Why are antibiotics alone not recommended for treating thyroglossal cysts with abscess formation?

From the Guidelines

Antibiotics alone are not recommended for treating thyroglossal cysts with abscess formation because they cannot adequately address the underlying anatomical problem. The primary treatment requires surgical intervention, specifically the Sistrunk procedure, which involves complete excision of the cyst, the central portion of the hyoid bone, and the tract leading to the base of the tongue. While antibiotics (such as amoxicillin-clavulanate 875/125 mg twice daily for adults or clindamycin 300-450 mg four times daily for penicillin-allergic patients) may be used initially to control acute infection and reduce inflammation before surgery, they cannot eliminate the epithelial-lined cyst itself. Without surgical removal, the cyst will persist and likely become reinfected, leading to recurrent abscesses. This is because thyroglossal cysts are congenital remnants of the thyroglossal duct that failed to involute during embryological development, creating a potential space for infection. The cyst's connection to the hyoid bone and its tract to the tongue base makes complete resolution with antibiotics alone impossible, resulting in high recurrence rates if surgical management is delayed or avoided.

According to the most recent and highest quality study, incision and drainage is the primary treatment for simple abscesses or boils 1. Antibiotics may be used in addition to incision and drainage in certain cases, such as severe or extensive disease, rapid progression, or signs of systemic illness. However, for simple abscesses, incision and drainage alone is likely adequate 1. The use of antibiotics should be individualized based on the patient's clinical response and the presence of underlying conditions that may affect the risk of infection or treatment outcomes.

Some key points to consider when treating thyroglossal cysts with abscess formation include:

• The need for surgical intervention to address the underlying anatomical problem
• The use of antibiotics to control acute infection and reduce inflammation before surgery
• The importance of individualizing treatment based on the patient's clinical response and underlying conditions
• The potential for high recurrence rates if surgical management is delayed or avoided

It is essential to prioritize the patient's morbidity, mortality, and quality of life when making treatment decisions. In this case, surgical intervention is the most effective way to prevent recurrent abscesses and improve the patient's quality of life. Antibiotics may be used as an adjunct to surgery, but they should not be relied upon as the sole treatment for thyroglossal cysts with abscess formation.

From the Research

Reasons for Not Recommending Antibiotics Alone

• Antibiotics alone are not recommended for treating thyroglossal cysts with abscess formation because they do not address the underlying cause of the infection, which is often a communication between the cyst and the mouth with subsequent contamination by oral flora 2.
• The use of antibiotics alone may not be effective in preventing recurrence, as the cyst can still be present and become infected again 3.
• Studies have shown that the Sistrunk procedure, which involves the removal of the cyst and a portion of the hyoid bone, is the most effective treatment for thyroglossal duct cysts, with low rates of complications and recurrence 4.

Importance of Surgical Intervention

• Surgical intervention, such as the Sistrunk procedure, is necessary to remove the cyst and prevent recurrence 3, 4.
• Incision and drainage of an infected thyroglossal duct cyst may not increase the risk of postoperative recurrence, but it is not a substitute for definitive surgical treatment 3.
• The Sistrunk procedure has been shown to be effective in treating thyroglossal duct cysts, with low rates of complications and recurrence, and is considered the gold standard for treatment 4, 5.

Complications and Recurrence

• Complications, such as reoperation, readmission, and surgical site infection, can occur after surgical treatment of thyroglossal duct cysts, but are generally rare 6.
• Recurrence can occur if the cyst is not completely removed, or if the hyoid bone is not excised 5.
• The use of antibiotics alone may not prevent recurrence, and may even contribute to the development of antibiotic-resistant bacteria 2.