Giant Epiglottic Cyst: A Comprehensive Case Report and Literature Review

Significance Statement

This case highlights the critical nature of recognizing and managing epiglottic cysts, especially in patients with misleading initial symptoms like a severe sore throat. It underscores the importance of differential diagnosis in patients with diabetes presenting with atypical oropharyngeal symptoms, where common conditions like the cold can mask more serious underlying issues. The successful identification and surgical resolution of an epiglottic cyst can prevent potential airway obstruction and ensuring patient recovery.

A 65-year-old male, with a long history of type II diabetes managed through pharmacotherapy, sought medical attention at the emergency department. One day before his visit to the emergency room, a local medical clinic attributed his severe sore throat to the common cold; however, the possibility of epiglottitis could not be ruled out. On evaluation, his vital signs were within normal limits, exhibiting no signs of desaturation. Physical examination revealed no tonsillar swelling, neck tenderness, or palpable masses. However, odynophagia was present. Laboratory findings indicated leukocytosis (White blood cell count of 11,290/μL) with a neutrophil predominance, alongside an elevated C-reactive protein level (5.45 mg/dL). A lateral neck radiograph disclosed swelling in the epiglottic area (Figure 1). Endoscopy was done and revealed a huge epiglottic cyst (Figure 2). A neck computed tomography (CT) scan uncovered an epiglottic cyst measuring approximately 2.1 cm × 1.6 cm (Figure 3). Under tentative diagnosis of epiglottic cyst with acute epiglottitis, he was admitted for antibiotic and surgical treatment. Following admission, the patient received antibiotic treatment with piperacillin and tazobactam, 4 days later, he underwent laser excision surgery and was discharged on the fifth day post operation, with notable improvement in symptoms. During the 2 week follow-up period, the patient reported a substantial improvement of all symptoms.

Figure 1.

Lateral neck radiograph, indicating of potential epiglottic involvement. The red arrow points to the area of swelling consistent with the clinical suspicion of an epiglottic cyst or acute epiglottitis.

Figure 2.

Endoscopic images of the epiglottis showing a large epiglottic cyst obstructing the view of the glottis. The cyst’s surface appears smooth, and vascular patterns are visible, suggesting a benign etiology.

Figure 3.

Axial and coronal sections of a CT scan of the neck, with red arrows highlighting a well-defined epiglottic cyst measuring approximately 2.1 cm × 1.6 cm. CT, computed tomography.

Epiglottic cysts represent a relatively rare clinical entity that can pose significant diagnostic and therapeutic challenges. These benign lesions arise from the epiglottis and, despite their often indolent nature, can lead to critical airway obstruction if not identified and managed appropriately.

The symptoms of epiglottic cysts can range from being asymptomatic to causing significant airway distress. Common presentations include dysphagia, odynophagia, voice changes, and, in severe cases, stridor indicating airway compromise. Hou et al highlighted slurred speech as a potential clinical manifestation, emphasizing the need for differential diagnosis in such cases, including considerations beyond acute cerebral infarction. ¹ Diagnostic modalities for epiglottic cysts encompass a combination of clinical examination and imaging techniques. Laryngoscopy offers direct visualization, whereas radiographic studies, including neck X-rays and CT scans, provide insights into the cyst’s size and impact on surrounding structures. Advanced imaging can be crucial for preoperative planning and to rule out malignancy or other pathologies.

Epiglottic cysts are categorized based on their etiology and histopathological features. DeSanto et al classified anomalies into ductal-type, caused by obstruction of the submucosal glands’ excretory duct, and saccular-type, arising from excessive ventricular fold saccule extension in the larynx. Notably, acquired cysts constitute the majority of epiglottic cyst cases, reflecting their diverse origins and potential for post-inflammatory sequelae. ²

Yoon et al investigated the incidence of epiglottic cysts in adults with acute epiglottitis and its impact on clinical outcomes and airway management. Findings reveal that patients with cysts had a higher need for airway intervention and a greater recurrence rate of acute epiglottitis compared to those without cysts. The presence of an epiglottic cyst was linked to an increased risk of airway obstruction, underscoring the importance of considering these cysts in the diagnosis and management of acute epiglottitis. ³

The cornerstone of management for epiglottic cysts is surgical intervention, with options ranging from marsupialization ⁴ to complete excision, often utilizing CO₂ laser ^{5 6} or microdebrider techniques. ⁷ The choice of treatment is guided by the cyst’s size, location, and impact on the patient’s airway and quality of life.

In summary, while epiglottic cysts often present a benign course, their potential to induce significant airway obstruction necessitates timely diagnosis and intervention. The evolution of surgical techniques continues to improve outcomes for patients, underscoring the importance of ongoing research and review of these intriguing entities.