City University of New York (CUNY) School of Medicine, New York, USA.
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Otolaryngology-Head and Neck Surgery, Hempstead, NY, USA; Cohen Children's Medical Center, Division of Pediatric Otolaryngology, New Hyde Park, NY, USA.
Int J Pediatr Otorhinolaryngol. 2022 Nov;162:111293. doi: 10.1016/j.ijporl.2022.111293. Epub 2022 Aug 27.
It is thought that many infants have a prominent venous plexus of the postcricoid area. In the past this entity had occasionally been reported as a postcricoid hemangioma or even a postcricoid mass. The term postcricoid cushion is now gaining acceptance to describe the prominent venous plexus of the posterior cricoid area. Although it rarely causes symptoms, it should be considered when patients present with symptoms of obstruction. Differentiating between normal variant postcricoid prominent venous plexuses, hemangiomas, and vascular malformations can be difficult and cannot be confirmed without immunohistochemistry. The objective of this systematic review is to describe current practices, clinical symptoms, management and outcomes of pediatric postcricoid lesions including postcricoid cushion.
A systemic review of the literature was done using the PRISMA (Preferred Reporting Items for Systemic Reviews and Meta-Analyses) guidelines to investigate postcricoid lesions. The following terms: Postcricoid, Postcricoid lesions, Postcricoid mass, Posterior cricoid, Pressure-dependent postcricoid mass, postcricoid prolapse, postcricoid hemangiomas, postcricoid vascular malformations, and postcricoid cushion were searched in PubMed and Google Scholar. Articles that were within the inclusion criteria were reviewed. Demographics, past medical and birth histories, clinical symptoms, evaluations, biopsy results, treatments, and outcomes were included. For the purposes of this review, postcricoid cushions, pressure-dependent postcricoid mass, and postcricoid prolapse will be group under normal variant postcricoid cushion.
15 articles with 42 distinct cases were included in this systemic review. 21/42 of the patients were female, the age ranged from 2 days to 18 years, the median age was 6.5 months, and 39/42 of patients were under the age of 2 years. 17/42 patients were diagnosed "hemangiomas" in the papers with only 1 case confirming the diagnosis of hemangioma with immunohistochemistry. 7/42 were diagnosed vascular malformations with 3 cases confirming the diagnosis of with immunohistochemistry. 17/42 of cases were normal variant postcricoid cushions. Most commonly, patients had a history of laryngomalacia (14/33) followed by no other medical history (9/33). The most common clinical symptoms were stridor, dysphonia, or weak cry in 30/42, dysphagia in 20/42, sleep disordered breathing in 9/42, and regurgitation or aspiration in 9/42.8/38 of patients diagnosed with postcricoid cushion did not have visualization of the lesion until a Valsalva maneuver was performed. The most common management for "hemangiomas" was observation (8/17), for "vascular malformations" was laser therapy (3/7), and for normal variant postcricoid cushions was observation (8/17). The most common outcome was complete resolution (14/30) followed by improvement of symptoms (9/30), and residual complications (4/30) The median time to follow-up was 12 months.
Due to the relatively new "discovery" of the normal variant postcricoid cushion, including postcricoid cushion, pressure-dependent postcricoid mass, and postcricoid prolapse, the majority of the literature are case reports. Although it is theorized that many children under the age of 2 have a prominent venous plexus, in some cases it could cause symptoms of obstruction. Because immunohistochemistry is rarely done and reported in the literature, many case reports may have misdiagnosed the postcricoid lesions. Also, in many cases visualizing the normal variant postcricoid cushion requires that the patients have increased intrathoracic pressure; therefore, if no postcricoid prominence is seen initially or when the patient is under general anesthesia and a postcricoid lesion is suspected, the patient should receive a Valsalva maneuver or be placed in Trendelenburg position. Most cases of normal variant postcricoid cushions can be managed with observation. Due to the rarity and novelty of the discovery, more research needs to be done on the management of symptomatic postcricoid lesions and differentiating between normal variants and pathological vascular lesions.
人们认为许多婴儿的会厌后区有明显的静脉丛。过去，这种实体偶尔被报道为会厌血管瘤，甚至是会厌肿块。现在，人们越来越接受“会厌垫”这个术语来描述会厌后区明显的静脉丛。尽管它很少引起症状，但当患者出现梗阻症状时，应考虑到它的存在。区分正常变异的会厌后区明显静脉丛、血管瘤和血管畸形可能很困难，如果没有免疫组织化学检查，就无法确诊。本系统综述的目的是描述包括会厌垫在内的小儿会厌病变的当前治疗方法、临床症状、管理和结局。
使用 PRISMA（系统评价和荟萃分析的首选报告项目）指南对文献进行系统综述，以调查会厌病变。在 PubMed 和 Google Scholar 中搜索了以下术语：会厌、会厌病变、会厌肿块、会厌后、压力依赖性会厌肿块、会厌后脱垂、会厌血管瘤、会厌血管畸形和会厌垫。综述了符合纳入标准的文章。纳入了人口统计学、既往病史和出生史、临床症状、评估、活检结果、治疗和结局等信息。为了本综述的目的，会厌垫、压力依赖性会厌肿块和会厌后脱垂将被归类为正常变异的会厌垫。
本系统综述共纳入了 15 篇文章，其中 42 例病例。42 例患者中，21 例为女性，年龄范围为 2 天至 18 岁，中位年龄为 6.5 个月，42 例患者中有 39 例年龄在 2 岁以下。在报道中，17 例被诊断为“血管瘤”，但只有 1 例通过免疫组织化学检查确诊为血管瘤。7 例被诊断为血管畸形，其中 3 例通过免疫组织化学检查确诊。17 例为正常变异的会厌垫。最常见的病史是会厌软骨软化症（14/33），其次是无其他病史（9/33）。最常见的临床症状是 30/42 例有喘鸣，20/42 例有声音嘶哑或哭声微弱，9/42 例有睡眠呼吸障碍，9/42 例有反流或误吸。8/38 例诊断为会厌垫的患者直到行瓦尔萨尔瓦动作后才发现病变。“血管瘤”最常见的治疗方法是观察（8/17），“血管畸形”最常见的治疗方法是激光治疗（3/7），正常变异的会厌垫最常见的治疗方法是观察（8/17）。最常见的结局是完全缓解（14/30），其次是症状改善（9/30），和残留并发症（4/30）。中位随访时间为 12 个月。
由于正常变异的会厌垫（包括会厌垫、压力依赖性会厌肿块和会厌后脱垂）是一个相对较新的“发现”，大多数文献都是病例报告。尽管理论上认为许多 2 岁以下的儿童有明显的静脉丛，但在某些情况下，它可能会引起梗阻症状。由于免疫组织化学检查很少在文献中报道，许多病例报告可能误诊了会厌病变。此外，在许多情况下，要观察到正常变异的会厌垫，需要患者有增加的胸腔内压力；因此，如果最初没有看到会厌突出，或者当患者在全身麻醉下并且怀疑会厌有病变时，应让患者行瓦尔萨尔瓦动作或采取特伦德伦堡体位。大多数正常变异的会厌垫可以通过观察来治疗。由于这一发现的罕见性和新颖性，需要对有症状的会厌病变的管理以及区分正常变异和病理性血管病变进行更多的研究。
