Hypopharyngeal cysts are benign lesions of the upper aerodigestive tract, but their location makes them disproportionately dangerous. The hypopharynx sits immediately behind the larynx, and in young children the supraglottic airway is only millimeters wide. A cyst that would be a harmless curiosity in an adult can encroach on that slender channel with alarming speed. Reported lesions in this region include retention cysts, ductal cysts, foregut duplication cysts, bronchogenic cysts, and other epithelial-lined structures, each with distinct embryological origins but a shared capacity for airway compromise. Small cysts are usually asymptomatic; larger ones typically announce themselves gradually with stridor, feeding difficulties, dysphagia, voice changes, or recurrent respiratory infections.

What makes this case striking is the absence of any such warning signs. According to the clinical team, the child had been entirely well the previous evening. On the morning of presentation she developed breathing difficulty and throat pain, accompanied by a low-grade fever that was never formally documented. There was no history of foreign body aspiration, no prior episodes of stridor or dysphonia, no swallowing problems, and no recurrent chest infections. On examination she was alert, pink, and hemodynamically stable, with a patent airway at rest—but dynamic inspection of the oropharynx revealed a translucent, smooth, bulging lesion that became visible in the posterior pharyngeal wall during swallowing, hinting at positional variability that would prove mechanistically important.

Flexible nasopharyngolaryngoscopy provided the pivotal diagnostic clue. The endoscope showed a well-defined, translucent, fluid-filled cystic mass situated directly above the laryngeal inlet, narrowing the supraglottic airway while leaving the overlying mucosa intact. Dynamic assessment confirmed preserved vocal cord mobility, an important finding that argued against invasive or malignant disease. The precise anatomical origin of the cyst—whether from the hypopharyngeal wall, the posterior surface of the epiglottis, or an adjacent mucosal fold—could not be pinned down at the bedside, a limitation imposed by the child’s age and limited cooperation. That uncertainty made cross-sectional imaging essential before any surgical planning could proceed.

Contrast-enhanced computed tomography of the neck delivered three decisive pieces of information. First, it characterized the lesion: a homogeneously hypodense, thin-walled cyst approximately two centimeters in greatest diameter, without internal enhancement, septations, solid components, or calcifications—imaging features classic for a benign epithelial or retention cyst. Second, it mapped the anatomy, showing anterior displacement of the supraglottic structures with narrowing of the airway lumen and confirming the lesion’s extrinsic relationship to the laryngeal framework across multiplanar reformats. Third, it excluded alternatives with far more complex surgical implications, including vascular malformations, thyroglossal duct cysts, and malignancy. No lymphadenopathy or bony abnormality was identified.

With the diagnosis provisionally established, a multidisciplinary team of pediatric emergency physicians and otolaryngologists opted for temporizing conservative management rather than emergency surgery. The child was admitted for close airway monitoring and placed in the lateral decubitus position—a deceptively simple intervention with a sound biomechanical rationale. In the supine position, gravity pulls a hypopharyngeal lesion directly over the laryngeal inlet, a phenomenon well documented in the vallecular cyst literature; lateral positioning reduces that gravitational vector toward the glottis. She was kept nil per os in anticipation of surgery and received intravenous dexamethasone to reduce peri-lesional mucosal edema, nebulized adrenaline to attenuate airway swelling, and nebulized budesonide as an adjunctive anti-inflammatory agent. Throughout the observation period she remained stable, with no deterioration in respiratory status.

The following day, surgeons performed complete transoral excision under general anesthesia. With the neck extended to optimize laryngoscopic access and pharyngeal packing in place to protect the lower airway, direct laryngoscopy revealed the cystic mass nestled between the base of the tongue and the posterior tonsillar pillar region. The lesion was well encapsulated with a smooth outer surface and, critically, was removed intact with cold instruments—without entry into the cyst cavity. Complete removal of the entire cyst wall is the surgical goal in such cases, because residual epithelial lining is the principal substrate for recurrence. The child remained vitally stable throughout the procedure.

Histopathology settled the question of what the cyst actually was. The excised specimen, measuring approximately 2.5 by 2 centimeters, showed a wall of fibrovascular connective tissue infiltrated by reactive inflammatory cells. The lining was a mosaic: non-keratinized stratified squamous epithelium in some areas and respiratory-type columnar epithelium in others, a pattern consistent with a simple epithelial cyst arising at the transitional zones where these two mucosal types meet physiologically in the hypopharynx. No cytological atypia, dysplasia, or malignancy was found, and cytology of the cyst fluid showed only reactive inflammatory and scattered squamous cells. The inflammatory infiltrate within the wall also lent support to an intriguing hypothesis about why the lesion decompensated so abruptly: retention cysts may enlarge acutely when inflammation obstructs their drainage orifice, a mechanism analogous to an acutely infected epidermal inclusion cyst. That would explain how a lesion that presumably existed quietly for some time could suddenly threaten the airway after a trivial febrile illness.

The recovery was uneventful. The child tolerated oral fluids, progressed to a soft diet, and was discharged on oral antibiotics. At follow-up two weeks later she was entirely well, and at five months she remained asymptomatic with no evidence of recurrence. The authors acknowledge the limits of that follow-up window—five months cannot speak to very long-term recurrence rates—and note that the precise developmental origin of the cyst, whether from minor salivary gland tissue, respiratory epithelial rests, or obstructed mucosal glands, cannot be determined with certainty from the histology alone. They also emphasize that the entire evidence base for pediatric hypopharyngeal cysts rests on isolated case reports and small series, which constrains how far generalizable recommendations can stretch.

The broader lesson is one of diagnostic humility in pediatric airway emergencies. Children presenting with apparent croup or acute epiglottitis who fail to respond as expected to conventional pharmacotherapy should prompt consideration of a cystic lesion, the authors argue, particularly when the onset is abrupt in a child with no antecedent airway history. The case also illustrates a rational division of labor between diagnostic tools: flexible endoscopy for immediate, dynamic, bedside characterization of the lesion and its effect on the airway, and contrast-enhanced CT for anatomical mapping, benignity assessment, and exclusion of dangerous mimics—provided the child is stable enough to undergo scanning. When conservative positional and pharmacological measures can temporize the obstruction, surgery can be elective rather than desperate, and complete transoral excision under general anesthesia remains safe, technically feasible, and curative in the majority of reported cases. For clinicians, the message is that even a lesion with no warning signs at all can sit silently above a toddler’s vocal cords until the night it suddenly does not.

Subject of Research: A pediatric case of acute airway obstruction caused by a rare simple epithelial hypopharyngeal cyst, diagnosed with endoscopy and CT and treated by transoral excision.

Article Title: Simple Epithelial Hypopharyngeal Cyst Presenting as Acute Airway Obstruction in a Three‐Year‐Old Child: A Case Report and Literature Review

Article References: Noori, F., Salahat, S., Salous, A., Thabet, T. M., Nazzal, K., & Daghlas, A. (2026). Simple Epithelial Hypopharyngeal Cyst Presenting as Acute Airway Obstruction in a Three‐Year‐Old Child: A Case Report and Literature Review. Clinical Case Reports, 14(10), Article e73666. https://doi.org/10.1002/ccr3.73666

Image Credits: AI Generated

DOI: 10.1002/ccr3.73666

Keywords: hypopharyngeal cyst, pediatric airway obstruction, stridor, nasopharyngolaryngoscopy, contrast-enhanced CT, transoral excision, supraglottic lesion, retention cyst, histopathology, otolaryngology, case report, airway management