History
With the advent of improved antenatal diagnosis, many infants are identified prior to the development of symptoms. Note the following:
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Chest pain and dysphagia are the most common symptoms in adults with bronchogenic cysts.
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Recurrent infections may be the clinical presentation in some children
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In infants, symptoms are most often produced as a result of airway or esophageal compression.
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Superior vena cava syndrome, tracheal compression, pneumothorax, pleurisy, and pneumonia were reported in a series of 30 adult patients. [10]
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Intra-abdominal cysts are rare. As with the mediastinal variety, most are asymptomatic; however, hemorrhage, infection, and compression of adjacent structures can be observed.
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The presence of symptoms is important in preoperative assessment because symptomatic patients are more likely to have perioperative difficulties.
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In 1995, Ribet and colleagues reported that 70.8% of children were symptomatic because 75% of the cysts were in a critical area around the level of the carina. [9] Approximately 60% of adults in this series were symptomatic, and 53% of those mediastinal cysts were at or above the carina.
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Limaiem et al reported 33 cases of bronchogenic cysts and identified 4 categories of presentation: asymptomatic 6%; general symptoms including anorexia, weight loss, and fever; respiratory symptoms including chest pain, hemoptysis, cough, and dyspnea; and other symptoms including dysphagia and back pain. [6]
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Jiang et al reported on 16 pediatric cases of bronchogenic cyst. Of those with palpable lesions in the neck or on the skin, only one was symptomatic (mild stridor). In the remaining eight cases, seven were located in the mediastinum and one was pulmonary; 75% of these children were symptomatic. These findings were in contrast to the 23 adults studied where 56% of the overall adult group were asymptomatic. [11]
Physical Examination
Location is more important than cyst volume in its association with symptoms of compression.
Signs of airway compression are more frequently observed in infants and small children than in adults and may include cough, wheeze, dyspnea, and respiratory distress.
Secondary infection of the cyst may occur and may present with fever and respiratory symptoms.
Gastric symptoms, including abdominal pain may be observed. Peptic ulceration may be identified in cysts containing gastric mucosa.
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Plain chest radiograph showing a left paraspinal mass. Photo courtesy of A Fruauff, MD.
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Esophagogram shows an anterior and lateral mass effect in the distal portion of the esophagus corresponding to the paraspinal mass (see the radiographic image above). Photo courtesy of A Fruauff, MD.
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Chest CT scan shows an increased soft tissue density in the left paraesophageal area. Photo courtesy of A Fruauff, MD.
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The left side shows a low-power view of a bronchogenic cyst showing cartilage and smooth muscle within the wall and the cyst lined by ciliated columnar epithelium. The right side shows a high-power view (40X) of a bronchogenic cyst demonstrating the ciliated columnar epithelial lining. Photo courtesy of A Schuss, MD.
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Extrapulmonary bronchogenic cyst. Unilocular cystic mass attached to mediastinal structures by a short pedicle. The inner surface is trabeculated, and the cyst contains mucinous material. The cyst measures 15 cm X 5 cm. Photo courtesy of K Kenigsberg, MD.
