Vagaries of thyroglossal duct cysts

The thyroglossal duct cyst is the most common congenital cyst found in the neck, classically presenting as a paramidline mass in a healthy young adult. Fifty-three cases managed at the Brigham and Women's Hospital and Boston's Beth Israel Hospital over the past 10 years were reviewed. The unique presentation of papillary adenocarcinoma in TGDCs and findings in the elderly population are discussed. These cases represent both diagnostic and therapeutic challenges. The existing literature is correlated with our data, providing a treatise on management.     

Presentations of thyroglossal duct cysts in adults

The thyroglossal duct cyst is the most common congenital neck mass, resulting from persistence and dilatation of remnants of an epithelial tract formed during migration of the thyroid during embryogenesis. Approximately 7% of the population has thyroglossal duct remnants. Although thyroglossal duct cysts generally present clinically in children, it is important to understand that the lesion can present in adults as well, sometimes much later in life. Incidental carcinoma of the thyroglossal duct cyst is rare, but is more likely to occur in adults than children. Between 1991 and 1998, 11 cases of thyroglossal duct cysts were seen in adult patients at Georgetown University Medical Center, including 2 cases containing papillary carcinoma. This report discusses their clinical presentations and management. Received: 11 September 1998 / Accepted: 23 October 1998     

Preoperative sonography in presumed thyroglossal duct cysts

OBJECTIVE: To determine the utility of ultrasonography as a sole diagnostic study in the preoperative preparation of patients with presumed thyroglossal duct cysts. DESIGN: Retrospective chart review. SETTINGS: Children's Memorial Hospital, Chicago, Ill. PATIENTS: Forty-five pediatric patients with midline masses. MAIN OUTCOME MEASURE: Accuracy in the determination of a normally positioned thyroid gland excluding the presence of a solitary ectopic thyroid gland. RESULTS: A retrospective chart review was performed at our institution for the period February 1990 to January 1996. A total of 45 patients with midline masses were identified, 39 of whom had undergone preoperative ultrasonography as their sole diagnostic imaging study. In all 39 patients, both a cyst and a normal thyroid gland were identified. All 39 patients underwent the standard Sistrunk procedure. Thirty-seven patients had pathologically confirmed thyroglossal duct cysts. The remaining 2 had dermoid cysts. There were no cases of postoperative hypothyroidism. CONCLUSIONS: The incidence of ectopic thyroid in the diagnosis of thyroglossal duct cysts has been reported to be as high as 1% to 2%. In our surgical and clinical experience, the actual incidence of solitary ectopic thyroid tissue is substantially lower. Nevertheless, to prevent the inadvertent removal of the only functioning thyroid tissue, with resultant postoperative hypothyroidism and possible medicolegal consequences, we advocate the routine preoperative identification of normal thyroid gland. We recommend ultrasound as an accurate, cost-effective, noninvasive imaging modality in the preoperative evaluation of all patients with neck masses suspicious for thyroglossal duct cyst. Also, it does not require sedation.     

Preoperative thyroid scanning in presumed thyroglossal duct cysts.

The purpose of this study was to determine if preoperative thyroid scans are essential in the workup of presumed thyroglossal duct cysts. Questionnaires were sent to pediatric otolaryngologists and pediatric general surgeons with a 65% response rate. Fifty-seven percent of the physicians have encountered ectopic thyroid. In 58% of these, this was the only functioning thyroid tissue. Twenty eight percent of pediatric surgeons vs 65% of pediatric otolaryngologists routinely order scans. Two of the physicians encountering ectopic thyroid volunteered that they had successful litigation directed against them for removing the sole functioning thyroid and creating permanent hypothyroidism. There is a likelihood of encountering ectopic thyroid during the course of one's practice. A case of ectopic thyroid is presented, and management strategies are discussed.     

Incidental radiographic findings of thyroglossal duct cysts: Prevalence and management

Objectives/HypothesisTo 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.MethodsA 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.ResultsA 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.ConclusionTGDCs 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.     

超声对特殊部位甲状舌管囊肿的诊断价值

目的 探讨超声对于特殊部位甲状舌管囊肿的诊断价值.方法 回顾性分析超声图像资料,总结特殊部位甲状舌管囊肿的超声表现并判断超声对病变诊断的准确性.结果 5例位于舌根部,1例位于声门下,超声显示率100％,超声定位准确率100％.超声表现:肿块大小1.1 cm×1.1 cm×1.2 cm～2.4 cm×2.2 cm×1.9 cm;均为类圆形,6例(100％)均为薄壁;4例(67％)内呈无回声,2例(33％)呈均匀低回声;5例(83％)为单房、无分隔,1例(17％)为多房、有细小分隔;后方回声均增强;所有肿块内部及周边均未见血流信号.结论 舌根部和喉内甲状舌管囊肿易导致儿童气道梗阻,超声对舌根部和喉内甲状舌管囊肿定位准确,有助于明确病变范围.     

Characteristics of lingual thyroglossal duct cysts under flexible laryngoscopy and treatment approaches

ObjectivesLingual thyroglossal duct cysts (LTGDCs) are clinically rare and easily misdiagnosed as epiglottic cysts. Misdiagnosis leads to mistreatment; thus,simple diagnosis is important. This study aimed to investigate the characteristics of LTGDCs with flexible laryngoscopy and imaging, improve their diagnosis and explore surgical methods for patients undergoing an initial operation and patients with recurrence.MethodsIn total, 10 patients with LTGDCs were admitted from April 2014 to December 2020.By reviewing the diagnosis and treatment of the first typical case, the characteristics of LTGDC under flexible laryngoscopy were summarized. According to these characteristic manifestations, a clinical diagnosis of LTGDC was made correctly in the other 9 patients. All 10 patients underwent preoperative CT of the neck and sagittal reconstruction and thyroid ultrasound.ResultsOf the 10 patients, the first 2 patients had recurrent LTGDCs after several operations and underwent Sistrunk surgery. The remaining 8 patients were newly diagnosed and underwent endoscopic radical resection with low-temperature coblation; of these patients, 7 had no recurrence, and 1 underwent Sistrunk surgery after developing short-term recurrence. All patients were followed up for 5 months to 6 years after the last operation and were without recurrence.ConclusionLTGDCs are easily misdiagnosed as epiglottic cysts in the clinic. A correct clinical diagnosis can be made based on the characteristics according to flexible laryngoscopy. To determine the relationship between the cyst and hyoid bone, CT was performed. The surgical method was chosen based on the relationship between the cyst and hyoid bone and history of recurrence.     

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

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

甲状舌管癌五例的临床特点及诊治分析

目的 探讨甲状舌管癌的临床特点、诊断、手术范围及预后.方法 回顾性分析1991-2011年收治的110例甲状舌管疾病患者的临床资料,其中5例经术后病理确诊为甲状舌管癌,乳头状癌4例,鳞状细胞癌1例.5例患者均为男性;年龄17～73岁,中位年龄41岁.1例乳头状癌患者术前即合并肺转移.5例患者均行手术治疗,其中2例接受Sistrunk术(切除肿瘤、甲状舌管及部分舌骨),1例行Sistrunk术+甲状腺结节切除术,1例合并肺转移的患者行Sistrunk术+甲状腺全切除术+中央区淋巴清扫术,1例鳞癌患者行Sistrunk术+受侵组织扩大切除术.结果 术后2例乳头状癌患者行促甲状腺激素抑制治疗,其中1例合并肺转移患者行核素治疗,其余3例患者均未行进一步治疗.术后随访14 ～45个月,1例73岁甲状舌管鳞癌患者术后2个月复发,并于术后7个月死于肿瘤复发,其余患者均生存.结论 甲状舌管癌临床少见,确诊依赖术后病理检查,外科手术为主要治疗手段.对于低危患者,Sistrunk术式可能是一种合适的治疗方法.     

Atypical thyroglossal duct cyst

Thyroglossal duct cysts most frequently present in childhood as a painless midline swelling of the neck. Uncommonly, these embryonal remnant cysts present clinically in adult life. The majority of adults with thyroglossal duct cysts present with a swelling at the level of the thyrohyoid membrane. On rare occasions, a thyroglossal duct cyst can present with more sinister symptoms, such as hoarseness, dysphagia and dyspnoea. On these occasions, the pre-operative clinical and investigative diagnosis remains in doubt until histology is available.     

Single-stage laryngotracheal reconstruction

The mainstay for repairing subglottic and tracheal stenosis has been the rib graft with prolonged stenting. A refinement of this treatment was the use of the anterior cricoid decompression (split). We present single-stage reconstruction of the airway as an additional refinement of the laryngotracheoplasty. This article describes the experience of two institutions with single-stage reconstruction and offers some observations on the principles of the technique.     

Atypical thyroglossal duct anomalies

OBJECTIVE: Thyroglossal duct (TD) anomalies are generally considered to be a distinct clinical entity. However occasional cases do not conform to the standard picture and are complex. This study aimed to scrutinise consecutive cases of TD anomaly managed surgically over 7 years at a tertiary teaching hospital and analyse those with atypical features. METHODS: This is a retrospective study of 62 children managed for a clinical diagnosis of TD anomaly from 1998 to 2005. Their medical records were reviewed for clinical presentation, investigations, operative findings, histopathology, management and outcome. After a clinical diagnosis, they had individualized investigations (USG, MRI, radioiodine scan, FNA) prior to the Sistrunk operation. RESULTS: 5/62 cases had atypical features. 2/5 were adolescents with a short history while 3 were below 5 years of age with onset since infancy. 4/5 were females. 1/5 had a Sistrunk operation earlier, 2/5 had a redo surgery prior to cure. 3/5 had a grossly identifiable tract at surgery, one with a midline course and two deviating laterally to open at the left pharyngeal wall. The final histological diagnosis was a mixed thyroglossal-dermoid cyst (case 1), TD anomalies with aberrant pharyngeal communication (cases 2 and 3), isthmic thyroglossal 'cold' cyst (case 4), and a tuberculous cyst (case 5). Postoperatively, Cases 2 and 3 had wound infections that were managed conservatively while case 5 developed an incisional sinus that healed after a month of anti-tuberculous chemotherapy. Cases 1 and 4 had an uneventful recovery. At an average f/u of 2 years, all are asymptomatic and well. CONCLUSIONS: 5-10% of apparent TD anomalies may present with atypical clinicopathologic characteristics. Atypical cases and late presentations may warrant additional investigations to establish the diagnosis and tailor management.