Thyroglossal Duct Flashcards
A 3-year-old child presents with a midline neck mass near the level of the hyoid bone. How would you evaluate this child? What would your differential diagnosis be? How would you determine the likely diagnosis based on physical exam, imaging, and/or laboratory data? How would the differential diagnosis change your operative approach?
. The classic presentation is a midline neck mass. This may be asymptomatic or symptomatic (i.e. the infected mass or draining sinus seen in 25%). If infected, patients may have bad taste in mouth from draining pus and the mass may be enlarged, erythematous or tender.
While it is usually midline, it may also be just lateral of midline (40%), suprahyoid or suprasternal.
Most patients present in first five years of life.
Key physical exam findings
The midline neck mass moves up and down with swallowing.
Differential diagnosis
Alternative diagnoses include dermoid or branchial cleft cysts, ectopic thyroid and lymphadenopathy.
Imaging
An ultrasound of the neck (not just the mass) should be obtained if you cannot feel a norma thyroid. It is important to confirm that the mass you are palpating is not an ectopic thyroid which may be patients only thyroid tissue.
In general, laboratory studies are not needed. Thyroid function tests may be obtained if you suspect hypothyroidism or ectopic thyroid. This is usually only an issue in the neonate.
A 4-year-old child presents with a tender, erythematous, fluctuant mass in the midline of the neck. How would you manage this child? Would you drain the abscess? If so, how? What antibiotics would you use, and for how long? Would you remove the cyst? If so, when and why?
Resection should be avoided in the face of active infection as it results in a higher risk of surgical site infection and recurrence. Infected thyroglossal duct cysts should be treated with antibiotics along with incision and drainage if necessary. Following adequate treatment, surgical resection can be performed six to eight weeks later once the inflammation has resolved.
A 3-year-old child is diagnosed with a thyroglossal duct cyst and is now in the operating room. You have decided to perform a Sistrunk procedure. How is this accomplished? How do you identify the hyoid bone? How do you determine when your extent of dissection is adequate?
The central portion of the hyoid bone is excised usually including one cm on either side of the midline once the mylohyoid and hyoglossus muscle attachments have been divided from the superior border of the hyoid.
The dissection of the tissue deep to the hyoid up to the level of the foramen cecum is done widely so as to include any residual tracts and branches. The proximal tract should be suture ligated prior to removal of the specimen. The anesthesiologist can press down on the base of the tongue to help confirm the depth of dissection. Skeletonizing the tract at this level should be condemned as it risks missing accessory tracts. Rather, a wide core of tissue should be excised along with the thyroglossal tract. Great care should be taken to resect the entirety of the cyst as well as the tract including the central portion of the hyoid bone extending up to the foramen cecum.
After resection of a thyroglossal duct cyst, the pathology comes back showing a focus of papillary ductal carcinoma. How would you manage this patient? Would you perform a reexcision? Would you excise the thyroid gland if it is present? Is a node dissection indicated? Would you assess and/or treat with radioactive iodine? What would your planned follow-up be? Should all thyroglossal duct cysts be removed because of the risk of malignancy?
A well differentiated lesion contained within the specimen and without evidence of capsular invasion or metastasis can be safely observed. Following the Sistrunk procedure, it is associated with a 95% cure rate with close follow up and surveillance.
A 5-year-old child has a recurrent thyroglossal duct cyst. How would you manage this condition, and what are the options? What leads to recurrence, and how can you prevent it? What would you do differently at the time of reexcision? What are the risks of reexcision?
.
