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Excision of Thyroglossal Duct Cyst

Contributors: Juliana Bonilla-Velez and Gresham Richter

This patient presented with an anterior neck mass that was mobile with tongue movement. This is consistent with a thyroglossal duct cyst.  The following video demonstrates the excision of a thyroglossal duct cyst using the Sistrunk procedure.

DOI#: http://dx.doi.org/10.17797/oelc9n6wlc

Thyroglossal duct cysts are the most common congenital neck masses in children. During embryogenesis, the thyroid gland develops at the foramen cecum and then subsequently descends to its normal location in the neck at the level of the thyrohyoid membrane. The thyroglossal duct normally accompanies the thyroid as it descends, but is then obliterated by the 10th week of gestation, leaving no connection between the thyroid and the foramen cecum. Thyroglossal duct cysts occur when portions of the thyroglossal duct do not obliterate and undergo cystic expansion. Thus, these cysts can occur anywhere along the original path of migration of the thyroid from the base of the tongue to the neck at the level of the thyrohyoid membrane. Most often a thyroglossal duct cyst will present in childhood as a painless neck mass that may become enlarged following an upper respiratory infection, though it should be noted that 1/3 of cases do not present until after the age of 20. Removal of cysts shortly following diagnosis is recommended to avoid the risk of the cyst becoming infected, which increases the risk of cyst recurrence. The technique for cyst removal shown in this video is the Sistrunk procedure, which is the most commonly preformed procedure for thyroglossal cyst excision.
It is indicated to remove all thyroglossal duct cysts, ideally before they become infected as infection is associated with a higher rate of recurrence. As many as 50% of cysts become infected if they are not removed.
Acute infection is a contraindication to cyst removal. The infection should be treated appropriately with antibiotics and once the infection has resolved the cyst can be safely removed. Removing cysts during acute infection has been associated with increased rates of recurrence.
Patient is lies in a supine position on the operating table and a shoulder roll is placed. Then the neck is prepped and draped from the mandible to the clavicles and the incision marked on a neck crease over the cyst for best cosmetic results.
Prior to surgery, a thyroid ultrasound should be done. The purpose of the ultrasound is to evaluate for the presence or absence of normal thyroid tissue outside of the cyst. If the only viable thyroid tissue is located inside the cyst, the patient will require thyroid hormone replacement following surgery.
A thyroglossal duct cyst can occur anywhere from the lower 1/3 of the neck up to the base of the tongue. They are usually located in the midline of the neck, at or below the level of the hyoid bone.
It is preferable to excise cysts before they become infected as infection is associated with a higher rate of recurrence. Historically, removal of the central portion of the hyoid bone as described for the Sistrunk procedure has been associated with decreased risk of recurrence and is now the standard of care for excision of thyroglossal duct cysts.
As with any surgery, there is a risk of infection. This risk is reduced by giving IV antibiotics until the Penrose drain is removed 24-36 hours following surgery. IV antibiotics can be followed by prophylactic oral antibiotics. There is also a risk for formation of a seroma. Finally, there is a risk of the cyst re-accumulating. Risk of recurrence can be decreased by ensuring the cyst and its tract are removed in their entirety.
As with any surgery, there is a risk of infection. This risk is reduced by giving IV antibiotics until the Penrose drain is removed 24-36 hours following surgery. IV antibiotics can be followed by prophylactic oral antibiotics. There is also a risk for formation of a seroma. Finally, there is a risk of the cyst re-accumulating. Risk of recurrence can be decreased by ensuring the cyst and its tract are removed in their entirety.
None
1. Al-Khateeb TH1, Al Zoubi F. Congenital neck masses: a descriptive retrospective study of 252 cases. J Oral Maxillofac Surg. 2007 Nov;65(11):2242-7. 2. Postsic, William P., et al. Surgical Pediatric Otolargyngology. New York: Thieme Medical Publications, 1997. Print. 3. Randolph, Gregory W., et al. Thyroglossal Duct Cysts and Ectopic Thyroid. Online. Ed September 18, 2013. Accessed March 19, 2016. www.uptodate.com. 4. Wetmore, Ralph F., et al. Pediatric Otolaryngology: Principles and Practice Pathways. 2nd Ed. New York: ThiemeMedical Publications, 2012. Print.

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