What is the initial management for a child with a midline neck mass, suggestive of an infected thyroglossal duct cyst with abscess, that moves with deglutition and tongue protrusion?

Management of Infected Thyroglossal Duct Cyst with Abscess in a Child

The initial management for a child with an infected thyroglossal duct cyst with abscess should be incision and drainage (I&D) followed by broad-spectrum antibiotics, not immediate excision or Sistrunk procedure. 1

Initial Management Algorithm

1. Confirm diagnosis:

   • Clinical features: Midline neck mass that moves with deglutition and tongue protrusion
   • Assess for abscess: Check for fluctuance, erythema, tenderness, and swelling
   • Ultrasound imaging to confirm diagnosis and identify abscess formation 1

2. Acute treatment:

   • Incision and drainage (I&D) for fluctuant, infected cysts with abscess formation 1
   • This allows for drainage of purulent material and resolution of acute infection
   • I&D is preferred over immediate excision during active infection

3. Antibiotic therapy:

   • Initiate broad-spectrum antibiotics targeting oral flora after I&D 1
   • Continue antibiotics until signs of infection resolve
   • Note: Antibiotics alone are insufficient for abscess treatment

Rationale for Staged Approach

The American Academy of Otolaryngology-Head and Neck Surgery recommends a staged approach for infected thyroglossal duct cysts with abscess 1:

• Why not immediate Sistrunk procedure? Performing the Sistrunk procedure during active infection significantly increases:

  • Surgical complications
  • Recurrence rates (up to 25%)
  • Postoperative wound infections 1, 2

• Evidence supporting staged approach: Research shows that performing the Sistrunk procedure after resolution of inflammation leads to a significantly lower recurrence rate (0%) compared to performing it during acute inflammation (25%) 2

Definitive Management

After complete resolution of infection:

• Schedule definitive Sistrunk procedure
• This involves excision of the cyst, central portion of the hyoid bone, and tract leading to the base of tongue 3
• The Sistrunk procedure reduces recurrence rates from approximately 50% to 3-5% 3

Follow-up Care

• Schedule follow-up within 2 weeks to assess resolution of infection 1
• Continue monitoring until complete resolution of infection before definitive surgery
• Complete evaluation is necessary once infection resolves to ensure the mass is benign 1

Clinical Pearls and Pitfalls

• Pitfall: Attempting immediate excision during active infection increases complications and recurrence
• Pitfall: Using antibiotics alone without drainage for abscess is insufficient
• Caution: Aspiration may provide temporary relief but has higher recurrence rates compared to I&D for fluctuant abscesses 1
• Important: Never assume a cystic neck mass is benign; complete evaluation is necessary once infection resolves 1

In summary, for a child with an infected thyroglossal duct cyst with abscess, the correct initial management is option B (I&D) followed by option C (broad-spectrum antibiotics), with the Sistrunk procedure (option D) performed only after complete resolution of infection.