What is the procedure for thyroglossal duct cyst removal surgery?

Thyroglossal Duct Cyst Removal Surgery: The Sistrunk Procedure

Origin and Background

Thyroglossal duct cysts (TGDCs) are the most common congenital neck masses and the second most common childhood cervical masses. They develop from remnants of the embryonic thyroglossal duct that fails to involute during development 1. These cysts typically present as midline neck masses that move with tongue protrusion and swallowing 1.

Surgical Procedure: The Sistrunk Procedure

The Sistrunk procedure is the gold standard for thyroglossal duct cyst removal, involving excision of the cyst, the tract connecting it to the foramen cecum, and the central portion of the hyoid bone to minimize recurrence. 1, 2

Step-by-Step Surgical Approach:

1. Preoperative Assessment:

   • Confirm normal thyroid gland presence through imaging (legally protective requirement) 1
   • Consider fine needle aspiration if malignancy is suspected (carcinoma in TGDC is rare) 1

2. Surgical Technique:

   • Patient is positioned with neck extended 2
   • A horizontal incision is made over the cyst in a natural skin crease 2
   • Subplatysmal flaps are raised superiorly and inferiorly 2
   • The cyst is identified and carefully dissected from surrounding structures 2
   • The central portion of the hyoid bone is identified and excised 1, 2
   • The tract is followed superiorly toward the foramen cecum, with removal of a core of tongue base muscle 2
   • Meticulous hemostasis is achieved 2
   • The wound is closed in layers with drainage if necessary 2

Clinical Considerations and Outcomes

Recurrence Rates:

• Overall recurrence rate is approximately 9.7% 3
• Recurrence rate after proper Sistrunk procedure: 5.3% 3
• Recurrence rate after simple cyst excision without hyoid bone removal: 55.6% 3

Risk Factors for Recurrence:

• Incomplete excision (failure to remove central hyoid bone) 3, 2
• Postoperative infection significantly increases recurrence risk 3
• Failure to excise the tract extending to the foramen cecum 2

Complications:

• Infection
• Hematoma
• Seroma
• Injury to surrounding structures (hypoglossal nerve, superior laryngeal nerve)
• Rare risk of airway compromise 4

Special Considerations

Adult Presentation:

• TGDCs can present later in life, often with infection as the initial symptom 4
• Infected cysts in adults may require initial antibiotic treatment before definitive surgery 4

Alternative Approaches:

• Endoscope-assisted transoral approach using a frenotomy incision has been described to avoid neck scarring, but requires further validation 5
• This approach takes approximately 60 minutes operatively but avoids external neck scarring 5

Postoperative Care

• Monitor for signs of infection or hematoma
• Antibiotics may be prescribed if infection was present preoperatively
• Follow-up to assess for recurrence, particularly in the first year after surgery 3

The Sistrunk procedure remains the definitive treatment for thyroglossal duct cysts with the lowest recurrence rates and acceptable morbidity 3, 2. Proper surgical technique with removal of the central hyoid bone and tract to the foramen cecum is essential for successful outcomes.