What is the best course of treatment for a patient with an infected thyroglossal duct cyst (TGDC) with abscess?

Management of Infected Thyroglossal Duct Cyst with Abscess

For an infected thyroglossal duct cyst with abscess, initiate broad-spectrum antibiotics immediately and avoid incision and drainage; once the infection resolves with antibiotic therapy, proceed with definitive Sistrunk procedure. 1, 2

Immediate Management: Antibiotics First

• Administer broad-spectrum antibiotics as the primary treatment for the infected thyroglossal duct cyst with abscess rather than performing incision and drainage 3, 4, 2
• The antibiotic regimen should cover common oral flora including Staphylococcus aureus and streptococci, as thyroglossal duct cysts communicate with the oral cavity 3, 5
• Appropriate empirical options include clindamycin (600-900 mg every 6-8 hours IV or 300-450 mg four times daily PO) or a combination of cephalosporin plus metronidazole for broader coverage 3
• Continue antibiotics until systemic signs of infection resolve and the abscess decreases in size 3, 2

Critical Pitfall: Avoid Incision and Drainage

Incision and drainage of an infected thyroglossal duct cyst significantly increases the risk of recurrence after definitive surgery and should be avoided whenever possible. 1, 6, 2

• A 2021 pediatric study of 251 patients found that incision/drainage before the Sistrunk procedure was a statistically significant risk factor for recurrence (p<0.05) 2
• History of infected TGDC was identified as the main determinant for recurrence, with a 20% recurrence rate in patients with preoperative infection versus only 4% in those without infection (p=0.002) 1
• The 2012 Archives of Otolaryngology study found that while preoperative infection increased recurrence risk, only 1 of 6 patients who underwent incision and drainage had recurrence, suggesting antibiotics alone are preferable 1
• When abscess formation occurs, aggressive antibiotic treatment should be applied, and incision/drainage should be avoided as much as possible 2

Definitive Treatment: Delayed Sistrunk Procedure

• Schedule the Sistrunk procedure only after complete resolution of infection with antibiotic therapy 1, 5, 6, 2
• The Sistrunk procedure involves excision of the cyst, the central portion of the hyoid bone, and a core of tissue extending to the foramen cecum at the base of the tongue 5, 7
• Performing the Sistrunk procedure during active infection or shortly after incision and drainage creates tissue planes that are difficult to identify and increases recurrence risk 6, 2
• In revision cases or patients with a history of infected cyst or prior incision/drainage, consider a more extensive central neck dissection rather than the standard modified Sistrunk procedure to reduce further recurrence risk 6

When Surgical Drainage Cannot Be Avoided

If the patient develops sepsis, hemodynamic instability, or fails to respond to appropriate antibiotic therapy after 48-72 hours:

• Perform incision and drainage as a temporizing measure to control the acute infection 3, 4
• Obtain cultures of the purulent material to guide antibiotic therapy 3
• Counsel the patient that this increases the risk of recurrence after definitive surgery from 4% to 20% 1
• Plan for a more extensive resection (potentially central neck dissection) at the time of definitive surgery 6

Preoperative Imaging Considerations

• Ultrasound should be performed in all patients before definitive surgery to evaluate cyst characteristics and identify multicystic disease, which is another risk factor for recurrence 6, 2
• In revision cases or complex presentations, CT or MRI may be warranted to define anatomy before the Sistrunk procedure 6