Case Presentation:

This patient is a 5–week–old male with no significant past medical history who presented with lack of expected weight gain. Patient was born at 39 5/7 weeks gestation to a 23–year–old G2 P2 mother with negative serologies. Birth weight was 3.8 kg (75%), and admission weight was 3.88 kg (10%). He did not regain birth weight until 2 weeks of age and has had minimal weight gain since. He took 3–4 ounces of formula every 3–4 hours, but had feeding difficulty and nonbloody, nonbilious emesis soon after eating. Additionally, he had “noisy breathing” since discharge from the nursery at 2 days of life. Trials of various formulas and 2 weeks of acid suppression resulted in no improvement in symptoms. He had normal bowel movements 1–2 times daily, and at least four wet diapers daily. One week prior to admission, he had a normal upper GI to rule out pyloric stenosis. Patient’s physical exam upon admission was notable for weight now at 10%, length at 50%, and OFC 25%. He was thin, pale, with poor skin turgor. He had no dysmorphic features and no cleft palate. He had suprasternal retractions and intermittent stridor which was worse when lying supine. Cardiac, abdominal and neurology exams were all normal. Initial laboratory evaluation was unremarkable, including a normal complete blood count, complete metabolic panel, and thyroid studies. Newborn screen was normal. Radiologic evaluation included a normal pyloric ultrasound and a normal esophagram to rule out tracheoesophageal fistula. Patient had frequent desaturations with feedings and with lying supine to the 80 s. This finding, along with the stridor, prompted ENT consultation. They evaluated the patient with a video fiberoptic endoscopy which revealed a vallecular cyst. He was then taken to the operating room and underwent a direct laryngoscopy, rigid bronchoscopy, and excision of the vallecular cyst through marsupialization. Over the next few days, the stridor greatly improved, and his weight increased to 4.1 kg.

Discussion:

Congenital vallecular cysts are an uncommon cause of respiratory distress in infancy. Infants usually present with feeding difficulty and stridor, often in the first week of life. They also frequently have noisy breathing, respiratory distress and cyanosis. Additionally, failure to thrive can be observed as a result of these symptoms. Our patient demonstrated all of these signs and symptoms. Diagnosis is confirmed by endoscopy of the hypopharynx. Treatment involves adequate marsupialization. Often, laryngomalacia is an associated finding. Our patient, upon follow up 1 week after discharge, demonstrated laryngomalacia, but no reoccurrence of the vallecular cyst.

Conclusions:

The purpose of reporting this case is to increase pediatric hospitalists’ awareness of congenital airway anomalies as a rare but potential cause for admissions for failure to gain adequate weight, and to recognize the need for referral to ENT for treatment.

Figure 1Vallecular cyst seen on laryngoscopy.