AJR 2005; 184:793-796
© American Roentgen Ray Society
Pharyngeal Retention Cysts: Radiographic Findings in Seven Patients
Courtney A. Woodfield1,
Marc S. Levine1,
Stephen E. Rubesin1,
Igor Laufer1 and
Natasha Mirza2
1 Department of Radiology, Hospital of the University of Pennsylvania, 3400
Spruce St., Philadelphia, PA 19104.
2 Department of Otorhinolaryngology, Head & Neck Surgery, Hospital of the
University of Pennsylvania, Philadelphia, PA.
Received April 22, 2004;
accepted after revision June 14, 2004.
Address correspondence to M. S. Levine
(marc.levine{at}uphs.upenn.edu).
Abstract
OBJECTIVE. The purpose of this study was to better characterize the
radiographic features of pharyngeal retention cysts on double-contrast
pharyngograms.
CONCLUSION. Pharyngeal retention cysts typically involve the
valleculae, appearing on double-contrast pharyngograms as small, round or
ovoid, well-circumscribed, smooth-surfaced submucosal masses that are best
visualized on frontal views of the pharynx. Such features should be highly
suggestive of benign retention cysts, obviating further diagnostic workup in
asymptomatic patients. When the cysts are lobulated or completely obliterate
the valleculae, however, further evaluation by otolaryngologic examination may
be required to rule out malignant tumor in the pharynx.
Introduction
Retention cysts are the most common benign mass lesions in the pharynx,
usually involving the valleculae or the aryepiglottic folds
[1,
2]. Pathologically, these cysts
are thought to result from dilatation of mucus glands in the lamina propria or
deeper layers of the pharyngeal wall secondary to retained secretions and
chronic inflammation [1]. They
usually occur as small, asymptomatic lesions, but cysts larger than 1 cm may
cause dysphagia or respiratory symptoms, such as coughing, choking, or
aspiration, that necessitate removal of these lesions
[1–3].
Rarely, retention cysts may become ulcerated or secondarily infected
[1].
In general, benign pharyngeal lesions appear en face on
double-contrast pharyngograms as smooth submucosal masses and in profile as
hemispheric lines etched in white
[4–6].
To our knowledge, however, little data are available in the radiology
literature about the findings of pharyngeal retention cysts on double-contrast
pharyngography. Because barium examinations of the pharynx frequently are
performed as the initial diagnostic test in patients with pharyngeal symptoms,
it is important to be familiar with the radiographic appearance of pharyngeal
retention cysts and to differentiate these common benign lesions from
malignant tumors in the pharynx. We therefore performed a retrospective study
of patients with pharyngeal retention cysts on double-contrast pharyngography
to better characterize the radiographic features of these lesions.
Materials and Methods
A computerized search of radiology files at our hospital during a 5-year
period from January 1998 to December 2002 revealed 37 patients with pharyngeal
retention cysts diagnosed on double-contrast pharyngoesophagograms. Sixteen
(43%) of the 37 patients underwent subsequent otolaryngologic examinations for
direct visualization of the pharynx. The mean interval between the barium
studies and otolaryngologic examinations was 31 days (range, 1–91 days).
When patients were stratified on the basis of whether the cysts seen on barium
studies were confirmed on otolaryngologic examinations, the mean interval
between these studies for patients with cysts confirmed on endoscopy was 21
days (range, 3–44 days) versus 42 days (range, 1–91 days) for
those with cysts not confirmed on endoscopy.
According to the endoscopy reports, seven (44%) of the 16 patients had
smooth, whitish, translucent submucosal masses characteristic of fluid-filled
retention cysts on otolaryngologic examination
[7]. Pathologic correlation was
available for two of these seven lesions (one was biopsied and the other
excised), and both were proven pharyngeal retention cysts. Another patient
(6%) had a submucosal mass of uncertain origin on otolaryngologic examination.
The lesion also was excised, and pathologic examination of the resected
specimen revealed a granular cell tumor. The remaining eight patients (50%)
had a normal-appearing pharynx on otolaryngologic examination, so no biopsy
specimens were obtained. Thus, seven patients had a final diagnosis of
pharyngeal retention cysts based on the gross appearance of the lesions on
otolaryngologic examinations in all seven and the histopathologic findings in
two. The study group comprised these seven patients.
The double-contrast pharyngoesophagograms were obtained by having the
patient ingest a high-density (250% weight/volume [w/v]) barium sulfate
suspension (E-Z-HD, E-Z-EM) in lateral, frontal, and, if necessary, oblique
positions with videotape recordings obtained during swallowing and subsequent
spot images obtained during suspended respiration, phonation
("eeeee") in the lateral position, and a modified Valsalva's
maneuver in the frontal position. Unless marked aspiration of high-density
barium was observed, the patient subsequently was asked to swallow a
low-density (50% w/v) barium sulfate suspension (Entrobar, Lafayette
Pharmaceutical) and a barium paste or barium-impregnated food substances such
as cookies or crackers. Depending on the patient's condition and clinical
history and the findings on the initial portion of the swallowing study, some
patients ingested additional high-density barium (E-Z-HD) in the upright, left
posterior oblique position or low-density barium (Entrobar) in the prone,
right anterior oblique position for double-contrast or single-contrast views
of the esophagus. The pharyngoesophagograms were obtained with digital
fluoroscopy equipment (Diagnost 76 Plus, Philips). All of the examinations
were performed by radiology residents or fellows or by one of three attending
gastrointestinal radiologists, and all were interpreted by the attending
gastrointestinal radiologists.
The original radiology reports and images from the double-contrast
pharyngoesophagograms in these seven patients were reviewed jointly by two
gastrointestinal radiologists to determine the location and morphologic
features of these lesions, including size, shape (round vs ovoid or other
shape), contour (smooth vs nodular or ulcerated), and borders (well
circumscribed vs poorly circumscribed). The images were also evaluated for the
presence of other pharyngeal findings, including aspiration or other
morphologic or functional abnormalities in the pharynx, or esophageal
findings, including hiatal hernias, gastroesophageal reflux, reflux
esophagitis, and esophageal dysmotility.
Medical records were also reviewed to determine the clinical presentation.
The pharyngoesophagograms for the eight patients with normal otolaryngologic
examinations and the one patient with a granular cell tumor of the pharynx
were also reviewed.
Our institutional review board approved all aspects of this retrospective
study and did not require informed consent for patients whose radiographic
images or medical records were included in our study.
Results
Clinical Findings
All seven patients with pharyngeal retention cysts were women. The mean age
of the patients was 51 years (range, 40–72 years); six patients were 55
year old or younger. Six patients presented with dysphagia that began a mean
of 5 weeks (range, 2–8 weeks) before presentation. The remaining patient
presented with a globus sensation and throat irritation of 3 weeks' duration.
Two patients (29%) had findings of reflux laryngitis on otolaryngologic
examinations.
Radiographic Findings
The seven pharyngeal retention cysts appeared on double-contrast
pharyngograms as ovoid (n = 6) or round (n = 1) submucosal
masses with a smooth contour in five cases (Figs.
1A,
1B,
2, and
3) and a lobulated contour in
two (Fig. 4). The lesions had a
mean size of 1 cm (range, 0.3–1.6 cm). The cysts were well circumscribed
in five cases and poorly circumscribed in two. The cysts involved the
valleculae in five cases (left, n = 2; right, n = 3) (Figs.
1A,
1B,
2, and
4), right piriform sinus in
one, and right aryepiglottic fold in one
(Fig. 3). Two (40%) of the five
vallecular cysts partially (n = 1) or completely (n = 1)
obliterated the underlying vallecula and the cyst protruded from the superior
border of this structure, which no longer filled with barium (Figs.
1A and
2). All of the cysts were seen
best on frontal views of the pharynx, and four (57%) were seen only on the
frontal views (Fig. 2).
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Fig. 1B. —72-year-old woman with pharyngeal retention cyst. Lateral view from
double-contrast pharyngogram also shows submucosal mass etched in white
(arrows) protruding superiorly from vallecula.
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Fig. 2. —52-year-old woman with pharyngeal retention cyst. Frontal view from
double-contrast pharyngogram shows smooth submucosal mass (arrows)
partially obliterating left vallecula. No definite lesion was seen in
vallecula on lateral view from same examination (not shown).
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Fig. 3. — 47-year-old woman with pharyngeal retention cyst. Frontal view from
double-contrast pharyngogram shows small submucosal lesion etched in white
(arrow) on right aryepiglottic fold. This was smallest pharyngeal
retention cyst in our series.
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Fig. 4. —52-year-old woman with pharyngeal retention cyst. Frontal view from
double-contrast pharyngogram shows large, slightly lobulated submucosal mass
etched in white (arrows) in right vallecula.
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Six patients (86%) had normal swallowing function, and one (14%) had mild
laryngeal penetration during swallowing. Similarly, six patients (86%) had
normal esophageal motility, and one (14%) had mild esophageal dysmotility with
intermittent nonperistaltic contractions. Gastroesophageal reflux was reported
in five (71%) of the seven patients. Three patients (43%) had hiatal hernias,
and two (29%) had reflux esophagitis on double-contrast esophagograms.
The pharyngeal lesions in the eight patients with normal otolaryngologic
examinations were all round or ovoid with a smooth surface and
well-circumscribed margins. The mean size of these lesions was 0.5 cm (range,
0.3–1.0 cm). These lesions involved the valleculae in seven cases and
the left piriform sinus in one.
The one patient with a granular cell tumor of the pharynx had a 1-cm
smooth, ovoid, well-circumscribed mass involving the right piriform sinus that
was seen best on frontal views of the pharynx
(Fig. 5).
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Fig. 5. —24-year-old woman with granular cell tumor. Frontal view from
double-contrast pharyngogram shows smooth submucosal mass etched in white
(arrows) in right piriform sinus. This lesion is indistinguishable
from retention cyst on basis of radiographic findings. Dilatation of proximal
esophagus above midesophageal stricture (not shown) caused by previous
ingestion of potassium chloride tablets was also noted.
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Discussion
Pharyngeal retention cysts are benign lesions with no risk of malignant
degeneration [1]. Nevertheless,
it is important for radiologists to be familiar with the appearance of these
lesions so they are not mistaken for malignant tumors in the pharynx. The
ability to identify characteristic radiographic features of pharyngeal
retention cysts therefore could lead to a decreased number of unnecessary
otolaryngologic examinations for biopsy or excision of the cysts, particularly
if affected individuals have no symptoms referable to these lesions.
All of the pharyngeal retention cysts in our patients involved the
valleculae or, less frequently, the piriform sinuses or aryepiglottic folds.
The lesions typically appeared on double-contrast pharyngograms as small,
round or ovoid, well-circumscribed, smooth-surfaced submucosal masses etched
in white that were best visualized on frontal views of the pharynx (Figs.
2 and
3). Such features should be
highly suggestive of benign retention cysts, obviating further diagnostic
workup unless symptoms are severe enough to warrant drainage or excision of
the cysts. In some cases, however, these cysts were lobulated
(Fig. 4) or completely
obliterated the underlying vallecula (Fig.
1A), findings that necessitate further evaluation by
otolaryngologic examination to rule out malignant tumor in this region. Thus,
radiologists should recognize that not all retention cysts have the classic
radiographic features of benign pharyngeal lesions.
The differential diagnosis for smooth, well-circumscribed submucosal masses
in the pharynx includes other uncommon benign neoplasms such as granular cell
tumors, lipomas, neurofibromas, chondromas, papillomas, hamartomas, and
oncocytomas [2,
5,
8,
9]. In our study, one patient
had a granular cell tumor that was indistinguishable from a pharyngeal
retention cyst on the basis of the radiographic findings
(Fig. 5). However, some
patients with granular cell tumors of the pharynx have associated granular
cell tumors in the esophagus or stomach
[10]. In other cases, the
correct diagnosis may be suggested by the clinical history, as in patients
with known neurofibromatosis or squamous papillomatosis. Another potentially
helpful finding is the location of the lesion: For example, pharyngeal
chondromas typically arise from the cricoid cartilage
[2,
5], whereas retention cysts
tend to involve the valleculae.
In our series, eight (50%) of the 16 pharyngeal retention cysts diagnosed
on double-contrast pharyngograms were not described on the reports from the
otolaryngologic examinations. It is well recognized that endoscopy may fail to
reveal small pharyngeal retention cysts because of their predominantly
submucosal origin and normal overlying mucosa
[2,
11]. Alternatively, some of
the cysts visualized on otolaryngologic examinations may not have been
mentioned in the endoscopy reports because of the general perception that
these lesions are not clinically important. Also, patients with cysts seen on
barium studies but not on endoscopy had a longer mean interval between these
examinations than those with cysts that were seen on endoscopy (42 days vs 21
days), raising the possibility that some of the lesions may have resolved
spontaneously before the otolaryngologic examinations were performed. To our
knowledge, however, spontaneous resolution of pharyngeal retention cysts has
not been described previously. Finally, one or more of the eight lesions
detected on barium studies that were not confirmed on otolaryngologic
examinations could have represented false-positive radiographic findings.
Whatever the explanation, our study is limited by a lack of pathologic
correlation in many of the patients with pharyngeal retention cysts diagnosed
on double-contrast pharyngography.
The presence or absence of symptoms in patients with pharyngeal retention
cysts or other benign pharyngeal masses is directly related to the size and
location of these lesions. In general, cysts smaller than 1 cm are less likely
to cause symptoms than those larger than 1 cm
[1]. However, cysts arising on
the aryepiglottic folds may cause dysphonia or respiratory symptoms regardless
of size, and cysts involving the valleculae, epiglottis, or aryepiglottic
folds may cause coughing, choking, or dysphagia
[2]. Cysts involving the
valleculae or epiglottis may also produce a globus sensation, and rarely,
pedunculated cysts may even occlude the larynx
[5]. Although six (86%) of the
seven patients in our series presented with dysphagia, only two of these
patients had cysts larger than 1 cm. In the remaining four patients with cysts
1 cm or smaller, the cysts may have been detected as fortuitous findings
unrelated to the dysphagia in these individuals.
In general, there is no reason to resect small pharyngeal retention cysts
that are not causing symptoms. However, larger cysts or those causing
dysphagia or other symptoms can be incised and drained with excellent results
[12]. Although it is not
always possible to remove the entire lesion, recurrence of the cysts after
complete or partial excision is rare
[3,
13].
In conclusion, pharyngeal retention cysts typically involve the valleculae,
appearing on double-contrast pharyngograms as small, round or ovoid,
well-circumscribed, smooth-surfaced submucosal masses that are best visualized
on frontal views of the pharynx. Such features should be highly suggestive of
benign retention cysts, obviating further diagnostic workup in asymptomatic
patients. When the cysts are lobulated or completely obliterate the
valleculae, however, further evaluation by otolaryngologic examination may be
required to rule out malignant tumor in the pharynx. It is important to
differentiate pharyngeal retention cysts from malignant tumors on the basis of
the radiographic findings because double-contrast pharyngography frequently is
performed as the initial diagnostic test in these patients.
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Abstract
Introduction
