Thyroglossal duct cyst

Considerations

• • Anatomy - Key adjacent structures

    • Hypoglossal nerve

    • Lingual artery 

    • Superior laryngeal nerve, internal branch 

  • TGDC location

    • Usually midline

    • May be supra-hyoid, at the level of the hyoid, or infra-hyoid

    • A few cases reports of unusual locations exist, such as within the hyoid and endolaryngeal extension 

  • Indications 

    • Infection

    • Mass effect 

    • Cosmesis 

    • Concern for malignancy 

  • Contraindications

    • Acute infection

    • Relative: Only functional thyroid tissue. Removal is still possible, but the patient will need post op thyroid hormone replacement. 

Preparation

• • Positioning

    • Supine

    • Shoulder roll with neck extension

  • Ultrasound 

    • Examine the thyroid 

    • Check the size, position, and other findings of the suspected TGDC  

  • Local anesthesia

  • Incision

    • Midline curvilinear in a natural skin crease overlying or near the TGDC

    • Include an elliptical incision around any skin involved by a draining or previously drained sinus tract

Procedure

• • Incise the skin

    • Avoid violating the TGDC

  • Raise superior and inferior flaps in the subplatysmal plane

    • Superiorly, extend the dissection to the hyoid bone

    • Inferiorly, dissect only minimally to gain exposure of the inferior extent of the TGDC

  • Identify and divide the strap muscles in the midline, retract laterally to expose the TGDC

    • Note the straps may already be divided by the TGDC itself

  • Dissect the TGDC from the underlying thyroid cartilage and thyrohyoid membrane

    • Preserve its tract to the hyoid bone 

  • Grasp the hyoid bone with a tenaculum or straight Allis clamp 

  • Dissect soft tissue off the body of the hyoid

  • Transect the hyoid at the lateral aspects of its body, preserving the lesser cornu

  • Dissect and excise the retro-hyoid TGDC tract with a cuff of surrounding soft tissue

  • Optional: Place a finger or curved retractor transorally into the vallecula 

    • Avoid entering the vallecula or tongue base 

  • Irrigate 

  • Optional: Place a closed suction drain exiting lateral to the wound 

  • Closure

    • Approximate the straps in the midline with 4-0 Polysorb

    • Approximate the platysma and deep dermis with 4-0 Polysorb

    • Approximate the skin with subcuticular 5-0 Biosyn 

Sample operative report

Post-op

• • Complications 

    • Recurrence - technique dependent 

    • Injury to hypoglossal nerve, lingual artery 

    • Hematoma (potentially life-threatening)

    • Infection, sinus or fistula tract formation

    • Hypothyroidism 

Pearls & Pitfalls

High-Yield

Links

• YouTube (5:02) - Sistrunks Procedure for Thyroglossal Duct Cyst. John Chaplin, Auckland, New Zealand

• Iowa protocols - Thyroglossal Duct Cyst Excision

• eMedicine - Thyroglossal Duct Cyst Imaging

• Radiopaedia - Thyroglossal duct cyst