagittal, and (D) coronal CT images revealing the mass (red arrows). CT indicates computed tomography.
Case 2—Laryngeal endoscopic image. A large unknown epiglottic cyst on the right side of the anterior surface of the epiglottis (black arrow) identified during video laryngoscopy that did not cause a difficult intubation.
Cases 3 and 4—Laryngeal endoscopic images. Unexpected epiglottic cysts (black arrows) on the right anterior epiglottic surfaces that did not cause difficulty while intubating with a video laryngoscope.
Case 5—CT images. An epiglottic cyst discovered on a preoperative CT that did not cause difficult intubation while using a video laryngoscope. (A) Axial, (B) sagittal, and (C) coronal CT images showing the epiglottic mass (red arrows). CT indicates computed tomography.
Case 6—Laryngeal endoscopic and CT images. Known epiglottic cysts obscuring the glottic view during an awake airway assessment using a video laryngoscope. (A) Two epiglottic cysts were detected, one on either side of the anterior surface of the epiglottis (black arrows). (B) Axial, (C) sagittal, and (D) coronal CT images showing the mass (red arrows). CT indicates computed tomography.
Recommended airway management for patients with unexpected and expected epiglottic cysts. (A) Unexpected epiglottic cysts: If epiglottic cysts are detected during initial intubation after induction of general anesthesia, assess whether face mask ventilation is adequate or not. (I) If face mask ventilation is adequate, use of a video laryngoscope is recommended for intubation. If unsuccessful and face mask ventilation is adequate, consider fiberoptic intubation or other alternative approaches. (II) If face mask ventilation is not adequate, initially attempt intubation using the planned method. If initially unsuccessful, consider use of a video laryngoscope, following the steps of the American Society of Anesthesiology Practice Guidelines for Management of the Difficult Airway 12 algorithm. Otolaryngology consultation may be warranted prior to extubation. (B) Expected epiglottic cysts: For the airway management of the patient with known epiglottic cysts, a consideration of the relative clinical merits and feasibility of 3 management choices is needed: (I) awake intubation using a video laryngoscope or a fiberoptic scope, (II) after an awake look using a video laryngoscope, awake intubation or intubation after induction of general anesthesia using a video laryngoscope or a fiberoptic scope, (III) intubation after induction. CT indicates computed tomography; ENT, ear, nose, and throat; MRI, magnetic resonance imaging; OR, operating room.
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