Treatment of Thyroglossal Duct Cyst
The Sistrunk procedure is the definitive surgical treatment for thyroglossal duct cysts, involving complete excision of the cyst, the entire thyroglossal duct tract up to the foramen cecum, and the central portion of the hyoid bone. 1, 2, 3
Preoperative Evaluation
Before proceeding with surgery, specific imaging and laboratory assessments are essential:
- Ultrasound imaging of the neck must be performed to document normal thyroid gland anatomy, as concomitant thyroid agenesis, though extremely rare, must be excluded for both clinical and medicolegal reasons 4, 2
- Thyroid function testing (TSH) should be considered if there is any concern about thyroid status 4
- Fine needle aspiration may be helpful if malignancy is suspected, though carcinoma in a thyroglossal duct cyst is unusual and rarely detected preoperatively 2
Surgical Technique: The Sistrunk Procedure
The standard surgical approach involves three critical components that must all be addressed to prevent recurrence:
- Complete excision of the cyst itself 1, 2, 3
- Removal of at least 10 mm of the central portion of the body of the hyoid bone (excision at the cartilage junction with lateral horns) 1, 5
- Excision of a core of tissue in the suprahyoid region extending all the way up to the foramen cecum to ensure complete removal of the thyroglossal duct tract 1, 2, 3
Technical Considerations
- The hyoid bone can be 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 5
- Central compartment neck dissection with mid-anterior neck dissection effectively prevents recurrence 3
- Surgical drains are generally not necessary, and most patients can be discharged within 48 hours postoperatively 3
Critical Pitfall to Avoid
The most serious complication occurs when the thyroid cartilage is mistaken for the hyoid bone, particularly in young children where the hyoid may override the thyroid notch 6. This can result in:
- Significant injury to the cricothyroid membrane and/or thyroid cartilages 6
- Need for urgent laryngotracheoplasty with cartilage grafts 6
- Tracheotomy requirement (average decannulation time 4.5 months) 6
- Poor voice outcomes in the majority of cases 6
Surgeons must remain precisely oriented to midline cervical anatomy throughout the procedure to avoid this devastating complication 6
Expected Outcomes
When performed correctly, the Sistrunk procedure demonstrates excellent results:
- No recurrence when all three components (cyst, hyoid bone, and complete tract) are removed 1, 3
- Recurrence rate of approximately 8.8% when technique is modified or incomplete 5
- No significant morbidity or mortality when performed by experienced surgeons 1
- Average surgical time of approximately 57 minutes 5
- Mean hospital stay of 2-3 days 1, 3