Tornwaldt cyst

Considerations

• • See Considerations for Nasopharyngeal mass page

  • Definition

  • a benign cyst consisting of outpouching of ectoderm into the pharyngobasilar fascia

  • Pathophysiology

    • A persistent communication between the roof of the nasopharynx and the notochord due to from a potential space developing in the nasopharynx at the point where the notochord retains its union with the pharyngeal ectoderm 

    • When this epithelial lined pouch secrets mucus, it leads to the cyst formation

• Etiology theories (2011: Tornwaldt Cyst: A Cause of Neck Pain and Stiffness)

  • • Congenital 

• • Mucus production may be spontaneous 

  • Mucous production may be secondary to inflammation. During inflammation there is edema of the orifice of pharyngeal diverticula which leads to formation of a cyst

  • Nasopharyngeal surgical procedures, i.e. adenoidectomy may lead to damage of the pharyngeal duct orifice and subsequent infection

  • Presentation 

    • History

      • Usually asymptomatic 

      • Nasal obstruction

      • Postnasal drainage 

      • Halitosis and Cacogeusia, if infected 

      • Hearing impairment from ET orifice obstruction and middle ear effusion

    • Exam

    • Yellowish, smooth mucosal covered round lesion in the superior, posterior midline NP

• Imaging 

• • Radiopaedia: Tornwaldt cyst 

  • Treatment 

    • Treatment is not always necessary 

  • Aspiration leads to recurrence 

    • If indicated, surgical biopsy followed by excision or marsupialization are preferred 

  • 2006: Thornwaldt's cyst and surgery with powered instrumentation

    • • When the lesion is large, symptomatic or close to the Eustachian tube torus:

        • Marsupialization is preferred

    • For small lesions

      • endonasal approach is recommended

    • For large lesions

      • transoral retrovelar approach using a 70 degree telescope

    • The powered instrumentation with a specific blade for adenoid resection permits large marsupialization with minimal trauma and bleeding and excellent postoperative results

  • 2013: Thornwaldt cyst - treatment with diode laser

    • • Precise, minimal thermal injury, adequate hemostasis 

    • Transoral coblation with the curved mirror is another conceivable option

Preparation

• • Standard FESS setup

  • Microdebrider

Procedure

• • Transnasal endoscopic biopsy and marsupialization 

Post-op

High-Yield

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