Complications and Disabilities After Hyoid Bone Excision in Sistrunk Procedure
Direct Answer
The Sistrunk procedure with hyoid bone excision is generally safe with a moderate complication rate, primarily involving temporary dysphagia (up to 4 weeks), self-limited aspiration, hematomas/seromas, wound healing disturbances, and temporary articulation distortions, though serious airway injury can occur if anatomical landmarks are misidentified. 1
Common Complications
Temporary Functional Impairments
- Dysphagia occurs commonly but typically resolves within 4 weeks postoperatively, representing the most frequent functional complaint after hyoid bone excision 1
- Self-limited aspiration may occur during the immediate postoperative period but generally resolves without long-term sequelae 1
- Temporary articulation distortions have been reported but are not permanent 1
Wound-Related Complications
- Hematomas and seromas represent common local complications that typically resolve with conservative management 1
- Disturbances of wound healing occur but are generally manageable 1
- Partial wound dehiscence has been reported in isolated cases (approximately 1.8% in one pediatric series) 2
- Postoperative local edema may occur immediately after surgery but resolves spontaneously 2
Serious but Rare Complications
Catastrophic Airway Injury
- Significant airway injury can occur if the thyroid cartilage is mistaken for the hyoid bone during the Sistrunk procedure, particularly in young children where the hyoid may override the thyroid notch 3
- Injury patterns include damage to the cricothyroid membrane and/or thyroid cartilages, requiring urgent laryngotracheoplasty with cartilage grafts 3
- All patients with significant airway injury ultimately required tracheotomy, with decannulation achieved after an average of 4.5 months 3
- Voice outcomes were poor in 75% of patients (3/4) who sustained airway injury, representing a permanent disability 3
- No aspiration occurred in patients who sustained airway injury after repair, though this required extensive reconstructive intervention 3
Prevention of Airway Injury
- Surgeons must remain precisely oriented to midline cervical anatomy throughout the procedure to avoid mistaking the thyroid cartilage for the hyoid bone 3
- Particular vigilance is required in young children where anatomical relationships differ from adults 3
- Complete hyoid bone section with electrocautery only (rather than bone forceps) may provide better anatomical orientation and more controlled dissection 2
Recurrence Rates
Overall Recurrence
- Recurrence rates range from 0% to 11.1% depending on surgical technique and completeness of excision 4, 5
- Inadequate excision of disease in the suprahyoid region significantly impacts recurrence, with rates dropping from 11.1% to 0% when a reliable approach to this area is consistently applied 4
- One pediatric series reported 8.8% recurrence requiring re-do surgery over a mean follow-up of 55 months 2
Surgical Technique Considerations
Hyoid Bone Division Methods
- Electrocautery-only division of the hyoid bone body ensures ideal access to the posterior hyoid space with negligible complication rates 2
- Bone excision by cut-bone forceps may prove inaccurate and somewhat dangerous compared to electrocautery 2
- Division of the cartilaginous portion of the hyoid (rather than conventional bone cutting) is feasible and shows comparable or better postoperative results, particularly in pediatric patients where 96% have non-fusion of the hyoid 6
Operative Details
- Mean surgical time ranges from 35 to 125 minutes (mean 57 minutes in one series) 2
- Postoperative drain is required in approximately 10% of cases 2
- No postoperative bleeding was observed in one series of 57 pediatric patients using electrocautery-only technique 2
- Average hospital stay is approximately 3 days with no need for blood transfusion in uncomplicated cases 5
Long-Term Disabilities
Functional Outcomes
- No persistent voice changes or dysphagia were reported in patients undergoing uncomplicated hyoid suspension or tongue base procedures that involve hyoid manipulation 1
- No changes in swallowing or speech were observed in patients undergoing radiofrequency surgery combined with hyoid suspension 1
- Permanent disabilities are rare when the procedure is performed correctly, with most complications being temporary 1
Exception: Airway Injury Cases
- Poor voice outcomes are anticipated in patients who sustain airway injury during the procedure 3
- This represents the only documented permanent disability associated with hyoid bone excision in the Sistrunk procedure 3
Critical Pitfalls to Avoid
- Never mistake the thyroid cartilage for the hyoid bone, as this leads to catastrophic airway injury requiring tracheotomy and resulting in permanent voice impairment 3
- Ensure complete excision of the suprahyoid region to minimize recurrence risk, as inadequate excision is the primary cause of disease recurrence 4
- Maintain precise midline orientation throughout the procedure, particularly in young children where anatomical relationships differ 3
- Consider electrocautery-only technique for hyoid division rather than bone forceps to improve accuracy and safety 2