Systematic review of pediatric postcricoid cushion and postcricoid lesions

Objectives: 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.

Methods: 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.

Results: 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.

Conclusion: 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.