THYROGLOSSAL DUCT CYST

Dr Syed Hasnain
TMO ENT-B
 INTRODUCTION
• Most common cystic lesion in the neck
• Most common upper neck midline lesion
• Age range-4 months to old age
• Mean age of presentation-5 years
• An equal male to female incidence
• Usually sporadic
• A rare familial variant has been documented-
autosomal dominant
 EMBRYOLOGY
• Thyroid gland develops from the floor of the
primitive pharynx between the first and second
pharyngeal pouches- 4th-5th week
• The thyroid enlage arises in an invagination of the
endoderm in the floor of the primitive pharynx
between tuberculum impar and copula and
develops/descends caudally
• The median enlage loses its lumen, breaks into
fragments,the lower end becomes bilobed to
form lobes of the thyroid gland
• Reaches its final position in the neck-7th week
• Smaller paired lateral enlages-parafollicular c
cells
• The tract that is left usually atrophies and
disappears-10th week
• Failure of the tract to involute may leave
epithelial remnants or an open area of the
duct –later develops into cyst
 PATH OF THE DUCT
• Foramen cecum>via genioglossus>hyoid>upper
border of thyroid cartilage
• Since the hyoid bone develops later and joins
from lateral to medial the thyroglossal duct may
get trapped in the substance of the body of hyoid
bone
• Tongue and foramen cecum forms after complete
descent of the thyroglossal duct, so rarely a tract
can be found at the level of foramen cecum
 THEORIES OF THYROGLOSSAL DUCT
CYST
• CYSTIC DEGENERATION:
– Recurrent throat infection could possibly stimulate
the epithelial remnants of the tract causing it to
undergo cystic degeneration
• RETENTION PHENOMENON:
– A blockage in the duct because of the retained
secretions can lead to the duct being expanded
leading to cyst formation
 THYROGLOSSAL DUCT FISTULA
• Usually caused by spontaneous drainage of
the abscess in thyroglossal duct cyst
• An attempted drainage of misdiagnosed
midline neck abscess
• Inadequate attempts at excision –leaving an
intact hyoid bone
 CLINICAL FEATURES
• Usually presents as an asymptomatic midline
cystic mass at or about the level of hyoid bone
• Moves up on swallowing or protrusion of the
tongue
• 5% present as an acute inflammatory episode
• 15%-associated discharging fistula
• 90% are in the midline
• 10%-lateral-usually left sided-95%
• 75% - prehyoid
• 25%- either above or below hyoid
• Can sometimes be found within the
mediastinum
 PATHOLOGY
• Usually lined by squamous or pseudostratified
columnar ciliated epithelium
• Ectopic thyroid gland tissue in the duct wall
• Decalcification of hyoid bone will often
confirm that the tract passes through it
 DIFFERENTIAL DIAGNOSIS
• Dermoid cyst
• Subhyoid bursitis
• Thyroid isthmus tumor
• Enlarged delphian node
• Submental lymph node
 DIAGNOSIS & INVESTIGATIONS
• Usually clinical
• TSH & T4 – to determine the thyroid status of
the patient
• Ultrasound scanning –
• location and diagnosis of cyst
• Confirm the presence of normal thyroid gland
• FNAC:
• Demonstrate cystic contents containing colloid
• Differentiate it from Dermoid cyst or submental lymph
node if the mass is suprahyoid
• Radionuclide scanning:
• Either Technitium99 or iodine123
• Reserved for patients with normal thyroid gland that
cannot be visualized
• To identify and exclude the possibility of lingual thyroid
• CT/MRI SCAN:
– Reserved for patients with
• Large cysts
• Suspicion of malignancy
• Possibility of a lingual thyroid
 TREATMENT
• SURGERY ( Sistrunk’s operation)
– Treatment of choice
– transverse midline neck incision just below the
cyst
– Dissection of the lesion from infrahyoid strap
muscles and the laryngeal cartilages
– Dissection proceeds upwards to the hyoid bone
– Suprahyoid muscles(mylohyoid,geniohyoid and
genioglossus ) are detached from the hyoid bone
– Middle third of hyoid bone between the lesser
cornu is cut and mobilized in continuity with soft
tissue specimen
– Further dissection upwards into the tongue base
to include an excision of a core of tissues
– It includes a core of tissue or raphe between
mylohyoid muscles,a portion of each genioglossus
muscles and upto the area of foramen cecum
– If a sinus is present an ellipse of skin around the
sinus is removed in continuity
 RECURRENT CYSTS AND FISTULA
• 8% of cysts recur following adequate surgical
excision
• If simple excision has been performed then
Sistrunk’s procedure should be performed
• If Sistrunk’s procedure has been performed-
– excise previous incision scar
– a full central compartment neck dissection
– Excision of scar tissue upto the foramen cecum
THYROGLOSSAL CYST CARCINOMA
• Extremely rare-1% of thyroid carcinomas
• 94% are papillary thyroid carcinoma
• 5% are of squamous cell origin-true carcinoma of
TGD
• Cause-unknown
• No predisposing factors
• Neither clinical history nor physical examination
can lead to preoperative diagnosis
• Diagnosis-usually h/p following sistrunk’s
operation
 THEORIES
• DENOVO THEORY:
– Ectopic thyroid tissue can be identified h/p in 62%
of the cases
– Supported by the absence of MTC in TGCs
• METASTATIC THEORY:
– TGC carcinoma is metastaic from an occult
primary thyroid carcinoma- PTC multifocal
 TREATMENT
• For pure Thyroglossal carcinomas of
squamous cell origin-Sistrunks’s operation is
adequate

• For DTC in Throglossal cyst- Sistrunk’s

operation + Total thyroidectomy is
recommended
 TREATMENT
• For DTC tumors in TGC
– greater than 1 cm
– Invasion through the duct cyst wall
– Suspected foci in the thyroid gland

Sistrunk’s operation + Total Thyroidectomy

followed by Radioiodine ablation and TSH
suppression with Thyroxine