A 45-Year-Old Man With Gradual Neck Swelling

Once diagnosed, thyroglossal duct cysts are removed because they are cosmetically undesirable and have the potential to become infected and undergo malignant transformation. The treatment of choice is the Sistrunk procedure, named after Walter Ellis Sistrunk and first described in an article in 1920.^[4] The procedure, rather than being simple excision of the cyst, involves dissecting the central portion of the hyoid bone, with extension of the excision up to the base of the tongue to include excision of a small block of muscle around the foramen cecum.

Because of the increased risk for thyroglossal duct carcinoma, some practitioners further recommend the addition of thyroid suppression therapy or complete thyroidectomy; however, this practice remains controversial.

The recurrence rate associated with simple excision of a thyroglossal duct cyst is approximately 50%, whereas the recurrence rate associated with a formal Sistrunk procedure is approximately 5%. The rate of recurrence after a Sistrunk procedure is increased, however, when a thyroglossal duct is ruptured during dissection. A history of previous infection of the cyst, previous incision and drainage procedures, and adherence of the cyst to the skin all increase the risk for rupture during dissection. If the cyst is infected at the time of diagnosis, treatment with antibiotics, such as ampicillin/sulbactam, amoxicillin/clavulanate, or clindamycin, is indicated before surgical excision.^[1,2,4]

The most common complications of thyroglossal duct cysts are infection with the possibility for abscess formation, spontaneous rupture, and formation of a secondary sinus tract. A Sistrunk procedure mistakenly performed for thyroid ectopia that removes thyroid tissue can cause hypothyroidism. The cysts can compress the trachea and lead to respiratory distress, especially if they are rapidly expanding (although this is uncommon).

Carcinoma is the most feared complication of thyroglossal duct cysts, occurring in about 1% of all cases; papillary carcinoma accounts for 85%-92% of cancers and follicular carcinoma accounting for the rest. Most patients who develop carcinoma tend to present at a later age. Cancer in a thyroglossal duct cyst seems to be more common in females than in males. Carcinoma arising in a thyroglossal duct cyst is typically diagnosed postoperatively by histology.^[1]

Because the patient in our case presented with a thyroglossal duct cyst that (on clinical grounds) was not infected, he was not given antibiotics. The ultrasound study confirmed the presence of a thyroglossal duct cyst and ruled out the possibility of an ectopic thyroid gland.

The patient underwent an elective Sistrunk procedure, with no rupture during dissection. No complications occurred. He was discharged from the hospital the following day. Postoperative histologic analysis did not reveal any evidence of cancer. On follow-up in the clinic 2 weeks later, the patient was noted to be doing well.

Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: Jitendra Gohil, Pramod Gupta. A 45-Year-Old Man With Gradual Neck Swelling - Medscape - Nov 30, 2016.

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