"Extended" Sistrunk procedure in the treatment of recurrent thyroglossal duct cysts: a 10-year experience

Does thyroglossal duct arborization play a role in the post-surgical outcome of Sistrunk procedure in children?

PURPOSE

The purpose of the present study is to analyze thyroglossal duct cyst (TGDC) histopathological features, with focus on "arborization", in a cohort of pediatric patients who underwent surgical removal, and evaluate a possible correlation with clinical recurrences.

METHODS

A retrospective analysis of all patients who underwent surgical resection for TGDC at the division of Pediatric Surgery of the University of Pisa from 2015 to 2020 was performed; for each patient, the following data were recorded: age, sex, clinical presentation, localization, size of the lesion, diagnostic tools, histopathological features, perioperative complications, recurrence and follow-up.

RESULTS

With respect to arborization, following histopathological analysis 25/30 patients (83.3%) presented thyroglossal duct branching. After a median follow-up of 3.5 years, only 2 out of 30 patients (6.7%), one male and one female, respectively aged 4 y.o. and 6 y.o., presented recurrence within one year from first surgery.

CONCLUSION

Surgery for TGDC remains a challenge for pediatric surgeons, while arborization was present in most of our cases which underwent surgery. With respect to the role of arborization, our study did not highlight sufficient conclusive data regarding their role in recurrence: instead, it showed wide resection as satisfactory, being the arborization present in most of the cases at histopathology.

A Rare Recurrence of a Thyroglossal Duct Cyst Accompanied by Several Postoperative Complications in an Eight-Year-Old Boy: A Case Report

A thyroglossal duct cyst (TGDC) is a fluid-filled mass in the neck resulting from the persistence of a duct from fetal development that typically regresses spontaneously. When it persists, it is most often removed in a surgical procedure known as a Sistrunk operation. This case study presents the intriguing case of an eight-year-old boy who presented to an otolaryngology clinic with both a recurrence of his TGDC, as well as several postoperative complications, after the Sistrunk operation was performed. After the initial procedure resulted in an incomplete removal of the TGDC, the patient was referred to Interventional Radiology for sclerotherapy. After several rounds of this treatment technique the cyst remnants still persisted along with their associated symptoms. Due to the very low likelihood of a recurrence being observed after surgical removal with subsequent sclerotherapy, the reappearance of the cyst raised several clinical questions. This report underscores the significance of a thorough evaluation and consideration of unique presentations when confronted with recurrent TGDCs.

Risk-adjusted analysis of perioperative outcomes after the Sistrunk procedure

Objectives

Thyroglossal duct cyst (TGDC) is the most common pediatric congenital neck mass. The Sistrunk procedure is the standard method of excision and is associated with low rates of recurrence. This study aimed to review our institution's outcomes following the Sistrunk procedure, specifically the rates of wound complications and cyst recurrence.

Methods

This was a retrospective case series of pediatric patients undergoing the Sistrunk procedure from June 2009 to April 2021.

Results

A total of 273 patients were included. Of these, 139 (53%) patients were male and 181 (66%) were white. The average age at the time of surgery was 7.1 years. The overall cyst recurrence rate was 11%. The most common wound complications were seroma (14%) and surgical site infections (SSIs) (12%). Wound complications were associated with prior history of cyst infection (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.07-3.60, z-test 2.2, p = .03). Pediatric surgery was associated with fewer wound complications (OR 0.18; 95% CI 0.05-0.6, z-test -2.78, p = .005). However, pediatric surgery operated on fewer patients with a history of cyst infection (36% vs. 55%, p = .012). Drain placement and postoperative antibiotics did not affect rates of wound complications.

Conclusions

Prior cyst infection is associated with increased rates of postoperative wound complications. Postoperative antibiotics and drain placement did not significantly affect complication rates.

Level of Evidence

4.

Evaluation of preoperative cutaneous fistula as a risk factor for recurrence of thyroglossal duct cyst in children

The aim of this study is to investigate the risk factors for recurrence after thyroglossal duct cyst (TGDC) surgery, differentiating between infections with and without a cutaneous fistula. This is a retrospective analysis of all paediatric TGDC in a tertiary care centre with at least 2 years of postoperative follow-up. One hundred and thirty-one patients met the inclusion criteria of the study. A multivariate analysis was performed to analyse the main risk factors for recurrence (presence of a fistula, infection, age). 116/131 patients were managed primarily in our institution; 15 patients had previously been operated on in another centre. The recurrence rate was 4.3% (5/116) when the patient was operated on in our institution at the first operation, and overall, recurrence of TGDC occurred in 20/131 (15.3%) patients. Age was not a risk factor for recurrence (p = 0.596). Two or more episodes of preoperative TGDC infection were a statistically significant risk factor in univariate analysis (p = 0.021) but not in multivariate analysis adjusted for age and the presence of a cutaneous fistula (p = 0.385). In multivariate analysis, cutaneous fistula formation was an independent risk factor for recurrence when adjusted for age and preoperative TGDC infection (Hazard ratio = 5.35; p = 0.011).

CONCLUSIONS

A preoperative cutaneous fistula was a critical and independent risk factor for recurrence of operated TGDC, whereas age and TGDC infection were not identified as risk factors for recurrence after surgery. This information should be given to patients and parents before surgery.

WHAT IS KNOWN

• The risk factors for recurrence after thyroglossal duct cyst surgery described in the literature are preoperative infection and young age, but this is not supported by strong evidence. • The role of cutaneous fistula formation is unclear.

WHAT IS NEW

• The main risk factor for recurrence of TGDC is the presence of a preoperative cutaneous fistula, with an estimated hazard ratio of 4.95 (p = 0.016) in multivariate analysis. • The presence of two preoperative infections was also associated with a greater risk of recurrence in univariate analysis; age and gender were not associated with an increased risk of recurrence.

[Benign skin neoplasms in children]

There are many different types of skin neoplasms in children and most are benign. Dermatologists should be able to differentiate between the various types of benign skin neoplasms and be able to recommend optimal treatment to concerned patients. Surgical removal of benign skin neoplasms is often the only treatment option. The aim of this paper is to provide a general overview of epidermal lesions (e.g., inflammatory linear verrucous epidermal nevus [ILVEN], nevus sebaceous), tumors of the epidermal appendages (e.g. pilomatrixoma), cutaneous neoplasms (e.g. angiofibroma), fibromatoses (e.g., knuckle pads), tumors comprised of fat, muscle, or bone tissue (e.g., osteoma cutis, subungual exostosis), epidermal cysts and pseudocysts, and pathologic fibrosis reactions after dermal injury (keloid). Scientific data are scarce and only in the last decade has it been possible to perform histopathological examinations and genetic studies together with detailed phenotyping to gain new understanding of the pathogenetic mechanisms.

Optimal age of surgery for children with thyroglossal duct cysts: A single-institution retrospective study of 340 patients

OBJECTIVE

The recommended age of surgery for thyroglossal duct cysts (TGDCs) in children is inconclusive. This study aimed to explore the optimal age of surgery by analyzing the natural history of the disease and the association between the age of surgery and postoperative complications.

METHODS

All TGDC patients who underwent a modified Sistrunk procedure at our hospital between March 2010 and May 2022 were reviewed retrospectively. The evaluation focused on the age of preoperative symptomatic cystic infection, pathological inflammation, postoperative wound infection, and recurrence.

RESULTS

Of the 340 patients included in the study, the median age of surgery was 47.5 months (IQR, 24.1-61.6). Preoperative symptomatic cystic infection and pathological inflammation frequencies were 27.1% (n = 92) and 48.5% (n = 165), respectively. The cumulative hazard of symptomatic cystic infection and pathological inflammation increased steadily with age. The ages of 50% cumulative incidence of symptomatic cystic infection and pathological inflammation were 97 months and 71 months, respectively. Postoperative wound infection was higher in patients of younger age (OR = 0.96, 95% CI, 0.93-0.98, P < 0.001) and with symptomatic cystic infection (OR = 8.16, 95% CI, 2.54-36.86, P = 0.002). There was no significant association between the age of surgery and recurrence.

CONCLUSION

Although wound infection was weakly associated with younger age, the symptomatic cystic infection increasing with age has a more remarkable impact on wound infection after the Sistrunk procedure. The recurrence rate did not increase in young patients receiving surgery. Therefore, the Sistrunk procedure was safe and effective at a young age, and prompt operation in children with TGDC once diagnosed was reasonable.

OK-432 treatment of pediatric patients with recurrent thyroglossal duct cyst after surgery

&lt;b&gt;Introduction:&lt;/b&gt; Recurrent thyroglossal duct cyst after surgery is not a rare condition and first-line treatment has not been established yet.&lt;br/&gt;&lt;br/&gt; &lt;b&gt;Aim:&lt;/b&gt; Evaluation of outcomes and complications of OK-432 treatment in patients with recurrent thyroglossal duct cyst after surgery. &lt;br/&gt;&lt;br/&gt; &lt;b&gt;Material and methods:&lt;/b&gt; This study is designed as a case series with planned data collection at Tohoku Medical and Pharmaceutical University and Fukase Clinic. Five patients with recurrent thyroglossal duct cyst after surgery received this therapy between January 2014 and February 2020 on an outpatient basis, without hospitalization. OK-432 solution was injected into the lesion using an 18- or 27-gauge needle, depending on the location and size of the lesion, as well as on possible complications.&lt;br/&gt; &lt;br/&gt; &lt;b&gt;Results:&lt;/b&gt; Lesions showed marked reduction or total shrinkage in all patients, with no local scarring or deformity at the injection site. Side effects manifested as local pain at the site of injection and fever (37.5-38.5°C) observed in three patients, but the symptoms resolved within a few days.&lt;br/&gt; &lt;br/&gt; &lt;b&gt;Conclusions:&lt;/b&gt; Since OK-432 therapy is simple, easy, safe and effective, it can be used as an alternative to surgery in the treatment of recurrent thyroglossal duct cyst after surgery.

Congenital Neck Masses

Congenital neck masses (CNMs) are developmental malformations that present with a wide spectrum of clinical symptoms and signs. They account for 21% to 45% of neck masses in children and 5% to 14% in adults. This study aimed to present the clinical manifestations and treatment of CNM from single-institution experiences. A retrospective analysis of patients surgically treated for CNM in a 12-year period was performed. Altogether, 117 patients (female/male ratio, 1:1.05) were diagnosed with CNM. The mean age at presentation was 26.91 years (range, 0.01-84 years). Within the study population, 120 CNMs were identified: 52 (43.33%) thyroglossal duct remnants, 48 (40.00%) branchial cleft anomalies, 7 (5.83%) epidermoid/dermoid cysts, 4 (3.33%) hemangiomas, 3 (2.50%) lymphangiomas, 1 (0.83%) hemangiolymphangioma, 1 (0.83%) hemangioendothelioma, 1 (0.83%) internal laryngocele, 1 (0.83%) external laryngocele, 1 (0.83%) ectopic thyroid gland, and 1 (0.83%) parathyroid cyst. The lateral neck region was the most frequently affected anatomical site, followed by the midline neck location and mediastinum (54%, 45%, and 1%, respectively). Surgical excision was performed in all cases. Recurrence was recorded in 5 (4.17%) patients. The results of this study provide comprehensive information regarding the clinical spectrum of CNM. Successful management of these lesions depends on a thorough understanding of neck embryology and anatomy. Misdiagnosis and improper treatment increase the morbidity and recurrence rate of CNM.

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.

Pediatric thyroglossal duct cysts: Post-operative complications

INTRODUCTION

Thyroglossal duct cysts (TGDCs) result from incomplete involution of the thyroglossal duct and are resected with a Sistrunk-procedure. We studied and graded severity of postoperative complications in children who underwent this procedure, with corresponding risk factors.

METHODS

In our electronic health record system we reviewed the medical records of all patients aged <18 years, with surgically treated TGDC between 01-01-2005 and 31-12-2015 in two university hospitals. Risk factors (age, gender, recurrence at presentation, treatment hospital, cyst inflammation, cyst rupture, drain placement, antibiotics or postoperative infection) were studied by univariate analysis. The Clavien-Dindo surgical complication classification was used as postoperative surgical grading system.

RESULTS

Of the ninety-one patients, with a mean age of 4.4 years, seven were referred from other hospitals with a recurrent TGDC. 24 patients (26.4%) had a complication. Hemorrhage and resection of thyroid cartilage were the most severe complications. Recurrence and wound infection (both n = 7, 7.7%) were most common. We could not identify risk factors for these complications.

CONCLUSIONS

The treatment of children with thyroglossal duct cysts shows a considerable amount of complications. Pre-selected risk factors did not show any significant correlation with these complications.

The Central Neck Dissection or the Modified Sistrunk Procedure in the Treatment of the Thyroglossal Duct Cysts in Children: Our Experience

Background

The aim of the study was to present the surgical techniques providing the lowest recurrence rate in treatment of the primary and recurrent thyroglossal duct cyst (TGDC) in children.

Methods

The study included 73 patients operated on because of TGDC in years 2011-2016. Ultrasound was performed in all patients preoperatively. In 8 patients with the recurrence of the disease, the CT or MR was carried out before the surgery. Children with the primary disease underwent the modified Sistrunk procedure. In the revision cases the central neck dissection was a method of choice.

Results

In 45 children, the modified Sistrunk procedure was performed and 28 underwent the central neck dissection. In 2 patients, hematoma occurred after the modified Sistrunk procedure with the need of the surgical revision in one. No complications were observed after the central neck dissection.

Conclusions

A modified Sistrunk procedure is method of choice in the treatment of the uncomplicated TGDC. In selected cases of the TGDC with a history of infected cyst or incision of an abscess or in revision cases the central neck dissection should be considered in order to avoid the risk of the further recurrences.

The Central Neck Dissection or the Modified Sistrunk Procedure in the Treatment of the Thyroglossal Duct Cysts in Children: Our Experience

Background

The aim of the study was to present the surgical techniques providing the lowest recurrence rate in treatment of the primary and recurrent thyroglossal duct cyst (TGDC) in children.

Methods

The study included 73 patients operated on because of TGDC in years 2011–2016. Ultrasound was performed in all patients preoperatively. In 8 patients with the recurrence of the disease, the CT or MR was carried out before the surgery. Children with the primary disease underwent the modified Sistrunk procedure. In the revision cases the central neck dissection was a method of choice.

Results

In 45 children, the modified Sistrunk procedure was performed and 28 underwent the central neck dissection. In 2 patients, hematoma occurred after the modified Sistrunk procedure with the need of the surgical revision in one. No complications were observed after the central neck dissection.

Conclusions

A modified Sistrunk procedure is method of choice in the treatment of the uncomplicated TGDC. In selected cases of the TGDC with a history of infected cyst or incision of an abscess or in revision cases the central neck dissection should be considered in order to avoid the risk of the further recurrences.

Midline cervical swellings: What a paediatrician needs to know

Midline cervical swellings are a heterogeneous group of conditions in children. Careful clinical examination will allow a diagnosis to be made in many instances and appropriate investigations to be performed before referral to surgical services. The approach to clinical examination, investigation and management of the most common conditions is described.

Five-years' experience with outpatient thyroglossal duct cyst surgery

OBJECTIVES

Many pediatric surgeons feel uncomfortable doing Sistrunk procedure without drain placement and in an outpatient setting. This study aimed to review our pediatric surgery department's experience in managing thyroglossal duct cyst surgery and to prove feasibility and safety of Sistrunk procedure without drain placement in an outpatient setting.

METHODS

A retrospective review was performed of all patients who underwent Sistrunk procedure, between January 2011 and December 2015, in our department.

RESULTS

A total of 36 patients were included, with age ranging from 1 to 14 years (mean 6.3 years). Sixteen patients underwent day surgery, and 20 stayed overnight (with less than 24 h postoperative discharge). The main reason to stay overnight was distance (greater than 60 km or 1 h driving) between the hospital and patient's residence. All patients had histopathological confirmation of the diagnosis. None of the patients had a drain placed intraoperatively. There was only one readmission at 48 h postoperative; a patient who underwent day surgery came back with cervical edema, which resolved with non-operative treatment. Short-term complications included post-operative local wound infection (8,5%) and hematoma (2,9%), none of which required surgical treatment.

CONCLUSIONS

Sistrunk procedure without drain placement is safe and can be performed in an outpatient setting.

Bilateral areolar endoscopic Sistrunk operation: a novel technique for thyroglossal duct cyst surgery

BACKGROUND

Sistrunk operation of the thyroglossal duct is a procedure for the removal of a cyst, the middle part of the hyoid bone and tract towards the foramen caecum. Unavoidably, this procedure results in a scar on the skin in the neck area. By performing a bilateral areolar endoscopic Sistrunk operation, this study is the first to develop a procedure that can solve the aesthetic problem. This operation results in both an excellent cosmetic result and the successful treatment of TGDC.

METHODS

A three-port technique was performed in this operation: 10-mm port for 30°, 10-mm laparoscope, 5-mm port for the instrument at the left circumareolar area and 5-mm port located at the right circumareolar area. Insufflation pressure of CO₂ gas was set at 6 mm Hg. The surgical working space was located over the breast tissue and pectoralis muscles, towards the anterior neck to the hyoid bone. The steps employed for resection were similar to a conventional Sistrunk operation using standard laparoscopic instruments and hook scissors.

RESULTS

A series of 11 patients were successfully treated using this novel technique with neither conversion to open surgery nor surgical complications. Average operative time was 88.54 min (ranging from 60 to 130 min). Average blood loss was 35 mL. (ranging from 15 to 67 mL). Patients were discharged in an average of 2.36 days after the procedure (ranging from 2 to 3 days).

CONCLUSION

This novel technique for TGDC Sistrunk surgery using an areolar approach is feasible, safe and effective. The benefit of this technique is the cosmetic result, which leaves no scarring on the neck after wound healing and may provide a new method for optimal aesthetic results.