Mucus Retention Cyst

A mucus retention cyst forms when one of the mucus glands just below the vocal cord’s free margin becomes plugged. Mucus glands in this location secrete mucus in order to bathe and lubricate the vocal cords, but if a gland becomes obstructed, then the mucus it produces gets trapped and accumulates, leading to a mucus retention cyst. They typically occur without any correlation to vocal overuse, in contrast to epidermoid cysts as well as nodules and polyps.

Symptoms

A mucus retention cyst can cause hoarseness, because it interferes with the normal vibrations of the vocal cords and the accuracy of their match with each other (see the videos below). The cyst is most often unilateral—that is, occurring on one cord but not the other. It appears as a bulge or deformation of the vocal cord’s free margin, and sometimes undersurface, and it may be yellowish in color.

Treatment

The cyst may be surgically removed, by creating a small incision on the vocal cord and then dissecting the cyst from the cord. Photos of the surgical process can be found below. Also, the two videos below show how removing this kind of cyst can improve the voice.

Excision of a Mucus Retention Cyst that Decompresses during Dissection

This man has had slight hoarseness for many years, possibly related to his self-described highly talkative and loud-spoken nature. His voice took a significant turn for the worse soon after a bout of mild laryngitis, and had remained extremely hoarse for many months.

An ENT doctor diagnosed a polyp of his left vocal cord.  Instead, this represents a mucus retention cyst. Removal provided dramatic return of clear speaking voice. Seen below is preop, intra-operative sequence, and then the result at 3 months after surgery.

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Mucus retention cyst (1 of 17)

When viewed at a distance, the left vocal cord lesion (right of photo) could be mistaken for a polyp, especially knowing that this man is a “vocal overdoer.”

Closer look (2 of 17)

At closer range, the white-yellow spherical submucosal mass is recognizable.

Cyst under narrow band light (3 of 17)

Under narrow band light, additional evidence of the spherical submucosal mass is gained.

Cyst interferes with phonation (4 of 17)

During phonation, marked interference with match and vibratory flexibility of the left cord is seen.

Surgical view (5 of 17)

Intraoperatively, initial view. Note that the overlying mucosa is gossamer-thin, like a dragonfly’s wing.

After infiltration (6 of 17)

After infiltration of lidocaine and epinephrine, partly for hemostasis but even more so for “hydrodissection” and to reveal more clearly where the overlying mucosa is adherent.

Lifting the mucosa (7 of 17)

An incision has been made and the dissector is between the extraordinarily thin mucosa and cyst wall (see dotted line)

Dissecting cyst from deep attachments (8 of 17)

The dissector is peeling the cyst from its deeper attachments to the vocal ligament.

Cyst has ruptured and emptied (9 of 17)

As often happens with a mucus retention cyst, the cyst has ruptured, spilling its contents, but the sac has been sufficiently dissected from both overlying mucosa and vocal ligament that its outline is still visible (see dotted line).

Dissection of empty sac (10 of 17)

Dissection of the decompressed sac from normal cord structures continues…

Flaps retract (11 of 17)

The exceedingly thin flap retracts on itself; there is no good way to stretch it across the empty space where the cyst had been, to meet the lateral flap.

Voice is virtually normal at 3 months (12 of 17)

At 3 months postop, speaking voice can pass for normal and falsetto is even clear. The left cord (right of photo) is still a bit inflamed (prominent capillaries) due to its recent surgical disturbance.

Evidence of vibration, standard light (13 of 17)

Producing voice under standard light, vibratory blurring seems to be present bilaterally.

Open phase at E3 (14 of 17)

Under strobe light, open phase of vibration at E3 (165 Hz).

Closed phase at E3 (15 of 17)

Closed phase of vibration, also at E3 (165 Hz).

Open phase at A4 (16 of 17)

Open phase of vibration at (falsetto) A4 (440 Hz)

Closed phase at A4 (17 of 17)

Closed phase of vibration also at A4 (440 Hz).

Removal of Mucus Retention Cyst, Still Intact

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Mucus retention cyst (1 of 8)

Surgical view of left vocal cord mucus retention cyst in a middle-aged business woman without any history of voice overuse. This cyst has resulted from a plugged mucus gland.

Injection in Reinke’s space (2 of 8)

Reinke’s space (the submucosa) has been infiltrated with 1% lidocaine and epinephrine for hydrodissection and hemostasis.

Incision begins (3 of 8)

The cyst wall and overlying mucosa are both the thickness of a dragonfly wing. The diameter of this cyst is estimated to be 4 mm. It contains retained mucus. The incision must always be longer than the diameter of the cyst.

Removal of cyst (4 of 8)

A left-curved forceps is holding the cyst as it comes away from the cord.

Removal nearly complete (5 of 8)

The cyst is almost free, with a tiny amount of the gossamer overlying mucosa that was tightly adherent.

Cyst is removed (6 of 8)

Only the incision remains, and the mucosa dissected from the cyst retracts. The key to understanding the result will be the postoperative voice and vibratory ability of this operated vocal cord.

Post-op (7 of 8)

At the time of this examination, 2 months postoperatively, the patient considers his voice to be normal. Here, he is producing F4 (349Hz) under strobe light (closed phase).

Open Phase (8 of 8)

Open phase of vibration, demonstrating full mucosal flexibility.

Removal of Mucus Retention Cyst

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Mucus retention cyst (1 of 7)

Mucus retention cyst of right vocal cord. Yellowish spherical mass shines through overlying mucosa. This was causing the patient severe hoarseness. Incision to enter the cord at dotted line.

Xylocaine prepares for removal (2 of 7)

After infiltration of 1% xylocaine with epinephrine. This provides “hydrodissection;” it expands the tissue planes; and diminishes bleeding via vasoconstriction.

Removal of Cyst (3 of 7)

At anterior curve of the cyst, left-turning scissors are dissecting at the layer between cyst wall and its attachments.

Removal of cyst (4 of 7)

At posterior attachment of cyst, dissection with curbed scissors.

Removal of Cyst (5 of 7)

Cyst dissected nearly free.

Voice immediately improves (6 of 7)

After cyst’s removal. The patient’s voice sounded virtually normal in the recovery room, though upper voice still abnormal.

4mm Cyst (7 of 7)

Intact cyst, measures about 4mm in diameter.

Example 2

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Injecting Xylocaine (1 of 5)

The physician injects xylocaine with epinephrine into the tissue before surgery, so as to inhibit bleeding and to cause some of the layers of tissue to expand and spread apart (hydrodissection).

Hydrodissection effect (2 of 5)

The hydrodissection effect of the injection is now visible

Removal of cyst (3 of 5)

The incision has been made. Now, curved scissors (pointing downward) release the cyst’s anterior attachment.

Removal of cyst (4 of 5)

The cyst is now almost fully released from the vocal cord.

Cyst is gone! (5 of 5)

Removal completed. The line of incision is visible.

Mucus-Retention Cyst—not Polyp—Before and After Removal

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Mucus-retention cyst (1 of 5)

This person has chronic hoarseness, without prior illness or voice overuse. The explanation is this left-sided mucus-retention cyst (right of photo). The next photo shows more clearly how we know this is a cyst and not a polyp.

Below the margin (2 of 5)

This photo is under a strobe light during the open phase of vibration and dotted line shows the free margin of the cord. It shows that the swelling originates from below this free margin, common for mucus-retention cysts. The two solid lines show the incision line options for planned dissection and removal of this cyst. Here the medial one (on the cyst) was chosen, as seen in the next photo.

One week post-op (3 of 5)

A week after incision and dissection and removal of the cyst. You can see the incision line at the dotted line.

Better medializtion (4 of 5)

Closed phase of vibration at E5 shows perfect match of the margins.

Better flexibility (5 of 5)

Open phase of vibration at same pitch shows that both cords make lateral excursions, confirming lack of stiffness and scarring due to the incision and dissection being below most of the vibrating part of the mucosa.
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Mucus Retention Cyst: Before and After

Watch this video to see images and hear audio of a mucus retention cyst’s effect on the vocal cords, followed by the surgical removal and the post-surgical results.

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Mucus Retention Cyst II: Before and After

Another example of a mucus retention cyst, with images and audio before, during, and after the cyst’s surgical removal. This video highlights a bit more of the vocal capability battery.

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