A Progressively Worsening Sore Throat and Cough

History 

A male in his twenties presented to his physician's office complaining of a sore throat for 7 days with a slightly worsening cough. He noted pain when swallowing but denied dysphagia, a choking episode or neck trauma prior to onset of his pain, fever, rhinorrhea, cough, vomiting, or difficulty breathing. 

He denied any history of frequent throat pain in the past and never had any surgery to his head or neck. He smokes cigarettes and drinks alcohol socially, but denied using street drugs. His past medical history was significant for bipolar disorder but he denied taking any current medications. His family history is negative for head and neck malignancy. He is unemployed and has had no recent sick contacts. 

Figure 1. A mass rising from the epiglottis.

Physical Examination

On examination, he was in no acute distress, afebrile, and with stable vital signs. His voice was normal and he has no stridor. He had no conjunctival injection and no rhinorrhea. External inspection and palpation of neck showed no masses, lymphadenopathy, or tenderness. Oropharyngeal exam demonstrated moist mucous membranes, no erythema, and no exudates, but a mass was noted arising from the epiglottis (Figure 1). 

The rest of physical exam was unremarkable. 

What's Your Diagnosis?

(Answer and discussion on next page)

ANSWER: Vallecular Cysts

A systematic approach with a thorough history and physical examination is paramount when a patient presents with complaints of sore throat. Problems range from mundane to life threatening problems and an urgent operative or airway intervention may be needed. Pain may result from trauma, gastroesophageal reflux, abrasions from swallowed objects, infectious processes caused by viruses, bacteria, or fungi, or tissue infiltration by a tumor.

 Epiglottitis, airway obstruction from a tumor, or deep neck abscess needs to be considered and ruled out. A sore throat may be a referred pain from other structures such as heart in unstable angina presenting with neck pain only. A sore throat may be a referred pain from other structures, such as heart in unstable angina presenting with neck pain only or from an inflamed ear canal in acute otitis externa. It is important to ascertain whether the patient has pain with swallowing (odynophagia), with head movements (whiplash, retropharyngeal abscess), or with palpation of the anterior neck (thyroiditis).

Vallecular Cysts

Our patient had a retention vallecular cyst, which is an uncommon although a well described cause of odynophagia in adults. Multiple cysts in adults appear to be very uncommon. Vallecular cysts form when a mucous producing cyst’s duct becomes obstructed or from lymphoid tissue at the vallecula. In adults, most cysts are asymptomatic and discovered incidentally. This sometimes results in unanticipated difficult airway when symptomatic, foreign body sensation, voice changes, dysphagia, odynophagia, hemoptysis, and dyspnea have been reported. 

If a mass is not noted on physical examination then flexible laryngoscopy is needed for diagnosis. Computer tomography of the neck can further help exclude inflammatory changes. Unlike children, adults are much less likely to rapidly decompensate so an urgent outpatient referral is appropriate unless there is a high suspicion for an acute infectious etiology or there are signs of airway compromise on presentation such as stridor, dysphonia, or choking episodes. 

Differential diagnosis must include malignant neoplasms, including those arising from the salivary glands. Both definitive diagnosis and management require surgery. As chronic inflammation is thought to be a factor in vallecular cysts formation, avoiding smoke and other irritants may help to reduce one’s chances of forming mucous vallecular cysts. 

Outcome of the Case

A CT neck with intravenous contrast was performed to emergently to rule out an abscess and exclude airway narrowing. It delineated a 12 mm mass in the left epiglottis/vallecular region most consistent with a mucous retention cyst without apparent compromise to the airway or inflammatory changes. An ENT referral was made and the patient underwent surgery the following day. In the operating room a second smaller epiglottic lesion was noted measuring 5 mm in diameter. Both masses were successfully excised and surgical pathology was consistent with a mucous retention cyst. The patient recovered uneventfully. ■

References: 

1.Romak J, Olsen S, Koch C, Ekbom D. Bilateral vallecular cysts as a cause of dysphagia: case report and literature review. Int J of Otolaryngol. 2010;2010:697853.

2.Uzochukwu NO, Shrier DA, Lapoint RJ. Clear cell carcinoma of the base of the tongue: MR imaging findings. AJNR Am J Neuroradiol. 2007;28:127-128.

3.Alsaleh S, Al-Ammar A. Haemoptysis. A rare presentation of a vallecular cyst. Saudi Med J. 2008;29:1497-1500.

Boris Garber, DO, is an assistant professor of emergency medicine at Case Western Reserve University and an attending physician in the department of emergency medicine at the MetroHealth Medical Center.

David Effron, MD, is assistant professor of emergency medicine at Case Western Reserve University, attending physician in the department of emergency medicine at the MetroHealth Medical Center, and consultant emergency physician at the Cleveland Clinic Foundation, all in Cleveland.