What is the recommended treatment for a child or young adult presenting with a thyroglossal duct cyst?

Thyroglossal Duct Cyst: Recommended Treatment

The Sistrunk procedure is the definitive surgical treatment for thyroglossal duct cysts in children and young adults, involving complete excision of the cyst, the central portion of the hyoid bone, and a core of tissue extending to the foramen cecum. 1

Preoperative Evaluation

Before proceeding to surgery, specific assessments are essential:

• Document normal thyroid anatomy with ultrasound imaging to confirm the presence of a functioning thyroid gland, as concomitant thyroid agenesis, though extremely rare, must be excluded 1, 2
• Consider thyroid function testing if there is any concern about thyroid status 1
• Obtain fine-needle aspiration if malignancy is suspected based on characteristics such as a hard, fixed mass with rapid growth or vocal cord paralysis 1

Surgical Technique: The Sistrunk Procedure

The gold standard surgical approach includes these specific components:

• Complete excision of the cyst and tract extending from the cyst to the foramen cecum at the base of the tongue 1, 2
• Removal of the central portion of the hyoid bone at its junction with the lateral horns, which can be accomplished safely using monopolar electrocautery 1, 3
• Excision of a core of deep lingual muscle extending to the foramen cecum to ensure complete tract removal 1, 2

This comprehensive approach achieves recurrence rates of only 3-5% when performed adequately, compared to significantly higher rates with simple cyst excision or marsupialization 1, 4

Risk Factors for Recurrence

Understanding these factors helps optimize surgical timing and technique:

• Non-adherence to the Sistrunk procedure is the only statistically significant risk factor for recurrence, with simple excision or marsupialization showing substantially higher failure rates 4
• More than 2 preoperative infections increase recurrence risk (P<0.05) 5
• Age less than 2 years at surgery is associated with higher recurrence (P<0.05) 5
• Multicystic lesions on histopathology carry increased recurrence risk (P<0.01) 5
• Previous incomplete surgical procedures significantly increase recurrence rates (P<0.05) 5

Optimal Surgical Timing

Based on recurrence risk factors, the ideal approach is:

• Perform definitive Sistrunk procedure before any infection occurs in children over 2 years of age to minimize recurrence risk 5
• For children under 2 years, surgery may be delayed unless there are compelling indications such as recurrent infections or significant symptoms 5
• If infection has occurred, allow complete resolution before proceeding with definitive surgery, though this must be balanced against the risk of multiple infections 5

Postoperative Management

• Postoperative imaging follow-up is not required if clinical evolution is favorable 1
• Ultrasound or CT with contrast may be indicated only if there is clinical suspicion of recurrence, such as return of a midline neck mass 1
• Mean follow-up should extend at least 55 months to adequately assess for late recurrences 3

Common Pitfalls to Avoid

• Never perform simple cyst excision or marsupialization as definitive treatment, as these approaches have significantly higher recurrence rates compared to the Sistrunk procedure 4
• Do not proceed with surgery without documenting normal thyroid anatomy, as this has become a legally protective requirement despite the extreme rarity of thyroid agenesis 2
• Avoid operating during active infection, as this increases recurrence risk; allow complete resolution first 5
• Do not underestimate the importance of complete hyoid bone removal, as incomplete excision is associated with higher recurrence 3, 4