What is the recommended treatment for a thyroglossal duct cyst?

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, 4

Preoperative Evaluation

Before proceeding with surgery, specific imaging and laboratory studies are essential:

• Neck ultrasound must be performed to document normal thyroid gland anatomy 1, as concomitant thyroid agenesis, though extremely rare, would fundamentally alter management 4

• Thyroid function testing (TSH) should be considered if there is any concern about thyroid status 1, particularly to ensure the patient has a functioning thyroid gland elsewhere

• Fine needle aspiration may be helpful if malignancy is suspected, though carcinoma in a thyroglossal duct cyst is unusual and rarely detected preoperatively 4

Surgical Technique: The Sistrunk Procedure

The standard surgical approach involves three critical components that must all be removed to minimize recurrence:

• Complete excision of the cyst itself 3, 4

• Removal of at least 10mm of the central portion of the hyoid bone body 3, with division at the cartilage junction with the lateral horns 2

• Excision of a core of tissue extending superiorly from the hyoid through the suprahyoid region up to the foramen cecum at the base of the tongue 3, 4

Technical Considerations

• The hyoid bone can be sectioned using monopolar electrocautery alone, which provides ideal access to the posterior hyoid space and allows more symmetrical access to the proximal thyroglossal duct 2

• Bone forceps for hyoid removal may prove inaccurate and somewhat dangerous, making electrocautery a preferred alternative 2

• The procedure typically requires 35-125 minutes of operative time 2

Critical Anatomical Pitfall

Surgeons must remain precisely oriented to midline cervical anatomy to avoid mistaking the thyroid cartilage for the hyoid bone, particularly in young children where the hyoid may override the thyroid notch 5. This misidentification can result in:

• Significant injury to the cricothyroid membrane and/or thyroid cartilages 5
• Need for urgent laryngotracheoplasty with cartilage grafts 5
• Tracheotomy requirement (average 4.5 months to decannulation) 5
• Poor voice outcomes in 75% of cases 5

Expected Outcomes

When performed correctly, the Sistrunk procedure demonstrates excellent results:

• Recurrence rates of approximately 8.8-10.5% 2, 3, which is significantly lower than simple cyst excision alone

• Minimal morbidity with average hospital stay of 3 days 3

• No mortality when performed by experienced surgeons 3

• Complications are rare, including occasional local edema, partial wound dehiscence, or need for postoperative drainage 2

Clinical Presentation Context

While thyroglossal duct cysts are most common in childhood, they should remain in the differential diagnosis for adults presenting with:

• Anterior midline neck mass that moves vertically with tongue protrusion and swallowing 4

• Infected neck mass or draining sinus, which is the most common presentation in adults 6

• Pain with swallowing when the cyst becomes infected 6