Unanticipated difficult intubation caused by vallecular cyst managed in an unconventional yet easy way

Abstract

Vallecular cysts are rare entities in adults and are often asymptomatic. Although rarely life-threatening, they pose an airway challenge when discovered incidentally. There is no technique that has been described in literature that is absolutely conclusive regarding the airway management in cases of vallecular cysts. We report a case of an asymptomatic vallecular cyst encountered in an adult male scheduled for laparoscopic cholecystectomy under general anaesthesia using ProSeal laryngeal mask airway (LMA). Despite selecting the proper size of ProSeal LMA and its correct placement, the patient could not be ventilated. Hence, endotracheal intubation was performed to maintain a patent airway. Direct laryngoscopy revealed a cyst measuring 2 cm × 2 cm at the base of the tongue completely obscuring the glottis. Fibreoptic bronchoscope-guided intubation was planned. The operating table was tilted to the left and direct laryngoscopy repeated after applying rightward external laryngeal manipulation. Cormack-Lehane Grade 3a was obtained allowing the passage of a bougie over which a 7.0 mm ID endotracheal tube was railroaded. The rest of the perioperative period was uneventful, and the patient was extubated without any problem.