Thyroglossal Duct Cyst and Ectopic Thyroid

Congenital Cystic Neck Masses

Congenital cystic masses are commonly encountered when imaging a patient presenting with a neck mass. Congenital cysts are present at birth; however, these cysts may not present until later in life with some growing slowly and others rapidly increasing in size due to hemorrhage of infection. A neonatal presentation is rare but when present may allow a narrower differential diagnosis. Imaging plays a significant role in defining a lesion as cystic, assessing location, and directing the next step in evaluation and or intervention.

Ectopic thyroid gland resembling a thyroglossal duct cyst

Key Clinical Message

This rare diagnosis highlights the importance of anatomical and embryological knowledge in the differential diagnosis of neck masses.

Abstract

A 41-year-old woman was referred to the head and neck surgery department because of a large midline neck mass at the level of the hyoid bone that was diagnostic for functioning thyroid tissue in a totally ectopic location.

The Outcome of Treatment for Thyroglossal Tract Anomalies

Background Thyroglossal tract anomalies are the most common cause of midline neck swelling. Thyroglossal cysts present between the base of the tongue and cricoid cartilage as painless, midline swelling that moves on deglutition and protrusion of the tongue. If the thyroglossal cyst gets infected or is violated surgically, it can result in a thyroglossal sinus or fistula. Investigations in patients with suspected thyroglossal cysts include a thyroid function test, ultrasonography of the neck, and fine needle aspiration cytology (FNAC). Computed tomography (CT) or magnetic resonance imaging (MRI) can be done for larger cysts or suspected malignancies. The gold standard treatment is Sistrunk surgery. Recurrence rates with Sistrunk surgery are lower when the surgery is performed accurately. This study was conducted to document the clinical presentation and treatment outcome in patients treated for thyroglossal tract anomalies. Methods This is a retrospective analysis of 46 medical case records of patients operated on for thyroglossal tract anomalies at a rural tertiary care hospital from April 1995 to April 2021. Patients fulfilling the inclusion and exclusion criteria were evaluated with a detailed history, various clinical presentations, location, extent of anomalies, and thyroid function test results documented. Ultrasound images were reviewed, and the findings were documented. All patients have consent, and they underwent Sistrunk surgery. Patients in whom the normal thyroid gland was found to be absent were started on replacement thyroxine after surgery. The specimen was subjected to histopathological examination by a senior pathologist. The outcome regarding complications, recurrence, and further treatment were reviewed. The outcome of the thyroglossal fistula was compared with that of thyroglossal cysts, and the outcome of infrahyoid thyroglossal tract anomalies was compared with that of suprahyoid thyroglossal tract anomalies. Results In this study, among the 46 patients, 24 (52.2%) were female and 22 (47.8%) were male. The minimum age was three years, the maximum was 58, and the mean was 20.6 years. In this study, 71.7% of the patients were diagnosed with thyroglossal cysts, 10.9% had thyroglossal fistulas, and two had lingual thyroids. The most common location of the cyst was infrahyoid (73.9%). 44 patients underwent Sistrunk surgery, and two patients diagnosed with lingual thyroid underwent excision. Three patients had complications (two pharyngo-cutaneous fistulas, one wound dehiscence), and all were managed conservatively. There were no recurrences in our study. Conclusion Thyroglossal tract anomalies are the most common congenital cervical anomalies. A complete Sistrunk procedure includes the removal of the entire thyroglossal tract, inclusive of the body of the hyoid bone along with the cuff of base tongue tissue, and gives the best result for thyroglossal tract anomalies.

Endoscopic management of intralingual thyroglossal duct cysts: Case series and systematic review

OBJECTIVE

To discuss our institutional experience with endoscopic management of intralingual thyroglossal duct cyst (TGDC) and review cases in the published literature in a systematic review.

METHODS

Pediatric patients with intralingual TGDC treated with endoscopic surgery at our institution from 2009-2019 were identified. Metrics from our case series were then compared to those in the literature in a systematic review to assess pooled outcomes of endoscopic or transoral management. Patient demographics, age of presentation, presenting symptomatology, size of cyst on imaging, type of surgery, and post-operative outcomes were assessed.

RESULTS

We identified 5 institutional cases of intralingual TGDC and 48 cases of intralingual TGDC described in the literature. The average age of presentation was 20.36 months. 69.8% (N=37) of patients presented with at least one respiratory symptom, 22.6% (N=12) presented with dysphagia, 9.4% (N=5) presented with an identified mass in the oropharynx, and 15.1% (N=8) had the cyst discovered as an incidental finding. Three patients required revision surgeries due to prior incomplete TGDC excisions and one patient experienced a recurrence >6 months after primary excision requiring a second procedure. Our data pooled with published case series in systematic review confirms that endoscopic or transoral management are excellent options for definitive management of intralingual TGDC.

CONCLUSIONS

Intralingual TDGC is a potentially life-threatening variant of TGDC. Our results pooled with published series in a systematic review suggest that endoscopic or transoral management of intralingual TGDC are excellent minimally invasive treatments with a low risk of recurrence. Postoperative surveillance up to one year is recommended.

Coexistence of thyroglossal duct cyst and second branchial cleft cyst in a young woman: A case report and literature review

Introduction

Thyroglossal cysts represent 70% of congenital neck anomalies, and second branchial cleft anomalies are the most common anomalies (90%) of the branchial apparatus. However, their coexistence, especially in adults, is very rare.

Presentation of case

A 23-year-old woman presented with a 1-year history of lateral left neck swelling and midline swelling. Imaging and histopathological examination confirmed the diagnosis of a thyroglossal duct cyst and a second branchial cleft cyst. The Sistrunk procedure was performed for surgical excision of the masses.

Discussion

Only three cases of a coexisting thyroglossal duct cyst and branchial cleft have been reported.

Conclusion

When encountering patients, even adults, with neck lesions, clinicians must keep in mind the possibility of a coexistence of a thyroglossal duct and a branchial cleft cyst.

•

Thyroglossal cysts represent 70% of congenital neck anomalies.

•

Second branchial cleft anomalies are the most common branchial apparatus anomalies.

•

Only three cases of coexisting thyroglossal duct and branchial cleft cysts have been reported.

•

We present a rare case of a young woman with the two cysts coexisting.

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.

Pediatric Neck Masses: Imaging Guidelines and Recommendations

Neck masses commonly present in children and several potential diagnostic and management pathways exist, though with a paucity of evidence-based recommendations. The purpose of this article is to evaluate the current literature and utilization of various diagnostic imaging modalities , with a review of imaging features and management pearls for pediatric neck masses. A comprehensive understanding and practical imaging workflow will guide optimal patient workup and management.

Cranial Mediastinal Thyroglossal Duct Adenocarcinoma in a Dog

A 7 yr old female spayed Canaan dog was presented for evaluation of a subclinical intrathoracic mass noted during meta-static staging for a digit and lingual mass. Thoracic ultrasound and computed tomography revealed a 6.0 × 5.5 cm mass within the cranial mediastinum. The mass was septated with mixed fluid and soft-tissue structures and no evidence of vascular invasion. Narrow excision of the mass via a sternal thoracotomy was performed. Histopathology of the mass was consistent with a thyroglossal duct cyst adenocarcinoma. This is the first reported case of a thyroglossal duct cyst adenocarcinoma arising in the cranial mediastinum of a dog. There was no evidence of metastasis or recurrence 25 mo after surgery and adjunctive therapy.

A dumbbell spinal mass derived from ectopic thyroid

Ectopic thyroid is a defect of embryologic development characterized by dislocation of the gland with or without an orthotopic thyroid gland, among other developmental issues. We report about an ectopic thyroid condition featured as an epidural dumbbell-shaped mass at the T6-7 level, also, with another gland located pre-tracheally. However, thyroid ectopy usually occurs along the trajectory of the embryologic migration of the thyroid, which is far from where the spine and spinal cord originate. To our knowledge, this is the first case reporting an ectopic thyroid tissue masquerading as a spinal neurogenic tumor but that the tumor was later confirmed to be an ectopic follicular variant of papillary thyroid carcinoma (FVPTC). Spinal epidural ectopy is a serious matter and we discuss some plausible explanations that may further our understanding of origination of ectopic thyroid.

Risks and complications of thyroglossal duct cyst removal

OBJECTIVES/HYPOTHESIS

Thyroglossal duct cysts (TGDCs) are the most common congenital neck cyst and typically present in childhood or adolescence, although a subset remains asymptomatic until adulthood. Although treatment involves surgical excision, few large-scale studies exist regarding the risks of surgical treatment of TGDCs in adults. This study aims to describe the characteristics of adult patients undergoing TGDC excision and to analyze risk factors associated with reoperation or other postoperative complications.

STUDY DESIGN

Retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

METHODS

Patients age ≥ 18 years in the NSQIP database who underwent TGDC removal from 2005 to 2014 were included. Covariates included patient demographics, comorbidities, preoperative variables, and intraoperative variables. Outcomes included reoperation, complications, and length of hospital stay.

RESULTS

A total of 793 cases met inclusion criteria. Patients were predominantly female (57.0%) and white (64.3%), with a mean age of 44.3 years. Thirty-day mortality did not occur in this cohort, but 3.0% of patients experienced at least one complication. Forty-eight patients (6.1%) underwent reoperation. Wound infection rates were higher in revision operations compared with primary operations (8.3% and 0.9%, respectively; P = .003). Low preoperative sodium was associated with reoperation (P = .047). Additionally, length of hospital stay was associated with increased total operative time (P = .02).

CONCLUSIONS

TGDC excision is a safe and well-tolerated procedure in the adult population, with low complication rates. However, the risk of reoperation, surgical-site infections, and medical complications should be taken into consideration during preoperative planning.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:381-384, 2020.

Congenital Neck Masses

Congenital neck masses can be a developmental anomaly of cystic, solid, or vascular origin. They can also constitute neoplasms, including malignancies, although this is rare in the pediatric population. The history and examination can help quickly narrow the differential diagnosis. Imaging also plays an essential role in defining the characteristics and likely cause of neck masses. The most common neck masses in young children are thyroglossal duct cysts, branchial cleft anomalies, and dermoid cysts. Also important to consider in the differential diagnosis are solid tumors, such as teratomas, or vascular lesions, such as hemangiomas.

Ectopic papillary thyroid carcinoma within a thyroglossal duct cyst: A case report

RATIONALE

Ectopic thyroid carcinoma within a thyroglossal duct cyst (TGDCCa) is an extremely rare entity. Thus, there is no unified appropriate therapeutic strategy, and individual approaches are controversial.

PATIENTS CONCERNS

We report the case of a 21-year old woman who underwent Sistrunk procedure for a thyroglossal duct cyst (TGDC).

DIAGNOSES

During histological evaluation of the resected TGDC a papillary thyroid carcinoma was found.

INTERVENTIONS

Due to a tumor size of 1cm and proximity to the surgical border, Sistrunk procedure was extended by total thyroidectomy, followed by radioiodine ablation.

OUTCOMES

Except of minimal follicular hyperplasia, the histological examination of the resected thyroid gland was unsuspicious.

LESSONS

Therapeutic management of TGDCCa is of interdisciplinary debate due to relative infrequence of the disease and consequently lack of unified therapeutic guidelines. We suggest a personalized therapeutic approach adjusted to individual risk stratification. In young patients with small tumor size and with confirmation of TGDCCa representing the primary tumor, Sistrunk procedure alone may reflect adequate treatment. In all other cases, total thyroidectomy and radioiodine ablation should be evaluated. Overall TGDCCa have an excellent prognosis with a 5-year survival rate of more than 90%.

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.

Thyroglossal Duct Cyst Carcinomas in Pediatric Patients: Report of Two Cases with a Comprehensive Literature Review

Thyroglossal duct cyst (TGDC) carcinomas are rarely encountered in the pediatric population. The clinical behavior of these tumors in the pediatric setting is unclear and management is not well defined. Two cases of pediatric thyroglossal duct cyst carcinoma were identified in a review of all thyroglossal duct cysts diagnosed over a ten year period. These two cases were analyzed along with 57 cases of thyroglossal duct cyst carcinoma affecting patients less than 21 years of age compiled from the English literature. Fifty-nine patients (36 females, 23 males) aged 6-20 years (mean 15.0 years) were identified. All presented with an anterior midline neck mass, which was typically mobile and non-tender. The average tumor size was 2.6 cm. Histologically, all tumors were papillary thyroid carcinomas arising in a background of a thyroglossal duct cyst. The tumors exhibited a papillary, follicular, or mixed architecture with classical papillary thyroid carcinoma nuclear features. Soft tissue extension was present in 16 cases. All patients were managed surgically with a Sistrunk procedure, with additional thyroidectomy performed in 29 patients, combined with a lymph node dissection (n = 15), or a Sistrunk and lymph node dissection (n = 5). All patients were stage I at presentation, with 11 showing lymph node metastases. Postoperative radioactive iodine was employed in 20 patients. A papillary carcinoma of the thyroid gland was reported in four of the patients who had concurrent/subsequent thyroidectomies. Recurrences were reported in four patients, with distant metastases in one patient, who died of disease (13 months). Follow up data was available for 45 patients, with an overall mean follow-up of 54.5 months. All patients were alive, with the exception of one who died with disease. TGDC carcinomas in pediatric patients is associated with a good overall prognosis, best managed by Sistrunk procedure alone, with selected lymph node dissection if clinically indicated.

Papillary carcinoma of hyoid

INTRODUCTION

Thyroglosal duct cyst is a common anomaly with an incidence of 7% in adults, the rate of carcinoma in TGDC is 0.7-1.6%, and are extremely rare those originated in the hyoid bone.

PRESENTATION OF CASE

A 60 years old male patient, had a hard mass in the anterior neck. CT revealed a hyoid tumor. Hyoid bone resection was performed, the pathological report show a conventional papillary carcinoma in bone tissue. We rule out primary tumor in thyroid gland. Five years later, he developed a neck node recurrence. Total thyroidectomy and a selective left neck dissection (II-IV levels) was performed. He received radioiodine adjuvant treatment.

DISCUSSION

Hyoid cancer originates of a persistent thyroglosal duct remnants inside hyoid bone.

CONCLUSION

We propose to add a new subdivision to pathology derived from thyroglosal duct remnants). The diagnostic approach with ultrasound and CT are necessary. A primary in te hyoid gland mustang be discorded, and then the entire hyoid bone must be removed. Treatment of the thyroid gland and neck should be considered when there are significant risk factors of recurrence, similarly to thyroid cancer based on the risk assessment.

Incidental radiographic findings of thyroglossal duct cysts: Prevalence and management

OBJECTIVES/HYPOTHESIS

To determine the epidemiology of incidental thyroglossal duct cysts (TGDC) discovered on imaging studies obtained in the head and neck area in children and to discuss subsequent management.

METHODS

A retrospective chart review was performed at Texas Children's Hospital of all computed tomography (CT) and magnetic resonance (MR) imaging studies obtained in the head and neck region between July 2011 and July 2014. Images obtained for the purpose of evaluating a neck or lingual mass were excluded from the study, as were patients with previously known TGDCs. Data including age, sex, location of TGDC, size, presence of symptoms, referral to Otolaryngology, and intervention were recorded.

RESULTS

A total of 60,663 CT and MR studies of the head, brain, sinus, neck, and C-spine during this time period were reviewed; of these 69 (0.1%) cases contained incidental discovery of probable TGDCs with more males (40) than females (29). Ages ranged from 3 days to 17 years old, with the mean age at 5 years. Locations varied, with majority at base of tongue (83%) followed by hyoid (13%) then infrahyoid straps (4%). Sizes ranged from 2 to 28 mm with average size at 8 mm. 11 of these patients were referred to an Otolaryngologist; 9 were asymptomatic and decision was made to observe, the other two subsequently underwent surgical excision secondary to mass effect and dysphagia with histologic confirmation of diagnosis.

CONCLUSION

TGDCs commonly present as an anterior neck mass, however the majority of incidentally discovered TGDCs on imaging are located at the base of tongue. Management of these findings should include referral to an Otolaryngologist for further evaluation with the decision to intervene surgically based on development of clinical symptoms.

Wide anterior neck dissection for management of recurrent thyroglossal duct cysts in adults

OBJECTIVE

Thyroglossal duct cyst recurrence following resection is attributed to anatomical variability and residual thyroglossal ducts. In adults, thyroglossal duct cyst recurrence is extremely rare and a surgical solution is yet to be well explored. This paper describes our approach to the management of recurrent thyroglossal duct cysts and sinuses in adults using a wide anterior neck dissection.

METHOD

A retrospective review was performed to identify adults who underwent a wide anterior neck dissection for recurrent thyroglossal duct cyst management between 1 January 2009 and 1 January 2015.

RESULTS

Six males and one female were included in the series (mean age, 26.4 ± 10.9 years). Recurrence occurred at a mean of 18 ± 9.8 months following primary surgical management (3 patients underwent cystectomy and 4 had a Sistrunk procedure). All patients subsequently underwent wide anterior neck dissection; there was no further recurrence over the 12-month average follow-up period.

CONCLUSION

This paper describes a wide anterior neck dissection technique for the management of recurrent thyroglossal duct cysts or sinuses in adults; this approach addresses the variable anatomy of the thyroglossal duct and is associated with minimal morbidity.