What is the primary treatment for a thyroglossal duct cyst?

Treatment of Thyroglossal Duct Cyst

The primary treatment for a thyroglossal duct cyst is the Sistrunk procedure, which involves complete excision of the cyst, the central portion of the hyoid bone, and a core of tissue extending to the foramen cecum. 1, 2

Clinical Presentation and Diagnosis

• Thyroglossal duct cysts typically present as an anterior midline neck mass that moves vertically with tongue protrusion and swallowing 1
• These are the most common congenital neck masses and usually manifest during the first decade of life, though they can present in adults as well 3
• Ultrasonography is the preferred diagnostic imaging modality (used in 66% of cases) to evaluate these cysts 3
• Documentation of normal thyroid gland function and position is recommended prior to surgery to rule out thyroid agenesis, which is rare but important to identify 1

Surgical Management

The Sistrunk Procedure

• The Sistrunk procedure is the gold standard treatment for thyroglossal duct cysts 4, 2
• This procedure includes:
  • Complete excision of the thyroglossal cyst
  • Removal of approximately 10mm of the central portion of the hyoid bone
  • Excision of a core of tissue in the suprahyoid region extending up to the foramen cecum 4
• The complete procedure significantly reduces recurrence rates from approximately 50% (with simple cyst excision) to 3-5% 2

Technical Considerations

• The procedure is typically performed under general anesthesia 4
• Complete hyoid bone section ensures ideal access to the posterior hyoid space and allows greater access to the proximal portion of the thyroglossal duct 5
• Some surgeons use electrocautery for hyoid bone removal as an alternative to bone-cutting forceps, which may provide more accurate excision 5

Outcomes and Complications

• The Sistrunk procedure is considered safe and effective with minimal morbidity 4
• Average hospital stay is typically around three days 4
• Potential complications include:
  • Local edema (observed in some cases)
  • Wound dehiscence (rare)
  • Recurrence requiring reoperation (approximately 8.8% in some series) 5
• Long-term follow-up shows excellent outcomes with very low recurrence rates when the procedure is performed correctly 4, 2

Special Considerations

• In rare cases, carcinoma may develop within a thyroglossal duct cyst, though this is uncommon and rarely detected preoperatively 1
• Fine needle aspiration may be helpful if malignancy is suspected, but the Sistrunk procedure remains the treatment of choice regardless 1
• Adult patients tend to have larger cysts (median 30mm vs 22mm in children) and require longer operation times compared to pediatric patients 3

Pitfalls to Avoid

• Simple excision of the cyst alone without removing the central portion of the hyoid bone and the tract leads to high recurrence rates and should be avoided 2
• Incomplete excision of the tract extending to the foramen cecum is a common cause of recurrence 4, 2
• Failure to document normal thyroid function and position preoperatively could lead to undiagnosed thyroid agenesis 1