What is the optimal depth for core-out toward the foramen cecum in a thyroglossal duct cyst operation?

The high recurrence rate of thyroglossal duct cyst operations is well documented. Sistrunk's operation is widely accepted as the best procedure to prevent recurrence. Nonetheless, the optimum depth of core-out is still not well documented. We previously reported a standard running pattern of the thyroglossal duct in an anatomical reconstruction study. In more detailed pathological studies, we have tried to determine the optimal depth for core-out toward foramen cecum and the optimal width of the hyoid bone to be resected. The following items were clarified. (1) Double the horizontal distance from midline to the most distant thyroglossal duct in front of the hyoid bone was 2.4 to 9.6 mm. (2) The length of the single duct above the hyoid bone which spreads into many ductuli as it approaches the foramen cecum was about 3 to 5 mm in 2- to 6-year old children. (3) The diameter of the thyroglossal duct at the level of the cranial top of the hyoid bone was 175 to 1,400 microns. Half of the examined cases were less than 500 microns, which may have rendered direct dissection impossible. Based on these studies, we propose: (1) that a minimum of 10 mm of the hyoid bone should be resected, and for the sake of safety, more than 15 mm is preferable; and (2) that the depth of the core-out should be less than 5 mm in young children to avoid the breakdown of the branched ductuli near the foramen cecum.     

Thyroglossal duct: a review of 55 cases

BACKGROUND: Thyroglossal duct remnants are the most common midline neck masses in childhood but can be found in adults and the elderly. Sistrunk's procedure, with dissection of the tract and removal of the hyoid bone, is accepted as the main operation of choice. STUDY DESIGN: Fifty-five patients were treated from January 1994 to November 2000, and these were studied. There were 29 men and 26 women, with a median age of 17 years. Diagnosis was clinical, with 13 cases of fistula and 42 of cyst. Size varied from 1.0 to 4.0 cm, with an average of 2.5 cm. Six patients presented with local abscess. RESULTS: All the patients underwent Sistrunk's procedure. Serum collection occurred in three patients as complication. In one patient papillary carcinoma was identified in the cyst. Total thyroidectomy was not performed. There was only one recurrence, managed with a second operation. CONCLUSIONS: We concluded that the diagnosis of thyroglossal duct is clinical. Sistrunk's procedure carries low rates of complications (9.08%) and recurrence (1.82%). Antibiotic therapy is avoidable as a rule and hospital stay is short.     

The clinical relevance of certain observations on the histology of the thyroglossal tract

A study of all patients operated on with a clinical diagnosis of midline neck cyst at the Children's Hospital of Eastern Ontario confirms our impression that certain important facts regarding the microanatomy of thyroglossal duct cyst and its associated tract are the subject of a number of misconceptions entrenched both in surgeon's minds and in some standard reference texts. Our own observations and a review of the literature dating back to Sistrunk's own original contribution in 1920 lead us to emphasize the following: (1) thyroglossal duct cysts seldom have an intact lining; (2) the thyroglossal duct is frequently multiple and arborizes; (3) its course is always anterior to the hyoid bone; (4) it is seldom discernible to the naked eye and it is futile to attempt to dissect it out at operation. By the same token, a full Sistrunk procedure must be done even if the tract is not seen; and (5) deep cervical dermoid cysts may mimic thyroglossal duct cyst when firmly fixed to the hyoid bone, but the presence of sebaceous material in the cyst will identify it as a dermoid because thyroglossal duct cysts do not undergo keratinizing squamous metaplasia.     

小儿甲状舌管囊肿和瘘手术成败分析

目的 总结分析小儿先天性甲状舌管囊肿和瘘手术成败原因。方法 18例甲状腺舌囊肿和瘘病例。均行甲状腺舌囊肿和瘘切除术。随访1～3年。结果 全部治愈,随访期间均无复发。结论 应尽早在感染发生前行正规Sistrunk's手术,特别强调舌骨中段切除及术中舌骨以上囊肿或瘘管探查与切除。     

Clinical results of the shallow core-out procedure in thyroglossal duct cyst operation

PURPOSE: This procedure for thyroglossal duct cyst operation based on pathological studies was first published in the Journal of Pediatric Surgery in 1992. This procedure is similar to Sistrunk's operation except that the core depth of the tongue excision is more shallow (about 5 mm in young children). The purpose of this report is to report and evaluate the clinical results of this operation compared with our earlier operative results. METHODS: Eighty-three patients underwent surgery for thyroglossal duct cyst from 1970 to 1997. They were divided into 3 groups. Group I consisted of 31 patients undergoing Schlange's operation (1970 to 1988). Group II were 18 patients undergoing Sistrunk's operation (1989 to 1990). Group III consisted of 34 patients operated on with the authors' procedure (1991 through 1997). The 3 groups are compared for recurrence rate. RESULTS: Recurrence in group I was 6 of 31 (19.3%), 1 of 18 (5.6%) in group II, and 1 of 34 (2.9%) in group III. The recurrence rate showed a statistically significant difference only between group I and III (P = .033). CONCLUSION: The recurrence rate with our procedure was not higher than that of Sistrunk's operation but was significantly lower than for Schlange's operation.     

Thyroglossal cysts in children

Of 69 cases of midline cervical swelling in children, the correct diagnosis was made in only 38 (55 per cent). Fifty cases of thyroglossal cyst or abscess were treated and 38 per cent suffered recurrence. Apart from failures in diagnosis, the main reasons for preventable recurrence were delay in surgery, failure to resect part of the body of the hyoid bone and a tendency to excise that portion of the duct above the level of the hyoid with insufficient surrounding muscle. In cases without florid abscess formation, the aim should be to perform a radical operation as soon as possible, then cure can be guaranteed at the first operation. Recurrence may occur many years after an apparent cure. Cysts in the submental region are not often recognized as being of thyroglossal duct origin.     

Is the treatment for thyroglossal duct cysts too extensive?

From 1970 to 1985, 64 patients underwent surgical management for thyroglossal duct cysts at the University of Oklahoma Health Sciences Center. Their ages ranged from 1 to 63 years with a mean of 12.4 years. Ninety-one percent of the patients were available for follow-up. All patients underwent one of three forms of treatment: the classic Sistrunk operation, a modified Sistrunk operation, or excision of the cyst only. Eleven percent had undergone a previous procedure. The majority of patients were found to have a cyst in the midline at the level of the hyoid bone. Eighty-eight percent of the patients underwent excision of the midportion of the hyoid bone. There were no postoperative deaths and the perioperative complication rate was 20 percent, the majority being wound-related. All recurrences took place within 4 months of operation. Factors that appeared to be associated with an increased risk of complications and recurrence included young patient age (less than 10 years), rupture of the cyst at the time of operation, infection, and failure to excise the midportion of the hyoid bone and the suprahyoid tract. One patient was found to have a mixed papillary and follicular carcinoma in the thyroglossal duct. We support the original premise of Sistrunk that "the cure of thyroglossal cyst are unsuccessful unless the epithelium-lined tract, running from the cyst to the foramen cecum is completely removed," including the hyoid bone.     

甲状舌管囊肿术后复发因素分析

目的探讨甲状舌管囊肿的术后复发原因及预防措施。方法回顾性分析26例甲状舌管囊肿患者的临床资料。结果所有手术标本均经病理学确诊。术后随访1年复发率为11.5%（3/26）,2例因未切除舌骨中段及舌骨上盲管导致舌管残留,1例为遗漏舌管分支,均再次手术治愈。结论术前充分认知甲状舌管囊肿的解剖学特点,明确诊断,选择合适的手术时机,操作轻柔,彻底切除舌管及其分支可减少术后复发。     

Squamous cell carcinoma arising from thyroglossal duct remnants: Report of a case and results of immunohistochemical studies

We report on the case of a 57-year-old male found to have squamous cell carcinoma (SCC) arising from thyroglossal duct remnants. The patient presented with an asymptomatic tumor in his anterior neck which was immovable on palpation. Aspiration biopsy cytology revealed class V malignancy with many atypical clusters and marked keratinization. After preoperative radiation, a radical operation employing Sistrunk's procedure with bilateral neck dissection was performed. Histopathological examination confirmed a diagnosis of moderately differentiated SCC, but revealed ciliated columnar epithelium in the walls of the cyst without a normal layer of squamous cells. Furthermore, immunohistochemical studies demonstrated the tumor to be negative for thyroglobulin staining, but positive for cytokeratin and carcinoembryonic antigen. These histopathological findings proved attributable to squamous metaplasia occurring in the ciliated columnar epithelium of the thyroglossal duct. Thus, SCC might originate in the metaplastic portion of the thyroglossal duct remnants. Although the prognosis associated with SCC in the thyroglossal duct is not as optimistic as that associated with papillary carcinoma, no evidence of recurrence has been observed in this patient in the 7 years since his operation. This suggests the effectiveness of our therapeutic approach for this unusual disease.     

Management of thyroglossal cysts in children

Forty children with a suspected thyroglossal cyst were operated on by one paediatric surgeon receiving primary and secondary referrals in an 8-year period. Nine patients (22 per cent) proved to have other pathology. Multiple operations were required in eight of 17 patients (47 per cent) who had infected thyroglossal cysts but in only one of 14 (7 per cent) with uninfected cysts. In the infected group preliminary incision and drainage was necessary in five cases and cyst recurrence occurred in four (24 per cent), whereas in the uninfected group there was only one recurrence (7 per cent) in a patient with double pathology. Infection and recurrent cysts were the chief reasons for multiple operations. Recurrence was caused by inadequate performance of the correct operation (Sistrunk's) or choice of the wrong operation. Two of our own three recurrences were due to the latter, other pathology being suspected intraoperatively. Histological study of the specimens showed that thyroglossal ducts were frequently multiple and widely spaced. In children any lesion whose presentation is typical of a thyroglossal cyst should be treated with an early Sistrunk's operation. The operation in children who have other pathology has no complications and is justified.     

Fistula of submaxillary gland following excision of thyroglossal cyst

A case of external submaxillary gland fistula opening through the midline of the neck anteriorly, midway between the thyroid cartilage and hyoid bone and following operations for excision of thyroglossal cyst and excision of thyroglossal sinus, is reported. Cure was obtained by removing the fistulous tract along with the left submaxillary gland through an incision as recommended by Sistrunk for the excision of a thyroglossal sinus. The occurrence of the submaxillary gland fistula is believed to have been due to branching of the thyroglossal tract at or near the hyoid bone and to operative trauma to the left submaxillary gland as a result of discoloration of normal tissue adjacent to the thyroglossal tract by the use of methylene blue for injection into the cyst prior to the initial operation.     

Operative treatment of median cervical cysts

Median cervical cysts are congenital anomalies arising from remaining thyroglossal duct epithelium. A major problem in the surgical treatment of these cysts is the high frequency of recurrence. Embryonic considerations indicate an important causal role for the hyoid bone in these recurrences. We studied the relationship between operative techniques and the number of recurrences in 36 patients treated in our hospital. Fourteen patients sent from other hospitals had a recurrent fistula; in thirteen cases the hyoid bone was still in place. All patients who had the central part of the hyoid bone excised were cured. In 14 patients without adequate excisions of the hyoid bone we found four recurrences. To prevent recurrence a total excision of thyroglossal duct epithelium is necessary.     

Familial occurrence of thyroglossal duct cyst

Persistence and dilation of the embryologic thyroglossal tract gives rise to the condition of thyroglossal duct cyst. Although these cysts have an embryologic origin, there is rarely a history of inheritance. A search of the literature shows only two family reports, which includes a total of nine patients. We report on a third family with thyroglossal duct cyst in two members. The patients were female siblings aged 2 and 6 years, both of whom underwent successful surgical excision of their thyroglossal duct cysts by modified Sistrunk's technique.     

Carcinoma arising in thyroglossal duct remnant: case reports and review of the literature.

Two cases of thyroglossal duct cyst carcinoma are presented and the world literature is reviewed. There are only 74 cases reported to date. In nearly all the cases the clinical diagnosis was thyroglossal cyst. Although the great majority of the tumours were papillary adenocarcinomas, 13-15 per cent were of other histological types. The treatment has been quite variable, but the most common initial treatment was Sistrunk's (1928) operation. Following the establishment of the diagnosis of malignancy, thyroidectomy was done in several cases, but it failed to show any evidence of malignancy in most of the thyroids removed, which establishes firmly the de novo origin of these tumours from the thyroglossal duct remnant. In only one case had tumour disseminated to distant organs, the lung, liver, etc. The scepticism as to whether some of the carcinomas associated with thyroglossal duct remnants may not in fact represent metastases from a small primary tumour of thyroid gland is examined. It appears that, though a possibility of primary or metastatic tumour in the thyroid does exist, the probability does not appear to be high. From our own experience it is suggested that local excision followed by radiotherapy, irrespective of recurrence, may be worth considering for the treatment of such carcinomas.     

Core excision of the foramen cecum for recurrent thyroglossal duct cyst after Sistrunk operation

The recurrence rate for thyroglossal duct cysts after a Sistrunk operation is 5% compared with 20% if the hyoid cartilage is not removed. However, few guidelines exist when a lesion recurs after an adequate Sistrunk operation. A 2-year-old boy was referred for recurrent thyroglossal duct cyst after complete and adequate resection. Reexploration of the wound and wider excision of the midline cervical tissues failed to treat the problem. Using a combined transoral/cervical approach, a core of tongue around the foramen cecum was removed. A cystic structure was found at pathologic examination. The child remains asymptomatic 24 months later. If thyroglossal duct cysts recur despite an adequate Sistrunk operation, an intralingual remnant should be suspected. Transoral excision of tongue tissue around the foramen cecum may offer a cure.     

The problem of recurrent thyroglossal duct remnants

The removal of a thyroglossal duct or sinus is a common pediatric surgical operation. It has been taught that if the duct remnant is removed down to and including the middle third of the hyoid bone, the "correct" operation has been done. The three authors have an experience totaling over 60 years in pediatric surgery during which time they operated on 270 thyroglossal duct cysts and sinuses. In this group were 27 recurrences of which three belonged to the authors. Most recurrent thyroglossal duct remnants were found to have the middle third of the hyoid bone still in place, and with its removal the patients were cured. However, during this period of time, there were thyroglossal duct cysts and sinuses which recurred in spite of the "correct" surgical procedure having been done. These patients had all been operated on between three and five times thus creating a difficult and unusual problem. The solution to these recurrent thyroglossal duct cysts and sinuses were deeper excisions to remove residual tracts deep to the previously removed hyoid bone, and/or wider excisions to excise previously missed respiratory epithelial remnants which deviated laterally from the midline. The latter tissue was found to be a more centrally directed branchial cleft sinus.     

Papillary thyroid carcinoma in thyroglossal duct cyst: case reports and literature review

Although thyroglossal duct cysts represent a common developmental abnormality of the thyroid gland, malignant transformation is rare and occurs in only 1% of cases. This article describes four clinical cases observed at the Surgical Science Department of "La Sapienza" University of Rome between 1996 and 2000. Histologic examination indicated two pure papillary carcinomas, a sclerosing papillary carcinoma, and a follicular variant of papillary carcinoma. In all cases, treatment involved removal of the body of the hyoid bone and total thyroidectomy, which we associated with removal of the thyroglossal duct cyst. In one case, laterocervical lymphectomy was performed. Carcinoma multifocality was found in one patient. We recommend associating total thyroidectomy with removal of the tumor of the thyroglossal duct and of the body of the hyoid bone, because the carcinoma may be multifocal and there may be lymphatic invasion of the thyroid and to ensure a correct follow-up.     

Thyroglossal duct cyst carcinoma (report of two cases)

Two cases of papillary carcinoma of thyroglossal duct cyst that were treated in our department are presented. Differential diagnosis and pathological features are emphasized. Radical excision of the cyst according to Sistrunk's technique is recommended. The recent literature concerning this subject is reviewed.     

SURGERY FOR THYROGLOSSAL CYSTS SISTRUNK'S OPERATION: REMAINS THE STANDARD

Surgical techniques for thyroglossal cysts still varyconsiderably. In this review, one-third of patients treated by simple cyst excision had recurrence and this operation cannot be recommended. There should be consensus that excision of the mid-portion of the hyoid bone be performed routinely. However, variations have been described in the syprahyoid dissection. The present review indicated that the classic Sistrunk operation provided the lowest rate of recurrence and should remain the standard procedure.     

Surgery for thyroglossal cysts: Sistrunk's operation remains the standard

Surgical techniques for thyroglossal cysts still vary considerably. In this review, one-third of patients treated by simple cyst excision had recurrence and this operation cannot be recommended. There should be consensus that excision of the mid-portion of the hyoid bone be performed routinely. However, variations have been described in the syprahyoid dissection. The present review indicated that the classic Sistrunk operation provided the lowest rate of recurrence and should remain the standard procedure.