“Apple Sign” in Epiglottic Inclusion Cyst

“Apple Sign” in Epiglottic Inclusion Cyst | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report “Apple Sign” in Epiglottic Inclusion Cyst Changqing Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9507216/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract We describe a rare epiglottic inclusion cyst with a distinctive ‘apple-like’ morphology on contrast-enhanced CT imaging. The imaging appearance, which we term the ‘apple sign’, may serve as a useful visual indicator for lesion characterization and preoperative planning, particularly in airway management. The case is concise and image-focused, aligning with the educational objectives of the Image of the Month category. We believe it provides clinical and radiological value due to the rarity of the condition and the clarity of the imaging findings. Head & Neck Surgery Cysts Epiglottis Airway obstruction Tomography Figures Figure 1 Full Text A 41-year-old woman presented with a 1-year history of obstructive foreign body sensation in the pharynx. During the clinical course, she experienced intermittent pharyngeal pain and occasional breathlessness, with no evident dyspnoea, chills, fever, cough, expectoration, or swallowing discomfort, and her oral intake remained normal. There was no history of laryngopharyngeal trauma. Indirect laryngoscopy demonstrated a giant cystic mass obstructing the laryngeal surface of the epiglottis; the mass had a smooth surface with telangiectasia, rendering the glottis invisible. Routine blood tests and hepatic and renal function tests revealed no abnormal findings. Contrast-enhanced computed tomography (CT) revealed a round, isodense lesion (approximately 1.4 cm diameter) in the epiglottic region. The lesion was attached to the left epiglottic wall, presenting a pedunculated, apple-like morphology, with no enhancement on contrast-enhanced scanning, corresponding to the characteristic “apple sign” (Fig. 1a, b). This distinctive imaging feature facilitates evaluation of lesion size, determination of the extent of lower airway involvement, and provides guidance for tracheal intubation and selection of surgical procedures [1]. The patient underwent tracheal intubation under intravenous anaesthesia combined with fibreoptic laryngoscopy guidance [1,2], followed by complete resection of the mass along the pedicle via suspension laryngoscopy using low-temperature plasma radiofrequency ablation. Histopathological examination with haematoxylin–eosin staining revealed fibrous tissue hyperplasia in the cyst wall, lined with simple cuboidal epithelium on the luminal surface, accompanied by squamous metaplasia in some epithelial cells (Fig. 1c). The pathological diagnosis was confirmed as an inclusion cyst of the epiglottis. Inclusion cysts commonly occur in the skin of the head and face, neck, or trunk, and epiglottic mucosal involvement is extremely rare in clinical practice. Postoperatively, anti-inflammatory and other symptomatic treatments were administered. At the 1-month follow-up after discharge, the surgical site of the epiglottis had healed well, and the patient’s clinical symptoms were substantially relieved. Declarations Consent to participate The written informed consent for publication was obtained from the patient. Consent to publish The authors affirm that human research participants provided informed consent for publication of the images in Fig. 1. Competing interests The authors have no relevant financial or nonfinancial interests to disclose. Funding The authors declare that no funds, grants, or other support were received during the preparation of this interesting image. Author contributions All authors contributed to the conception, design, and drafting of this submission in its final format. References Kc AK, Shrestha BL (2021) Multiple epidermal inclusion cysts of epiglottis. Kathmandu Univ Med J (KUMJ) 19:275–277 Kawaida M, Kohno N, Kawasaki Y, Fukuda H (1992) Surgical treatment of large epiglottic cysts with a side-opened direct laryngoscope and snare. Auris Nasus Larynx 19:45–50. https://doi.org/10.1016/s0385-8146(12)80201-x Additional Declarations The authors declare no competing interests. Supplementary Files Titlepage.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9507216","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":628423418,"identity":"d295c0c3-74f2-496d-a9ed-fadc0ec44d68","order_by":0,"name":"Changqing Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYFACHgbmHwY2cvzsjY0PPxCthaEgzViy53CzsQTxWj4cTtxwI71NgIcYDQbHzx68XWAAtGXmwzYGCQY7Od0GQlrO5CVbzwD5RTqx7UEBQ7Kx2QECWsxu8JhJ8IBsmZ3YbiDBcCBxG5FagH65ebBNgodYLdJgLTcYidRifybH2HIGyGE9icBANiDCL5LtZwxvfPgDisrjDx9+qLCTI6gFBJAi0IAI5WhaRsEoGAWjYBRgAQBldENPNnJHggAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-7679-4837","institution":"People's Hospital of Xishuangbanna Dai Nationality Autonomous Prefecture","correspondingAuthor":true,"prefix":"","firstName":"Changqing","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2026-04-23 13:13:54","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9507216/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9507216/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107687588,"identity":"0faba167-7c8d-4b9e-96e5-4a0a2f199fd4","added_by":"auto","created_at":"2026-04-24 04:55:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1225974,"visible":true,"origin":"","legend":"\u003cp\u003e(a, b) Axial and sagittal contrast-enhanced computed tomography (CT) images show that the lesion was attached to the left epiglottic wall, presenting a pedunculated, apple-like morphology, with no enhancement on contrast-enhanced scanning, corresponding to the characteristic “apple sign” (arrows).(c) Histopathology (haematoxylin–eosin) shows fibrous tissue hyperplasia in the cyst wall, lined with simple cuboidal epithelium on the luminal surface, accompanied by squamous metaplasia in some epithelial cells.\u003c/p\u003e","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9507216/v1/39fdd0605a414ea3646b552e.jpg"},{"id":107707083,"identity":"d782143b-8564-4caa-81c8-665e7a9d1322","added_by":"auto","created_at":"2026-04-24 09:19:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1320644,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9507216/v1/20b1935f-ec9f-4ed8-bcfa-872b04f40df4.pdf"},{"id":107687591,"identity":"ada20f12-d53e-4bc2-a16f-d484b7c80b00","added_by":"auto","created_at":"2026-04-24 04:55:01","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18637,"visible":true,"origin":"","legend":"","description":"","filename":"Titlepage.docx","url":"https://assets-eu.researchsquare.com/files/rs-9507216/v1/9d244114c0f209d119fbe928.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003e“Apple Sign” in Epiglottic Inclusion Cyst\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Full Text","content":"\u003cp\u003eA 41-year-old woman presented with a 1-year history of obstructive foreign body sensation in the pharynx. During the clinical course, she experienced intermittent pharyngeal pain and occasional breathlessness, with no evident dyspnoea, chills, fever, cough, expectoration, or swallowing discomfort, and her oral intake remained normal. There was no history of laryngopharyngeal trauma. Indirect laryngoscopy demonstrated a giant cystic mass obstructing the laryngeal surface of the epiglottis; the mass had a smooth surface with telangiectasia, rendering the glottis invisible. Routine blood tests and hepatic and renal function tests revealed no abnormal findings.\u003c/p\u003e\n\u003cp\u003eContrast-enhanced computed tomography (CT) revealed a round, isodense lesion (approximately 1.4 cm diameter) in the epiglottic region. The lesion was attached to the left epiglottic wall, presenting a pedunculated, apple-like morphology, with no enhancement on contrast-enhanced scanning, corresponding to the characteristic “apple sign” (Fig. 1a, b). This distinctive imaging feature facilitates evaluation of lesion size, determination of the extent of lower airway involvement, and provides guidance for tracheal intubation and selection of surgical procedures [1].\u003c/p\u003e\n\u003cp\u003eThe patient underwent tracheal intubation under intravenous anaesthesia combined with fibreoptic laryngoscopy guidance [1,2], followed by complete resection of the mass along the pedicle via suspension laryngoscopy using low-temperature plasma radiofrequency ablation. Histopathological examination with haematoxylin–eosin staining revealed fibrous tissue hyperplasia in the cyst wall, lined with simple cuboidal epithelium on the luminal surface, accompanied by squamous metaplasia in some epithelial cells (Fig. 1c). The pathological diagnosis was confirmed as an inclusion cyst of the epiglottis. Inclusion cysts commonly occur in the skin of the head and face, neck, or trunk, and epiglottic mucosal involvement is extremely rare in clinical practice. Postoperatively, anti-inflammatory and other symptomatic treatments were administered. 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Kathmandu Univ Med J (KUMJ) 19:275\u0026ndash;277\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawaida M, Kohno N, Kawasaki Y, Fukuda H (1992) Surgical treatment of large epiglottic cysts with a side-opened direct laryngoscope and snare. 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