Thyroglossal duct cyst  ‑ How 1 Will Usually Manage It

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How we usually manage it?

Background

What is a thyroglossal duct cyst?

           A thyroglossal duct cyst is a neck mass or lump that develops from cells and tissues remaining after the formation of the thyroid gland during embryonic development. It is most commonly diagnosed in preschool-aged children or during mid-adolescence, and often appears after an upper respiratory infection when it enlarges and becomes painful.

What causes a thyroglossal duct cyst?

          A thyroglossal duct cyst is a congenital (present from birth) defect. When the thyroid gland forms during embryonic development, it begins at the base of the tongue and moves down the neck through a canal called the thyroglossal duct. This duct normally disappears once the thyroid reaches its final position in the neck. Sometimes, portions of the duct remain leaving cavities or pockets called cysts. These cysts can fill with fluid or mucus, and may enlarge if they become infected. Very enlarged cysts can cause difficulty swallowing or obstruct breathing passages.

Reliable clinical diagnostic cues for thyroglossal duct cyst:

The following are the most common symptoms of a thyroglossal duct cyst. However, each child may experience symptoms differently. Symptoms may include:

1.      a small, soft, round mass in the center front of the neck

2.      tenderness, redness, and swelling of the mass, if infected

3.      a small opening in the skin near the mass, with drainage of mucus from the cyst

4.      difficulty swallowing or breathing

The symptoms of a thyroglossal duct cyst may resemble other neck masses or medical problems.

Goal of treatment..

·          complete removal of the cyst with no recurrence

Nonsurgical treatment:

Surgical treatment.

Thyroglossal duct remnants that contain thyroid gland (ectopic) tissue can also be candidates for removal if a normal functioning thyroid gland is identified, so removal of the ectopic tissue will not cause the patient to become hypothyroid (have too little thyroid hormone).

If the only thyroid tissue found in the patient is located in the thyroglossal duct cyst, the treatment options are as follows:

1.      Remove the thyroglossal duct cyst and thyroid tissue, and start lifelong thyroid hormone replacement therapy (under a specialist's supervision)

2.      Attempt keep the ectopic thyroid tissue in place, while stopping further growth of the tissue with medications (thyroxine - a thyroid hormone). Unfortunately, if the ectopic thyroid gland continues to cause symptoms in the patient (breathing or swallowing problems, bleeding or repeated infections), it will ultimately be recommended for removal. For those patients unable to tolerate surgery and who have failed a thyroid hormone trial, radiation therapy may be an option.

Timing of operation.

·          Once diagnosed with the condition, the patient may be scheduled for elective surgery.

What parameters are used for determining cases as easy to excise 1 difficult to excise?

·          The presence of a concomitant infection would make the contemplated procedure more difficult.

Operative technique:

·        GA

·        Neck hyperextended

·        Transverse incision directly over the cyst in the infrahyoid region carried thru the platysma and cervical fascia until cyst bwall is exposed

·        Skin flaps are developed  and dissection performed down to and around the cyst

·        The tract is dissected up  to the hyoid bone

·        Muscular attachements to the superior and inferior aspects of the body of the hyoid bone are divided

·        Central portion of hyoid bone resected and removed in continuity with the cyst and duct

·        Dissection is continued as a coring out of tissue about 5-10 mm in diameter through the muscles of the base of the tongue to the foramen cecum.

·        The dissection is directed superiorly and posteriorly in a sagittal plane at an angle of approximately 45° to the long axis of the body.

·        The dissection thus includes the central raphe of the mylohyoid and genioglossus muscles.

·        Anatomic orientation may be simplified by having an assistant place a finger on the tongue and push the foramen cecum downward.

·        The duct is ligated and divided at the base of the tongue using silk 3-0 suture.

·        Bone need not be reapproximated

·        Hemostasis

·        Complete sponge and instrument count

·        A small penrose drain may be placed for 24 hours if there is history of infection

·        Closure in layers

·        Skin  closed subcuticularly using vicryl 4-0 suture

Important neck structures to identify and preserve during dissection and excision

·        thyroid gland

 How to deal with flabby skin resulting from huge size?

By using an elliptical incision

 Common postoperative complications and how to avoid

     Wound infections and bleeding are complications of any surgical procedure. These complications are minimized using antibiotics and cautery (application of heat to bleeding areas).

     An additional complication of the surgery could be creating an opening into the throat. This would be repaired immediately if recognized. Complications are more likely with repeat or revision surgeries.

     Recurrence of a thyroglossal duct remnant is also a risk.

     Finally, hypothyroidism, is an expected concern in those patients with all the body's thyroid tissue located in the thyroglossal duct remnant. An endocrinologist (gland specialist) will be required with the follow up of these patients.

What is the recurrence rate? Causes of recurrence? How to manage recurrence?

     A thyroglossal duct cyst has a small chance of regrowing if small portions of the tissues remain after surgery. Infection of the cyst prior to surgery can make the removal more difficult and increase the chance for regrowth. Always consult your child's physician for more information.