Laryngeal ventricular cysts, although rare in adults, are benign lesions originating from laryngeal saccule that can be confused with other more common laryngeal anomalies. It has a tendency to progressively enlarge and if left undiagnosed, it can cause life-threatening acute airway obstruction., Conventional endotracheal (ET) intubation in the presence of large ventricular cyst becomes difficult, and meticulous attention must be paid for preoperative airway assessment and availability of resources for airway securement. A 48-year-old male patient presented to outpatient's department of otolaryngology at our institute with a history of hoarseness of voice and noisy breathing for 6 months that were insidious in onset and gradually progressive. However, there was no difficulty in swallowing and deglutition. There was no history of any other systemic illness. Physical examination and routine blood investigation were within normal limits. Airway examination was normal. Laryngeal endoscopy revealed a large saccular growth arising from the left lateral aspect of larynx just above the left vocal cord [Figure 1], and contrast-enhanced computed tomography neck revealed a heterogeneously enhancing lesion of size 19 mm × 25 mm in the left supraglottic larynx involving aryepiglottic fold causing significant narrowing of the laryngeal inlet. The patient was posted for excision of this cyst under general anesthesia. Preoperatively, consent for tracheostomy was also obtained from the patient. On the day of surgery, difficult airway cart including different sizes of ET tubes, bougie, C-MAC video laryngoscope, flexible fiber-optic bronchoscope, and tracheostomy cart were made available in the operating room.
Figure 1: Preoperative laryngeal endoscopy revealing a large ventricular cystic lesion just above the left vocal cord and beneath the epiglottis
In view of anticipated difficult airway, our plan was to secure the airway of the patient awake. However, the patient did not cooperate and hence plan was changed to secure the airway after inhalational induction with preservation of spontaneous respiration. Routine American Society of Anesthesiologists monitors including electrocardiography, noninvasive blood pressure, and SpO2 were attached, and an 18-gauge IV access was secured. The patient was premedicated with injection midazolam 1 mg, injection glycopyrrolate 0.2 mg, and injection fentanyl 70 mg. The patient was preoxygenated with 100% oxygen and an inhalational induction with sevoflurane was attempted till loss of consciousness and bispectral index value reached <60. However, spontaneous respiration was maintained, and a video-laryngoscopy was performed without the use of muscle relaxant. A large ventricular cyst obscuring the glottic aperture was visualized [Video 1]. Bougie was inserted in the narrowed glottic aperture, and a cuffed ET tube of size 6.0 mm was railroaded over the bougie.
After confirmation of ET tube placement by capnography, muscle relaxation was achieved. Injection hydrocortisone 100 mg and injection dexamethasone 8 mg were administered to reduce the possible laryngeal edema anticipated in the postoperative period. Endoscopic excision of ventricular cyst was performed. After completion of an uneventful surgery, the patient was fully awakened and extubated.
To conclude, in a case of ventricular laryngeal cyst, proper execution of plan by experienced anesthesiologist and use of advance airway resources can avoid airway trauma and repeated attempts of intubation and unnecessary tracheostomy.