OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
THYROGLOSSAL DUCT REMNANTS Johan Fagan
The surgical management of thyroglossal
duct remnants (TGDRs) requires an
understanding of the embryology of the
thyroid gland, as failure to include the
embryological course of the thyroid gland Branching suprahyoid tract
in the surgical resection increases the
probability of recurrence.
Relevant Embryology
Thyroglossal duct tract
The thyroid gland originates in the base of
the tongue at the foramen caecum. In early
embryonic life the base of the tongue is
adjacent to the pericardial sac. As the Thyroglossal duct cyst
embryo unfolds, TGDRs may remain any-
where between the pericardial sac and the
foramen caecum. A persistent thyroglossal Figure 2: Schematic representation of the
duct courses through the base of the tongue suprahyoid duct branching within the
from the foramen caecum. It then passes muscle of the base of tongue
inferiorly, anterior to, and rarely through,
the hyoid body, and often has a diverti- Clinical presentation
culum that hooks below and behind the
hyoid, before it courses towards a thyro- TDGRs may present at any age as a cyst
glossal duct cyst or the thyroid gland (Figure 3, 4), abscess, sinus, fistula or
(Figure 1). tumour, anywhere along the embryological
course of the thyroid gland.
Foramen caecum
Hyoid bone
Retrohyoid diverticulum
Thyroglossal duct cyst
Figure 1: Typical course of thyroglossal
duct remnants (yellow line)
The suprahyoid ductal segment may have a
branching pattern like the tips of a broom
(Figure 2). These multiple ductules com-
municate with secretory glands in the base Figure 3: Thyroglossal duct cyst in
of the tongue and might drain directly into thyrohyoid region
the mouth.1
Relationship of TGDR to hyo
Lingual: 2%
Suprahyoid: 24%
Thyrohyoid: 61%
Suprasternal: 13%
Figure 4: Thyroglossal duct cyst in thyro- Mediastinal: Rarely
hyoid region
Patients classically present with a mobile, Figure 6: Distribution of thyroglossal duct
painless mass in the midline of the neck in cysts
proximity of the hyoid bone. Occasionally
a cyst may be off the midline (Figures 5,
10).
Figure 7: Dermoid cyst
A lingual thyroid usually presents as a
mass in the base of the tongue (Figures 8,
9); this may be the patient’s only thyroid
tissue in the majority of cases.
Figure 5: Thyroglossal duct cyst to left of
midline overlying lamina of thyroid carti-
lage
Figure 6 illustrates the distribution of
thyroglossal duct cysts. 1
A cyst generally moves upward during
deglutition or protrusion of the tongue
because of its close anatomical relation to
the hyoid bone. This is considered a
reliable diagnostic sign as it distinguishes
it from other midline neck masses such as
a lymph node or a dermoid cyst (Figure 7). Figure 8: Lingual thyroid
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and/or calcification on ultrasound exami-
nation should raise the possibility of carci-
noma, most commonly papillary. How-
ever, even if the diagnosis of thyroid
cancer is suspected it does not alter the
type of surgery (Sistrunk operation).
Surgical principles
It is imperative to achieve a complete
resection of the TGDR and its embryo-
nic tract so as to avoid symptomatic
recurrence
A thyroglossal cyst abscess should
Figure 9: CT scan of lingual thyroid initially be aspirated and treated with
antibiotics, not incised and drained, so
Preoperative evaluation as to facilitate complete resection once
the infection has settled
The principal issues to determine prior to
surgery are: Sistrunk operation
Is it a TGDR? Unlike other midline mass- The Sistrunk operation is the standard of
es, only TGDRs are treated with a Sistrunk care for TGDRs. It includes resection of
operation. Therefore it is important to entire embryological tract i.e. the thyro-
exclude other causes of midline masses glossal duct cyst, the central portion of the
prior to surgery such as dermoid cysts and body of the hyoid bone, and a broad
lymph nodes. (>1cm) core of suprahyoid muscle exten-
ding up to / close to the foramen caecum.
Is it the patient’s only thyroid tissue?
Occasionally a TGDR comprises the only The following description is for a cyst in
functioning thyroid tissue, and its removal the thyrohyoid region:
results in hypothyroidism. Ultrasound exa- Make an incision in a skin crease over
mination to establish the presence of nor- the cyst. Note that the platysma muscle
mal thyroid tissue is a simple investigation. may be absent in the midline, so take
Should imaging not be possible, the care not to puncture the cyst (Figure
surgeon should explore the neck to deter- 10)
mine the presence of a normal thyroid Raise superior and inferior flaps in
gland. subplatysmal planes. The superior flap
should be raised to approximately
Is the patient hypothyroid? The majority 2cms above the body of the hyoid bone
of patients with lingual thyroids are hypo- Identify the infrahyoid strap muscles
thyroid. Therefore patients with lingual that are stretched over the superficial
thyroids should have a TSH level deter- aspect of the cyst
mined prior to surgery. Divide the cervical fascia vertically in
the midline, separate the infrahyoid
Does the TGDR contain thyroid cancer? strap muscles, and expose the cyst
Thyroid cancer occurs in only about 1% of (Figure 11)
operated TGDRs. A solid component
3
Divide the mylohoid and geniohyoid Divide the inferior attachments of the
muscles just above the body of the thyroglossal duct cyst, and mobilise the
hyoid bone with diathermy remaining deep aspect of the cyst from the thyro-
between the lesser cornua of the hyoid hyoid membrane up to the hyoid bone
so as not to place the hypoglossal with sharp dissection (Figure 13)
nerves or lingual arteries at risk of Expose the hyoid bone on either side of
injury (Figure 12) the cyst (Figure 14)
Figure 10: Initial skin crease incision
Figure 13: Mobilise deep aspect of cyst
from thyroid cartilage and thyrohyoid
membrane
Figure 11: Expose and part infrahyoid
strap muscles overlying cyst
Figure 14: Expose hyoid bone on either
side of cyst
MHM
Divide the hyoid bone about 1cm to
each side of the midline with heavy
scissors (children) or a bone cutter
(Figures 15, 16)
Figure 12: Divide mylohoid (MHM) and
geniohyoid muscles just above body of
hyoid bone
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Figure 15: Dividing hyoid bone
Figure 17: Resect a 2cm wide core of
tongue (hyoglossus) tissue
Figure 16: Divided hyoid bone
Next resect the suprahyoid thyroglossal
duct. Do not attempt to identify the
thyroglossal duct, as branches of the
duct may be transected in the process
increasing the likelihood of recurrence
Using monopolar diathermy resect a
Figure 18: Superimposed image (yellow)
2cm wide core of tongue tissue
illustrates direction of suprahyoid
(hyoglossus) in continuity with the
dissection and extent of final resection;
remainder of the operative specimen,
note proximity of vallecula to hyoid
including the hyoid bone, directed at an
angle of approximately 450 in the
sagittal (vertical) plane towards the
foramen caecum (Figures 17, 18, 19)
If in doubt about the required direction,
place a finger in the mouth and on the
foramen caecum as a guide. It is remar-
kable how much base of tongue tissue
can be resected without interfering
with speech or swallowing. Note the
proximity of the hyoid bone to the
vallecula. Should the vallecula or base
of tongue be accidentally entered, Figure 19: Core of tongue (hyoglossus)
simply close the defect with vicryl tissue extending up to just short of foramen
sutures from the neck side. caecum
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accurate description of the original surgery
to determine whether the hyoid bone and
suprahyoid tissues had been resected. An
MRI scan should be done to serve as a
roadmap for the surgeon to find residual
TGDRs (Figure 21).
Figure 20: Final defect in base of tongue
up to just short of forman caecum with free
floating cut ends of hyoid bone
Figure 22: MRI of recurrence demonstra-
ting multiple cysts
Reference
Mondin V, Ferlito A, Muzzi E, Silver CE,
Fagan JJ, Devaney KO, Rinaldo A. Thyro-
glossal duct cyst: Personal experience and
literature review. Auris Nasus Larynx 35
(2008) 11–25
Figure 21: Resected specimen Author & Editor
The tongue defect (Figure 20) is then Johan Fagan MBChB, FCORL, MMed
partially obliterated with vicryl sutures. Professor and Chairman
The two cut ends of the hyoid are not Division of Otolaryngology
approximated, but left floating free. University of Cape Town
The supra- and infrahyoid muscles are Cape Town, South Africa
approximated in a transverse plane, as [email protected]
is the platysma muscle, and the skin is
closed over a drain THE OPEN ACCESS ATLAS OF
Antibiotics are not required unless the
oral cavity has been entered
OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
www.entdev.uct.ac.za
Recurrent TGDR
Managing recurrent TGDR becomes chal-
lenging because cysts may be multifocal
with the presence of fibrosis, distorted The Open Access Atlas of Otolaryngology, Head &
Neck Operative Surgery by Johan Fagan (Editor)
surgical landmarks and possible absence of
[email protected] is licensed under a Creative
hyoid bone. It is important to obtain an Commons Attribution - Non-Commercial 3.0 Unported
License
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