What is the best treatment for a patient with a tender, fluctuant, and erythematous (red) central neck cyst, without fever or throbbing pain?

Management of Tender, Fluctuant, Red Central Neck Cyst

The Sistrunk procedure is the definitive treatment of choice for a patient with a tender, fluctuant, and red central neck cyst, which is most likely a thyroglossal duct cyst with signs of inflammation. 1, 2

Clinical Assessment and Diagnosis

• The presentation of a tender, fluctuant, red midline neck mass is highly suggestive of an inflamed thyroglossal duct cyst (TGDC), which is the most common congenital anomaly of the neck 1, 3
• The absence of fever or throbbing pain suggests inflammation without frank abscess formation, making it suitable for definitive surgical management rather than just drainage 1
• TGDCs typically present as firm, midline masses that move with swallowing or tongue protrusion due to their embryologic connection to the thyroid gland 3

Rationale for Sistrunk Procedure

• The Sistrunk procedure is the gold standard treatment for thyroglossal duct cysts with a recurrence rate of less than 3% when performed correctly 1, 3
• Simple excision or aspiration alone results in unacceptably high recurrence rates of approximately 50% 2, 4
• The Sistrunk procedure involves removal of the cyst, the central portion of the hyoid bone, and a central core of tongue musculature to eliminate the entire embryologic tract 3

Why Other Options Are Inferior

• Incision and drainage (I&D): This approach addresses only the inflammatory component without removing the epithelial lining of the cyst, leading to almost certain recurrence 2
• Aspiration: While this may temporarily decompress the cyst, it fails to remove the epithelial lining and tract, resulting in recurrence rates as high as 50% 4
• Broad spectrum antibiotics: Antibiotics alone cannot eliminate the epithelial-lined tract and will only temporarily address the inflammatory component without providing definitive treatment 2

Surgical Considerations

• The procedure should ideally be performed when acute inflammation has subsided, as surgery during the inflammatory phase is a risk factor for recurrence 1
• Care should be taken to avoid cyst rupture during dissection, which increases the risk of recurrence 1, 2
• Complete excision of the central portion of the hyoid bone is essential for successful treatment 2
• The procedure has evolved to include removal of a core of tongue base tissue to ensure complete excision of any remnant thyroglossal tract 3

Potential Complications

• Perioperative complication rates are approximately 20%, with most being wound-related 2
• Factors associated with increased risk of complications include young patient age (<10 years), cyst rupture during operation, infection, and failure to excise the midportion of the hyoid bone 2
• Recurrences typically occur within 4 months of the operation if the procedure was inadequate 2

Modern Approaches

• Newer techniques such as the transoral endoscopic vestibular approach Sistrunk procedure (TEVAS) may be considered for patients concerned about visible neck scarring, though this should be performed only by surgeons experienced with the technique 5