Treatment of Thyroglossal Duct Cyst
The Sistrunk procedure—complete surgical excision of the cyst, thyroglossal duct tract up to the foramen cecum, and the central portion of the hyoid bone—is the definitive treatment for thyroglossal duct cysts to prevent recurrence. 1, 2
Preoperative Evaluation
Before surgical intervention, confirm the presence of normal thyroid tissue to avoid removing the patient's only functioning thyroid gland, as concomitant thyroid agenesis, though extremely rare, has important legal and clinical implications 2. This can be accomplished through:
- Ultrasound imaging of the neck to document normal thyroid gland anatomy 3
- Thyroid function testing if there is any concern about thyroid status 4
Fine needle aspiration may be considered if malignancy is suspected based on clinical presentation, though carcinoma in a thyroglossal duct cyst is unusual and rarely detected preoperatively 2.
Surgical Technique: The Sistrunk Procedure
The standard surgical approach involves 1, 2, 5:
- Complete excision of the thyroglossal cyst
- Removal of the entire tract connecting the cyst to the foramen cecum at the base of the tongue
- Excision of the central portion of the hyoid bone (approximately 10mm of the body of the hyoid bone) 1
- Core of tissue removal in the suprahyoid region extending up to the foramen cecum 1
Technical Considerations
The hyoid bone can be safely sectioned using monopolar electrocautery alone, which provides ideal access to the posterior hyoid space and allows greater, more symmetrical access to the proximal thyroglossal duct with negligible complication rates 6. This technique avoids the potential inaccuracy and danger of using bone-cutting forceps 6.
Critical Surgical Pitfall
Surgeons must remain carefully oriented to midline cervical anatomy throughout the procedure. The hyoid bone may override the thyroid notch in young children, and if the thyroid cartilage is mistaken for the hyoid bone, significant airway injury can occur, potentially requiring urgent laryngotracheoplasty, tracheotomy, and resulting in poor voice outcomes 7. This represents the most serious complication of the Sistrunk procedure 7.
Postoperative Management
- Surgical drains are not necessary in most cases 5
- Hospital discharge within 48-72 hours is typical 1, 5
- No blood transfusion is typically required 1
- Follow-up monitoring for recurrence, though recurrence rates with proper Sistrunk technique are very low (0-8.8%) 1, 6, 5
Management of Infected Cysts
If the thyroglossal duct cyst presents with infection, treat with appropriate antibiotics first, then proceed with definitive surgical excision once the infection has resolved 5.
Outcomes
When performed correctly with complete excision of all thyroglossal duct remnants and the central hyoid bone, the Sistrunk procedure demonstrates excellent outcomes with minimal recurrence rates and low morbidity 1, 5. The procedure is safe and effective across all age groups, including children under 2 years of age 6.