What is the treatment for a pilonidal cyst with a tail behind the neck?

Pilonidal Cyst Behind the Neck: Treatment Approach

Critical Clarification: Location Matters

A "cyst with a tail" behind the neck is NOT a pilonidal cyst—pilonidal disease occurs exclusively in the sacrococcygeal region (natal cleft/buttocks area), not the neck. 1, 2, 3 A cyst with a tract ("tail") in the neck region represents a dermal sinus tract (DST) or other congenital/acquired neck pathology that requires completely different management. 4

If This is Actually a Neck Mass with a Tract

Immediate Evaluation Required

Any neck mass with a draining tract or "tail" in an adult requires urgent evaluation to exclude malignancy before assuming it is benign. 4

• Do NOT assume this is a simple sebaceous cyst just because it has drainage—cystic neck masses can represent metastatic squamous cell carcinoma, particularly HPV-positive oropharyngeal cancer. 4
• Do NOT prescribe antibiotics empirically unless there are clear signs of bacterial infection (fever >38°C, tachycardia >90 bpm, leukocytosis >12,000 cells/µL). 4, 5

Diagnostic Workup

Obtain contrast-enhanced CT or MRI of the neck immediately to characterize the mass and identify any connection to deeper structures. 4

Perform fine-needle aspiration (FNA) rather than open biopsy as the initial tissue diagnosis if malignancy risk exists. 4

• FNA should be ultrasound-guided if the mass is cystic or difficult to palpate. 4
• Continue evaluation until a definitive diagnosis is obtained—do not assume a cystic neck mass is benign. 4, 5

High-Risk Features Requiring Oncologic Evaluation

You are at increased risk for malignancy if the mass has:

• Fixation to adjacent tissues 4
• Firm consistency 4
• Size >1.5 cm 4
• Duration ≥2 weeks without fluctuation 4

If high-risk features are present, perform targeted examination of the upper aerodigestive tract (larynx, base of tongue, pharynx) to identify a primary tumor site. 4

If This is Actually in the Sacrococcygeal Region (True Pilonidal Disease)

Acute Inflamed/Draining Pilonidal Cyst

Incision and drainage is the cornerstone treatment for an acutely inflamed, draining pilonidal cyst. 5

• Thoroughly evacuate all pus and probe the cavity to break up loculations to ensure complete drainage. 5
• Cover the wound with a dry sterile dressing only—do NOT pack the wound with gauze, as packing increases pain without improving healing. 5
• Do NOT routinely obtain Gram stain or culture of the drainage. 5
• Do NOT routinely prescribe antibiotics unless systemic infection signs are present (fever, tachycardia, tachypnea, leukocytosis). 5
• If antibiotics are necessary, they must cover Staphylococcus aureus. 5

Definitive Surgical Management

After acute inflammation resolves, definitive excision of the cyst and its entire tract/wall is recommended to prevent recurrence. 1, 2, 3

• Primary closure with a lateral (off-midline) approach gives the best results regarding recurrence and healing. 1
• Excision with open healing versus primary closure remains debated, but lateral closure techniques show superior outcomes. 1
• Some surgeons prefer incision and curettage for lower morbidity, though recurrence rates vary. 2, 3

Preventing Recurrence

• Hair removal (shaving) of the sacrococcygeal area is essential to prevent hair insertion, which drives the disease process. 1, 3
• Meticulous wound care is critical regardless of surgical technique chosen. 3

Common Pitfalls to Avoid

• Never assume a neck mass with drainage is benign without tissue diagnosis—this can delay cancer diagnosis. 4
• Never perform open biopsy of a neck mass before FNA and imaging—this can compromise oncologic outcomes if malignancy is present. 4
• Never close a drained abscess cavity without ensuring complete evacuation—this leads to recurrent infection. 5
• Avoid unnecessary antibiotics—inflammation in cysts is often sterile (foreign body reaction to cyst contents), not infectious. 5