Foregut Duplication Cysts in the Head and Neck Presentation, Diagnosis, and Management

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ORIGINAL ARTICLE Foregut Duplication Cysts in the Head and Neck Presentation, Diagnosis, and Management

Stephen M. Kieran, MB; Caroline D. Robson, MB, ChB; Vaˆnia Nose´, MD, PhD; Reza Rahbar, DMD, MD

Objective: To review the presentation, diagnosis, and of involvement, with 12 patients (55%) being asymptom- management of foregut duplication cysts of the head and atic. The cysts were found in the oral cavity (n=12), oro- neck in our institution. pharynx (n=6), supraglottis (n=2), and neck (n=3). Imaging, which was performed in 13 patients and con- Design: An institutional review board–approved retro- sisted of magnetic resonance imaging (n=8), computed spective review of all patients treated for foregut duplica- tomography (n=5), and ultrasonography (n=1), demon- tion cysts of the head and neck over an 18-year period. strated the cystic nature of the lesions. All patients under- Setting: Pediatric otolaryngology tertiary referral center. went surgical excision, which focused on excising the cyst, while preserving surrounding normal tissues. No patient Patients: Twenty-two patients with 23 pathologically demonstrated recurrence at follow-up. confirmed foregut duplication cysts of the head and neck were identified. Fourteen patients (64%) were male. The Conclusions:Foregutduplicationcystsoftheheadandneck, median age at diagnosis was 1.5 years (age range, 5 days although uncommon, should be included in the differen- to 7 years). tial diagnosis of cystic head and neck lesions. Preoperative imaging is recommended to differentiate these lesions from Main Outcome Measures: Clinical data, including age, other congenital head and neck masses. Surgical excision presenting symptoms, anatomical site(s), evaluation, treat- biopsy with complete removal of the mucosal lining is cura- ment, and complication, were recorded and analyzed. tive, with no instances of recurrence in our series.

Results: Presentation varied depending on anatomical site Arch Otolaryngol Head Neck Surg. 2010;136(8):778-782

N THE DEVELOPING EMBRYO, THE Foregut duplication cysts are benign de- foregut gives rise to the pharynx, velopmental anomalies that contain fore- lower respiratory tract, and upper gut derivatives. Traditionally, there are 3 gastrointestinal tract (esophagus, criteria that must be met to make a diag- stomach, duodenum, and hepato- nosis of foregut duplication cyst: they must biliaryI system). During the first trimester, (1) be covered by a smooth muscle layer, heterotopic rests of foregut-derived epithe- (2) contain epithelium derived from the lium may persist, resulting in foregut du- foregut, and (3) be attached to a portion plication cysts. Such cysts can occur any- of the foregut.2 Duplication cysts are lined where along the alimentary tract; however, by 1 or more types of epithelium: gastric mucosa, ciliated respiratory-type epithe- CME available online at lium, stratified squamous epithelium, and www.jamaarchivescme.com simple cuboidal epithelium. All types of and questions on page 760 cysts may show squamous metaplasia, mucosal ulceration, inflammation, and ne- they are most frequently seen in the tho- crosis, making distinction between the rax or abdomen. Foregut duplication cysts cysts sometimes impossible. in the head and neck have rarely been re- Based on their epithelial type and other ported.1 Their clinical presentation can features, foregut duplication cysts may ap- mimic that of other masses in the head and pear to closely resemble airway, esopha- neck, many of which are optimally man- gus, or small intestine. Therefore, the term Author Affiliations: aged differently. We report our institu- foregut duplication cyst includes broncho- Departments of Otolaryngology tion’s experience with these cysts (to our genic cyst, esophageal duplication cyst, and and Communication Disorders (Drs Kieran and Rahbar), knowledge the largest such series to be re- enteric duplication cyst. Bronchogenic cysts Radiology (Dr Robson), and ported in the English-language literature) represent 50% to 60% of all mediastinal Pathology (Dr Nose´), Children’s and delineate their clinical presentation, ra- cysts. They have a ciliated columnar, cu- Hospital Boston, Boston, diologic appearance, pathologic character- boidal, or pseudostratified epithelial cell Massachusetts. istics, and management. layer, with cartilage and respiratory glands

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Table. Summary of Clinical and Radiologic Findings in Patients With a Foregut Duplication Cyst of the Head and Neck

Findings Patient No./ Sex/Age Clinical Features Clinical Imaging 1/M/7 y Asymptomatic Lower anterior neck mass CT: monocyctic mass inferior to thyroid 2/F/7 y Asymptomatic Midline tongue mass MRI: circular tongue base mass and sinus tract 3/F/1 y Asymptomatic Midline mass above sternal notch and pit None draining mucous material 4/F/8 mo Asymptomatic Blue FOM cyst None 5/M/2 y Speech difficulties Midline cystic mass of tongue MRI: cystic mass, tongue tip to base 6/M/2 y Asymptomatic Midline anterior mass of tongue None 7/F/6 y Sore throat, dysphagia, and Large cystic mass arising from surface of None drooling epiglottis 8/M/5 y Intermittant tongue swelling Midline tongue mass posterior to circumvallate MRI, thyroid scan, and US: cystic mass extending papillae to tongue base 9/M/9 mo Asymptomatic FOM and tongue mass None 10/M/6 mo Asymptomatic Midline mass in FOM and tongue Thyroid scan and CT: midline cyst anterior to hyoid 11/F/5 d Feeding problems Sublingual mass MRI: midline sublingual mass 12/F/4 mo Asymptomatic Sublingual mass MRI: midline sublingual mass 13/F/1 mo Asymptomatic Midline mass in anterior undersurface of tongue Prenatal US: tongue mass 14/M/7 y Asymptomatic Midline mass in posterior tongue MRI and thyroid scan: posterior tongue mass 15/M/9 d Feeding problems FOM and tongue mass MRI: FOM cyst 16/M/5 mo Possible otitis media Mass posterior to left tonsil None 17/M/8 mo Mild snoring Two lesions: cyst in right uvula and mass in None right side of palate 18/F/2 mo Respiratory distress Blue vallecular cyst None 19/M/3 y Loud snoring Left bluish retropharyngeal mass CT and carotid arteriography: left parapharyngeal space mass 20/M/7 y Odynophagia Right soft palate mass None 21/M/4 y Asymptomatic FOM mass CT: cystic FOM mass 22/F/3 y Asymptomatic Anterior neck mass CT: level of hyoid, oval lesion with rim enhancement, fluid filled, 1.2 ϫ 0.8 cm

Abbreviations: CT, computed tomography; FOM, floor of mouth; MRI, magnetic resonance imaging; US, ultrasonography.

and a fibromuscular connective tissue, which identifies (n=2), and otitis media (n=1). The clinical, radiologic, them as bronchial in origin. Esophageal duplication cysts and pathologic findings are summarized in the Table. have a mucosa with either ciliated columnar epithelium Presenting signs on physical examination included an- or stratified squamous epithelium and a layer or 2 of mus- terior cervical masses (n=3), apparent vallecular cysts cularis propria. Enteric duplication cysts may be lined by (n=2), tongue masses (n=6), palatal cysts (n=3), tonsil- gastric and/or respiratory mucosa and are located in the lar mass (n=1), retropharyngeal mass (n=1), and masses posterior mediastinum, distinct from the esophagus.3 in the floor of the mouth and anterior aspect of the tongue (n=7). Imaging was performed in 13 patients (59%). Four METHODS patients underwent more than 1 imaging study. Imaging included ultrasonography (US) (n=1), computed tomog- We retrospectively reviewed all patients treated for foregut du- raphy (CT) (n=5), magnetic resonance imaging (MRI) plication cysts of the head and neck over an 18-year period at (n=8), and thyroid uptake scanning (n=3). In 1 patient, Children’s Hospital Boston, Boston, Massachusetts. Patients were the mass was noted on prenatal US. identified from a prospectively maintained head and neck da- Thyroid uptake scanning was performed if a lingual thy- tabase and the hospital pathology database. Local institutional roid was considered in the preoperative workup. Imaging review board approval for this study was obtained before the study began. All patients who underwent surgical excision of studies, which were available for review in 8 patients, con- a foregut duplication cyst between 1989 and 2007 were in- sisted of CT (n=4) and MRI (n=4). All examinations re- cluded in the study, and their clinical and operative records were vealed cystic, nonenhancing masses with density or signal reviewed. In each case, pathologic specimens were reviewed intensity similar to cerebrospinal fluid in all (Figures 1, by a senior pathologist (V.N.), and all available images were 2, and 3) but 1 patient who had proteinaceous or hem- reviewed by a senior radiologist (C.D.R.). orrhagic contents within the cyst. Lesions typically in- volved the floor of the mouth (Figure 1), appearing to ex- RESULTS tend into the anterior third of the tongue (n=6) (Figure 2), and were midline (n=5) or midline and extending to the Of the 22 patients, 14 were male (64%) and 8 were fe- left (n=1). Less commonly, the cysts were located slightly male. The mean age at surgery was 1.5 years, with a range to the left of midline (n=2), adjacent to the supraglottic of 5 days to 7 years. Twelve patients (55%) were asymp- airway (n=1) and trachea (n=1) (Figure 3). The cysts usu- tomatic. Symptoms in the other 10 patients included air- ally appeared unilocular (n=6). Less frequently, a serpigi- way obstruction (n=3), feeding difficulties (n=2), tongue nous tubular component extended posterior to the cyst swelling (n=1), speech difficulties (n=1), odynophagia (n=2) (Figure 2).

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Figure 1. A 7-week-old girl with a tongue mass. A, An axial fast spin-echo inversion recovery magnetic resonance image reveals a unilocular, sharply circumscribed midline lesion that is isointense with cerebrospinal fluid located within the anterior aspect of the floor of the mouth. B, A gadolinium-enhanced, fat-suppressed sagittal T1-weighted image reveals a cystic mass that does not enhance.

All patients underwent surgical excision of their cysts. foregut rests forming cysts4; (2) cystic duplications arise Simple excision with preservation of surrounding struc- from a supernumerary lung bud found in the foregut dur- tures was performed in all cases. Twenty lesions were ex- ing the fifth and seventh week of embryogenesis5; and (3) cised transorally. The remaining lesions were located in part of the developing stomach may become trapped be- the anterior aspect of the neck and were excised via lo- tween the lateral lingual swellings as they close over the cal neck incisions. tuberculum impar.6 The latter theory is supported by the Pathologic examination was performed in all cases. finding that columnar and goblet cells in foregut duplica- Grossly, the median maximum dimension of the cysts was tion cysts tend to be well differentiated, with local induc- 1.4 cm, with a range of 0.5 to 8.5 cm. The lesions were tive factors possibly acting on primitive endothelial cell rests.7 mostly spherical cystlike structures with a pink, tan, and Foregut duplication cysts most commonly occur in the smooth glistening surface. The cysts were found to con- chest and abdomen.8-10 The estimated incidence of ali- tain gastric mucosa in 5 cases and respiratory epithelium mentary tract duplications is 1:4500, approximately one- in 16 cases. They were filled with clear, mucinous fluid. A third of which are foregut duplication cysts.2 While fore- thick, layered muscular wall lined by diverse epithelium gut duplication cysts may occur anywhere from the mouth characterized the specimens. In some areas, the epithelial to the anus, occurrence in the head and neck is uncom- cells were of the ciliated type, while in others, there was mon, with approximately 65 reported cases by 1997.1 The gastric-foveolar–type mucosa or focally squamous epithe- oral cavity is the most common location in the head and lium. Occasional seromucous glands were seen. Areas of neck, with approximately 50 reported cases.11-15 How- cartilaginous tissue were also present. Ganglion cells were ever, to our knowledge, no reports have mentioned fore- found in between the muscular layers, and a few mixed in- gut duplication cysts of the pretracheal neck. flammatory cells were also seen. In our institution, we have treated 22 patients with 23 Only 1 patient had a postoperative complication: a foregut duplication cysts of the head and neck over the past tongue wound dehiscence after excision of a foregut du- 18 years. These cysts may contain only a mucosal lining or plication cyst on the anterior aspect of the tongue. All mucosa, submucosa, and muscularis propria.15 The muco- patients were followed up in the pediatric otolaryngol- sal lining may be squamous, respiratory, intestinal, or mixed, ogy clinic. Duration of follow-up ranged from 11 months with the secretory epithelium causing gradual enlargement to 6 years, with a mean follow-up of 2.4 years. of the cyst. The most common presenting clinical features are feeding difficulties, odynophagia, stridor, tongue edema, COMMENT and speech difficulties. The neonate, however, may present withfrankrespiratorydistressduetoairwayobstructionfrom The primitive foregut gives rise to the oropharynx, the lower the mass. Only 1 of the 3 patients who presented perinatally respiratory system, the esophagus, the stomach, parts 1 and did so with respiratory distress, while a second patient pre- 2 of the duodenum, the liver, the pancreas, and the biliary sented with feeding problems. Overall, 12 of our 22 patients apparatus. The mucosa observed in the cyst may not cor- (54%) were asymptomatic at presentation. respond to the normal gastrointestinal mucosa at the level The most common site of foregut duplication cysts in of the cyst, and multiple mucosal types may occur within the head and neck is the oral cavity; our study supports this a single cyst. Therefore, even though pure esophageal, gas- finding.11 Of the 23 cysts described in our study, 12 (52%) tric, and colonic enteric cysts are seen, they often defy ana- presented in the oral cavity, with 5 masses in the anterior tomical categorization and are termed foregut duplication aspect of the tongue and 7 masses in the floor of the mouth. cysts. A number of theories exist as to the etiology of fore- Five of these oral cavity lesions were asymptomatic; the oth- gut duplication cysts: (1) duplication abnormalities may ers presented with feeding or speech-related problems. Fore- occur because of disturbed recanalization with abnormal gut duplication cysts in the oropharynx are also uncommon,

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 with possibly only 2 previously reported cases.16,17 We identified 6 oropharyngeal foregut duplication cysts, with 3 soft palate lesions (2 lesions were synchronously identified in 1 patient), 1 tonsil lesion, 1 retropharyngeal mass, and 1 tongue base mass. As might be expected from their location, oropharyngeal lesions are unlikely to present on routine neonatal examination; in our series, all 6 oropharyngeal cysts presented with symptoms. We have identified 3 patients who presented with anterior or pretracheal neck masses that on histologic examination were most consistent with a foregut duplication cyst. This phenomenon is highly unusual. According to our experience,thesecystswouldhavebeenexpectedtohavearisen fromthefloorofthemouthortheanteriorthirdofthetongue, pharynx, or esophagus. One possible explanation is that a transition occurs, from a bronchogenic cyst to a less differentiated foregut duplication cyst containing enteric mucosa. Two patients presented with cysts in the region of the val- leculla and epiglottis: one with odynophagia and drooling, and the other with airway distress from birth. In evaluating these lesions, imaging (CT or MRI) is in- valuable. Previous authors have found that endoscopic examination and barium swallow studies have only limited utility in the diagnosis and preoperative planning of the esophageal duplication cyst.18 Endoscopically, a submu- cosal mass with normal overlying mucosa is typically found, making it difficult to distinguish from other lesions, such as a leiomyoma. Similarly, extraluminal compression is seen on barium swallow. While technically difficult, endosonog- 19 raphy has been used to assist in diagnosis. For the rare Figure 2. An axial contrast-enhanced computed tomographic image in a lesion that communicates with the spinal canal, MRI is usu- 3-year-old boy demonstrates a cystic mass involving the anterior third of the ally performed. Although a foregut duplication cyst is in- tongue. There is a tubular cystic projection extending in a posterior direction distinguishable from a thyroglossal duct cyst and a der- (arrow). moid cyst in terms of appearance on CT and routine MRI pulse sequences, the presence of a cystic mass in the anterior floor of the mouth or anterior third of the tongue dis- tinguishes a foregut duplication cyst from a thryoglossal duct cyst or a vallecular cyst. Thyroglossal duct cysts are usually located between the foramen cecum and hyoid bone or within the infrahyoid neck. Vallecular cysts are located in the vallecula. Mucous retention cysts may appear indis- tinguishable from foregut duplication cysts in terms of both imaging characteristics and location. Studies have demonstrated the association of vertebral anomalies with foregut duplication cysts, termed neurenteric cysts, as the cyst in- terferes with anterior fusion of the vertebral mesoderm. The patients in our series who underwent neck CT or MRI did not have any evidence of vertebral or spinal anomalies. With the increased use of maternal US, cystic lesions are being diagnosed before birth. One patient in our series had a tongue foregut duplication cyst diagnosed by Figure 3. A 6-year-old girl with a neck mass. An axial contrast-enhanced antenatal US. Because the patient was asymptomatic at computed tomographic image of the base of the neck demonstrates a sharply circumscribed, nonenhancing, low-attenuation, soft-tissue mass that birth, with no evidence of respiratory distress, surgical in- abuts the ventral surface of the trachea. The lesion also abuts the inferior tervention was deferred until the patient was 1 month old. aspect of the thyroid gland. Two cases of enteric duplication cyst of the oral cavity being detected in utero have been previously reported; both were initially decompressed before formal surgical excision.20 almost exclusively at the beginning of our 18-year review, Even though 9 of our 22 patients did not undergo pre- when such imaging modalities were not as readily available. operative imaging, we recommend imaging (either MRI or The differential diagnosis of pediatric cystic head and CT) in all patients to localize the lesion, to assess the ex- neck masses is extensive and includes mucocoele, ran- tent of the mass, and to look for other pathologic entities. nula, dermoid, lymphatic malformation, venous malfor- Those patients without imaging in our series were included mation, teratoma, thyroglossal duct cyst, epidermoid cyst,

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 and lymphoepithelial cyst. The management of some of Author Contributions: Drs Kieran and Rahbar had full ac- these lesions is substantially different from that of foregut cess to all the data in the study and take responsibility for duplication cysts. For example, for suspected thyroglos- the integrity of the data and the accuracy of the data analy- sal duct cysts, the Sistrunk procedure (removal of the cyst sis. Acquisition of data: Kieran. Analysis and interpretation in continuity with the central portion of the hyoid bone) of data: Kieran, Robson, Nose´, and Rahbar. Drafting of the is performed to avoid recurrence in contrast to the foregut manuscript: Kieran. Critical revision of the manuscript for duplication cyst, for which simple excision suffices. Fur- important intellectual content: Kieran, Robson, Nose´, and thermore, in the case of venous and lymphatic malforma- Rahbar. Statistical analysis: Kieran. Administrative, tech- tions, sclerotherapy or nonoperative management may be nical, and material support: Nose´ and Rahbar. appropriate. Therefore, awareness of foregut duplication Financial Disclosure: None reported. cysts as a differential diagnosis is essential, and preoperative imaging of suspected cases is recommended. The treatment options proposed for such cysts include REFERENCES observation, resection, and aspiration. However, if the cyst 1. Edwards J, Pearson S, Zalzal G. Foregut duplication cyst of the hypopharynx. is left untreated, there is the potential for complications to Arch Otolaryngol Head Neck Surg. 2005;131(12):1112-1115. develop. Malignant transformation has been reported to oc- 2. Qi BQ, Beasley SW, Williams AK. Evidence of a common pathogenesis for fore- cur in long-standing foregut duplication cysts of the head gut duplications and esophageal atresia with tracheo-esophageal fistula. Anat and neck, with 1 previous case report of an adenocarcinoma Rec. 2001;264(1):93-100. and 1 of metaplasia.21,22 In the chest, where foregut dupli- 3. Strollo DC, Rosado-de-Christenson ML, Jett JR. Primary mediastinal tumors, II: tumors of the middle and posterior mediastinum. Chest. 1997;112(5):1344-1357. cation cysts are more frequently encountered, early excision 4. Bremer JL. Diverticula and duplications of the intestinal tract. Arch Pathol. 1944; has traditionally been recommended to avoid serious com- 38:132-140. plication.23 Because gastric epithelium may be a component, 5. Teele RL, Henschke CI, Tapper D. The radiographic and ultrasonographic evalu- peptic ulceration can occur, resulting in bleeding or tissue ation of enteric duplication cysts. Pediatr Radiol. 1980;10(1):9-14. 10 6. Gorlin RJ, Kalnins V, Izant RJ Jr. Occurrence of heterotopic gastric mucosa in perforation. If the cyst is left untreated, sinus formation the tongue. J Pediatr. 1964;64:604-606. with chronic mucous secretion may develop, as occurred 7. Woolgar JA, Smith AJ. Heterotopic gastrointestinal cyst of oral cavity: a devel- in 1 patient in our series with an anterior neck cyst.11 opmental lesion? Oral Surg Oral Med Oral Pathol. 1988;66(2):223-225. In certain circumstances, temporary aspiration of the cyst 8. Laraja RD, Rothenberg RE, Chapman J, Imran-ul-Haq, Sabatini MT. Foregut du- may confirm a benign diagnosis and temporarily alleviate plication cyst: a report of a case. Am Surg. 1995;61(9):840-841. 9. Horwitz JR, Lally KP. Bronchogenic and esophageal duplication cyst in a single symptoms such as respiratory distress and feeding difficul- mediastinal mass in a child. Pediatr Pathol Lab Med. 1996;16(1):113-118. ties. Asymptomatic simple cysts have the potential to grow 10. Burgner DP, Carachi R, Beattie TJ. Foregut duplication cyst presenting as neo- and if they become symptomatic can result in higher rates natal respiratory distress and hemoptysis. Thorax. 1994;49(3):287-288. ofperioperativecomplications.Therefore,inviewoftheneed 11. Eaton D, Billings K, Timmons C, Booth T, Biavati JM. Congenital foregut duplication cysts of the anterior tongue. Arch Otolaryngol Head Neck Surg. 2001; for definitive histologic diagnosis and the risk of malignant 127(12):1484-1487. potential without treatment, as well as to relieve associated 12. Gorlin RJ, Jirasek JE. Oral cysts containing gastric or intestinal mucosa: unusual symptoms, surgical resection is the treatment of choice. embryological accident or heterotopia. Arch Otolaryngol. 1970;91(6):594-597. In conclusion, foregut duplication cysts of the head 13. Willner A, Feghali J, Bassila M. An enteric duplication cyst occurring in the anterior and neck may present a diagnostic dilemma and should two-thirds of the tongue. Int J Pediatr Otorhinolaryngol. 1991;21(2):169-177. 14. Surana R, Losty P, Fitzgerald RJ. Heterotopic gastric cyst of the tongue in a newborn. be included in the differential diagnosis of a congenital Eur J Pediatr Surg. 1993;3(2):110-111. lesion of the head and neck, particularly in cases that in- 15. Tucker R, Maddalozzo J, Chou P. Sublingual enteric duplication cyst. Arch Pathol volve the anterior floor of the mouth and tongue or that Lab Med. 2000;124(4):614-615. are located in proximity to the airway. Surgical interven- 16. Frenkiel S, Remsen KA. Foregut duplication arising from the pharynx. J Otolaryngol. 1990;19(4):279-281. tion in the form of simple excision is recommended as it 17. Fraser L, Howatson AG, MacGregor FB. Foregut duplication cyst of the pharynx. is both diagnostic and therapeutic. Preoperative imaging J Laryngol Otol. 2008;122(7):754-756. is used to provide a limited differential diagnosis and as- 18. Azzie G, Beasley S. Diagnosis and treatment of foregut duplications. Semin Pe- sists with surgical planning. Surgical excision has been diatr Surg. 2003;12(1):46-54. shown to be both diagnostic and curative. 19. Geller A, Wang KK, Dimagno EP. Diagnosis of foregut duplication cysts by endoscopic ultrasonography. Gastroenterology. 1995;109(3):838-842. 20. Chen MK, Gross E, Lobe TE. Perinatal management of enteric duplication cysts Submitted for Publication: December 13, 2009; final re- of the tongue. Am J Perinatol. 1997;14(3):161-163. vision received January 20, 2010; accepted March 9, 2010. 21. Volchok J, Jaffer A, Cooper T, Al-Sabbagh A, Cavalli G. Adenocarcinoma arising Correspondence: Stephen M. Kieran, MB, Department in a lingual foregut duplication cyst. Arch Otolaryngol Head Neck Surg. 2007; 133(7):717-719. of Otolaryngology and Communication Disorders, Chil- 22. Kim YS, Ahn SK, Lee SH. Sublingual foregut cyst. J Dermatol. 1998;25(7):476-478. dren’s Hospital Boston, 300 Longwood Ave, Boston, MA 23. Parikh D, Samuel M. Congenital cystic lung lesions: is surgical resection essential? 02115 ([email protected]). Pediatr Pulmonol. 2005;40(6):533-537.

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