The incidence of microscopic thyroglossal duct tissue superior to the hyoid bone

Some uncommon cystic lesions in the anterior head and neck region: Pitfalls to be avoided on cytology

Cystic lesions of the anterior head and neck region are a challenging and frequent finding on cytological smears. The scant amount of cellular material in cystic slides poses the greatest difficulty to interpretation, so that frequently they are diagnosed as inadequate or with minimal cellular component. Despite the majority of cystic lesions being benign, a minor portion consist of malignant cystic entities. In these latter cases, the evidence of very scant malignant cells can be misdiagnosed and/or underestimated, leading to a false negative diagnosis. Many papers have already described and detailed the range of possible benign and malignant cystic lesions in head and neck. In the current review we have focused on the less common entities that often lead to serious misinterpretation.

Imaging of pharyngeal pathology

The pharynx plays a significant role in swallowing and speech, and this is reflected in both its complex anatomy and degree of physiological motility. Patients who present with pharynx-related symptoms such as sore throat, globus, dysphagia or dysphonia will usually undergo visual and nasal endoscopic examination in the first instance. Imaging is frequently required to supplement clinical assessment and this typically involves MRI and CT. However, fluoroscopy, ultrasound and radionuclide imaging are valuable in certain clinical situations. The aforementioned complexity of the pharynx and the myriad of pathologies which may arise within it often make radiological evaluation challenging. In this pictorial review, we aim to provide a brief overview of cross-sectional pharyngeal anatomy and present the radiological features of a variety of pharyngeal pathologies, both benign and malignant.

Two-centre experience in the treatment of thyroglossal duct remnants using the modified muscle-sparing Sistrunk technique

The Sistrunk procedure has long been the method of choice for treating patients with thyroglossal duct remnants (TDRs). However, the extent of the surgical resection in the suprahyoid segment of the TDR remains controversial, as this anatomical site is the origin of both disease recurrence and surgical morbidity. The aim of this two-centre retrospective cohort study was to investigate the outcomes of a modified muscle-sparing Sistrunk procedure in primary TDRs. The primary predictor was the surgical approach, and the outcome variable was the recurrence rate. A total of 110 consecutive patients (62 (56.4%) male, 48 (43.6%) female) who underwent a modified muscle-sparing Sistrunk procedure were included in the study. Their mean age at presentation was 26.9 ± 18.9 years. A modified muscle-sparing Sistrunk procedure using cold instruments, electrocautery, and a harmonic scalpel was performed in all patients. Recurrence was recorded in six (5.5%) patients. The median hospital stay was 2 days (range 1-7 days), and the median follow-up duration was 7 years (range 2-13 years). There was no significant difference in recurrence rate between the conventional and modified muscle-sparing Sistrunk procedure in primary TDRs. The study findings showed that the modified muscle-sparing Sistrunk procedure had low recurrence and complication rates in the context of primary TDR.

Removal of Thyroglossal Duct Cyst by a Submental Approach

BACKGROUND

Thyroglossal duct cyst (TGDC) is the most common congenital cyst in the neck and is removed by the Sistrunk procedure. This surgery involves a horizontal skin incision over the cyst that may leave a noticeable scar on the front of the neck. Therefore, this study examined the clinical outcomes and cosmetic benefits of the Sistrunk procedure by an incision in the submental area that is not easily visible from the front.

MATERIALS AND METHODS

This observational study was performed on 152 patients who underwent the Sistrunk procedure by a submental approach to remove TGDC at a university medical center. Intraoperative findings, postoperative complications, subjective pain levels, and satisfaction with incision scars and neck and facial deformities, and recurrence were prospectively evaluated.

RESULTS

The length of the submental incision was about 3 cm and the median total operation time was 36 min. Postoperative complications were minimal. Hematoma occurred in two cases (1.3%), surgical site infection in 1 case (0.7%), and dysphagia for more than 1 week occurred in 1 case (0.7%). On a 0-10 visual analogue scale, the pain had a median value of 2 on the first day after surgery, and satisfaction with incision scars and neck and facial deformities showed median values of 8 and 10 at 6 months after surgery, respectively. Recurrence occurred in one patient (0.7%) during the median follow-up period of 68 months.

CONCLUSIONS

The submental approach for TGDC excision may be a reliable new surgical method that is safe and has cosmetic advantages. This observational study evaluated the clinical outcomes and cosmetic benefits of the Sistrunk procedure by a submental incision for thyroglossal duct cyst in 152 patients. The surgical procedure showed no increased operation time, no need for wide flap elevation, easy suprahyoid dissection, and an invisible scar in a natural position of the neck.

Coexisting Thyroglossal Duct Cyst with Papillary Thyroid Cancer: A Case Report and Literature Review

Thyroglossal duct cysts (TGDCs) are common developmental anomalies in which the thyroglossal duct is not obliterated. Coexisting papillary thyroid cancer and TGDC are uncommon and should be investigated thoroughly to rule out TGDC carcinoma. We report a rare case of coexisting papillary thyroid cancer and TGDC in a 48-year-old man, who presented with a history of recurrent mild painful midline neck swelling, and ultrasound (US) revealed a TGDC that was subsequently managed conservatively. On follow-up after 1.6 years, a thyroid US and a fine-needle aspiration (FNA) biopsy were performed, which showed malignant papillary thyroid carcinoma. Total thyroidectomy, the Sistrunk procedure, and central neck dissection were implemented. After three days, the patient was discharged on 150 mg of levothyroxine. Follow-up was unremarkable with no complications. The authors would like to stress the importance of regular TGDC and thyroid gland follow-ups for early detection and diagnosis of thyroid malignancy via clinical examination and US.

Pediatric thyroglossal duct cyst excision: A NSQIP-P analysis of 30-day complications

OBJECTIVE

Identify and compare clinical risk factors, perioperative sequelae, and surgical complications of infants age 2 or younger to children above age 2 undergoing thyroglossal duct cyst (TGDC) excision.

METHODS

Retrospective analysis of the American College of Surgeons National Surgical Quality Improvement-Pediatric Database (2014-2018). Study population includes pediatric patients (≤18 years) who underwent excision of TGDC. Infants aged 2 years or younger were compared to children older than 2 years.

RESULTS

A total of 3052 cases were identified. There were 375 infants with an age of 2 years or younger and 2977 children who were older than 2 years. Mean age at time of surgery was 6.3 years, with a female-to-male ratio of 1:1.1. Following hospital discharge, there were 70 related readmissions and 3 related reoperations. There was no statistically significant gender (p = .270) or ethnic (p = .122) differences between groups. Additionally, a history of prematurity (p = .759) and postoperative admission status (ie, inpatient versus outpatient, p = .697) were not statistically significantly different between groups. Lastly, general complication rates between age groups including Clostridium difficile colitis, occurrences of bleeding and blood transfusion, surgical site infections, related readmission, and reoperation were not statistically significantly different.

CONCLUSION

TGDC excision was not shown to be associated with increased risk when performed in infants age 2 or younger compared to children older than age 2.

Modified Sistrunk procedure in a pediatric population: Infected thyroglossal duct cysts as a risk factor for recurrence and review of the literature

AIM

To analyze the rate of recurrence and possible risk factors after surgical treatment in pediatric patients with thyroglossal ductus cyst (TGDC), who underwent the Modified Sistrunk Procedure (MSP).

DESIGN

Retrospective study.

INSTITUTION

The pediatric otorhinolaryngology clinic of a university.

MATERIALS AND METHODS

The study included a total of 251 pediatric patients aged between 2 and 17 years, whose histopathological diagnosis was confirmed and who underwent MSP due to TGDC over a period of 10 years from January 2009 to December 2019. The chi-square test was used to determine the relationship between the independent variables and the dependent variables. Parameters used in the study: The parameters were age, gender, the history of infected TGDC before surgery (cellulitis, abscess), incision and drainage in patients with abscess, number of cysts detected in ultrasonographic imaging, postoperative histopathology, and the number of recurrences.

RESULTS

The study included a total of 251 pediatric patients. The mean age of the children was 6.2 years (2-17 years), the mean follow-up period was 4.8 years (2-6 years), and 38 (15.13%) recurrences were observed after 251 MSP applications. Five risk factors were found to be statistically significant in terms of recurrence rates (p<0.05). These risk factors were surgery during the school period (6-10 years), history of infected TGDC, abscess formation, incision/drainage before MSP, and multicystic cyst in ultrasonographic evaluation.

CONCLUSION

The main determinant for the five significant risk factors among the causes of MSP recurrence is a history of infected TGDC before surgery. When there is no history of TGDC infection in pediatric patients before surgery, surgery should be planned under appropriate conditions before infection occurs. The risk of infected TGDC, cellulitis, and abscess formation increases at school age in particular due to frequent upper respiratory tract infections. When there is a cyst infection, antibiotic treatment should be applied, and incision and drainage should be avoided as much as possible in the presence of an abscess.

The Relevance of and Surgical Approach to the Suprahyoid Region in Thyroglossal Duct Surgery

OBJECTIVES

Persistent or recurrent disease following excision of a thyroglossal duct cyst/sinus (TGDC) is often found in the suprahyoid region. Cadaver dissections were performed to identify and name important surgical landmarks in the suprahyoid area; a histopathologic analysis of surgical specimens was completed to determine the incidence and extent of microscopic disease; and clinical outcomes were compared to determine the efficacy of a specific anatomic dissection.

STUDY DESIGN

Retrospective case series.

METHODS

Standardized dissections of four adult cadavers were performed. Consecutive surgical specimens were examined for evidence of microscopic TDGC disease in the suprahyoid region, measuring the greatest width and length of disease. A retrospective review of all consecutive TGDC procedures was completed.

RESULTS

The important surgical landmarks in the suprahyoid area were identified in all cadavers. Microscopic disease in the suprahyoid area was found in 79% (37 of 47) of surgical specimens. The mean greatest length and width of microscopic disease was 12.4 mm and 1.4 mm, respectively. Following identification of these landmarks, the incidence of recurrent or persistent disease decreased (P = .02) from 5% (8 of 159) to 0% (0 of 112).

CONCLUSION

The majority of pediatric patients with a TGDC will have microscopic disease in the suprahyoid area. The surgical landmark of the fascial plane between the geniohyoid and genioglossus muscles demarcates the anterior and lateral borders of resection in the suprahyoid area. This approach can be used as a reliable and easily reproducible technique in TGDC surgery to increase confidence of achieving complete removal of disease in the suprahyoid area, avoiding persistent or recurrent disease and a revision procedure.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:553-558, 2021.

Thyroglossal Duct Cyst Carcinoma in a Young Female: Case Report and Review of Literature

Thyroglossal duct remnants form during embryologic development and can develop into a thyroglossal duct cyst (TGDC). In rare cases, carcinoma is present within these cysts, most commonly papillary thyroid carcinoma. Diagnosis is difficult, but imaging and fine-needle aspiration (FNA) biopsies can help with the diagnosis. Given the rarity of TGDC carcinoma, treatment is not well agreed upon and can include the Sistrunk procedure, thyroidectomy, nodal dissection, and postoperative radioactive iodine treatment. Here, we describe the presentation, workup, and treatment of a 20-year-old female with papillary thyroid carcinoma present within both a thyroglossal duct cyst and the thyroid gland.

Why Central Neck Dissection Works (and Fails) for Recurrent Thyroglossal Duct Remnants

OBJECTIVE

To review the patient characteristics and outcomes for children and undergoing central neck dissection for control of recurrent thyroglossal duct cysts and fistula following prior Sistrunk procedures and children requiring surgery for refractory infection.

METHODS

We performed a computerized review of all children who were evaluated for thyroglossal duct cysts during the years 1999-2018 by a single surgeon operating at an urban children's hospital and an outpatient surgical center. Those requiring a central neck dissection for control of recurrent disease or intractable infection were identified. Age at time of surgery, sex, surgical procedure, and postoperative complications were recorded. These data were combined with similar data from a published report by the same surgeon in the years 1990-1998 to complete a 28-year review.

RESULTS

18 central neck dissections were performed including 13 for recurrent thyroglossal duct remnants after Sistrunk procedures and 5 primary surgeries for intractable infection. Ages ranged from 3 to 19 years (median = 10 years) and 13 of 18 were girls (72%). Four children had their first Sistrunk surgery performed by the senior author. Three children operated elsewhere had intact hyoid bones at the time of revision surgery, suggesting less-than-Sistrunk primary surgeries. Central neck dissection controlled disease in the lower neck in all cases. One child re-fistulized at the level of the hyoid.

CONCLUSIONS

Central neck dissection in combination with a Sistrunk-type dissection of the tongue base is effective in the control of recurrent infection following unsuccessful Sistrunk surgery and aids in dissection for children with intractable infection. Although this technique reliably controls infrahyoid disease and improves access to the hyoid and posterior hyoid space, it does nothing to address the difficulties of following the thyroglossal tract into the tongue base.