What is the best treatment for a patient with a tender, fluctuant, and erythematous (red) central neck cyst, suggestive of an infected thyroglossal duct cyst, without fever or severe pain?

Management of Tender, Fluctuant, Red Central Neck Cyst

Incision and drainage (I&D) is the best initial treatment for a tender, fluctuant, and erythematous central neck cyst suggestive of an infected thyroglossal duct cyst. 1

Rationale for Incision and Drainage

The presence of a tender, fluctuant, and erythematous mass in the central neck strongly suggests an infected thyroglossal duct cyst with abscess formation. According to the American Academy of Otolaryngology-Head and Neck Surgery and the Infectious Diseases Society of America:

• Fluctuance indicates a collection of pus that requires evacuation 1
• I&D provides immediate decompression of the infected cyst, relieving pain and preventing further spread of infection 1
• I&D is superior to aspiration for fluctuant abscesses, as aspiration is associated with higher recurrence rates 1

Treatment Algorithm

1. Initial Management: Incision and Drainage

   • Perform I&D to evacuate purulent material
   • Send drainage for culture and sensitivity testing

2. Antibiotic Therapy

   • Consider antibiotics only if there are systemic signs of infection (which are absent in this case) or extensive surrounding cellulitis after I&D 1
   • If antibiotics are needed, use broad-spectrum coverage targeting oral flora, as infection often results from communication between the cyst and oral cavity 2

3. Follow-up Assessment

   • Schedule follow-up within 2 weeks to assess resolution of infection 1
   • Complete evaluation is necessary once infection resolves, as cystic neck masses should never be assumed benign 1

4. Definitive Treatment

   • Once infection has completely resolved, perform the Sistrunk procedure to prevent recurrence 1, 3
   • The Sistrunk procedure involves excision of the cyst, the central portion of the hyoid bone, and the tract leading to the base of the tongue

Why Other Options Are Inferior

• Sistrunk procedure (Option A): While this is the definitive treatment for thyroglossal duct cysts, performing it during active infection increases the risk of complications and recurrence 1. The Sistrunk procedure should be delayed until the infection has completely resolved.

• Aspiration (Option C): May provide temporary relief but is associated with higher recurrence rates compared to I&D for fluctuant abscesses 1. It is not the optimal first-line treatment for a fluctuant, infected cyst.

• Broad spectrum antibiotics alone (Option D): The American Academy of Otolaryngology-Head and Neck Surgery recommends against routine antibiotic therapy for neck masses unless there are systemic signs of infection 4, 1. In this case with a fluctuant collection, drainage is necessary regardless of antibiotic use.

Important Considerations

• The recurrence rate following treatment of thyroglossal duct cysts is approximately 11% overall 3, highlighting the importance of proper initial management
• Attempting definitive surgery during active infection increases complication risk 1
• Factors associated with recurrence include inaccurate initial diagnosis (50%), infection (15%), unusual presentation (15%), and incomplete surgical technique (20%) 5
• Ultrasound is the recommended initial imaging modality for evaluation of neck masses 4

Remember that once the infection has resolved completely, definitive treatment with the Sistrunk procedure should be performed to prevent recurrence of the thyroglossal duct cyst.