Management of suspected thyroglossal duct cysts

Management of suspected thyroglossal duct cysts

Journal of Pediatric Surgery 53 (2018) 281–282 Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.elsevier...

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Journal of Pediatric Surgery 53 (2018) 281–282

Contents lists available at ScienceDirect

Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg

Management of suspected thyroglossal duct cysts Hannah G. Povey, Haran Selvachandran, Robert T. Peters, Matthew O. Jones ⁎ Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Eaton Road, Liverpool, UK

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Article history: Received 27 October 2017 Accepted 8 November 2017 Key words: Anterior midline neck swelling Thyroglossal duct cyst Sistrunk procedure

a b s t r a c t Aim of study: The aim of this study was to evaluate management of children with an anterior midline neck swelling by establishing 1) whether a preoperative ultrasound scan (USS) was appropriately requested, performed and reported; 2) whether there was preoperative infection; 3) whether a Sistrunk procedure was performed; 4) the rate of thyroglossal duct cyst (TGDC) recurrence following simple excision vs. Sistrunk procedure. Methods: A single centre retrospective study of children who underwent surgery for anterior midline neck swelling between April 2000 and May 2015 at our institution was performed. These were identified using a clinical coding system, and data were collected from electronic medical records, radiology, and histopathology reports. Recurrence rates between simple excision and Sistrunk groups were compared using Chi-square test. Main results: 227 patients were identified (115 male, 112 female). 169 (74%) had a preoperative USS. The presence of a thyroid gland was stated in 79% of USS reports. This increased to 92% when the requesting surgeon had specifically asked about this. 48 (21%) patients underwent simple excision, while 175 (77%) had a Sistrunk procedure. Recurrence was significantly more likely following simple excision than a Sistrunk procedure (29% vs 6.9%; P b 0.0001). Of 25 TGDC recurrences, 9 (36%) had an inconclusive or alternative histopathological diagnosis at first operation. Conclusion: Preoperative USS should be performed in all patients with an anterior midline neck swelling. Appropriate requesting increases likelihood of a report confirming (or otherwise) the presence of a thyroid gland. A Sistrunk procedure is the operation of choice in all children presenting with an anterior midline neck swelling. The surgeon cannot reliably differentiate a TGDC from alternative pathology intraoperatively. Level of evidence: Treatment study: level IV. © 2017 Published by Elsevier Inc.

A Sistrunk procedure, including resection of the middle third of the hyoid bone, is considered the gold standard treatment for thyroglossal duct cysts (TGDC) [1–3]. However, the surgeon assessing a child with an anterior midline neck swelling does not know whether they are dealing with a TGDC or an alternative diagnosis such as a dermoid cyst [4,5] for which a simple excision will suffice. We sought, therefore, to evaluate the management of children presenting with an anterior midline neck swelling at our institution. In particular we looked at which operation was performed, the histopathological diagnosis and whether there was recurrence. We believe that before any definitive surgery an ultrasound scan (USS) of the neck should be performed to confirm the presence of a normally situated thyroid gland distinct from the swelling [2,6,7]. In its absence, the swelling may represent the child's only functioning thyroid tissue and excision might render the child hypothyroid,

⁎ Corresponding author at: Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK. Tel.: +44 151 252 5361; fax: +44 151 252 5677. E-mail address: [email protected] (M.O. Jones). https://doi.org/10.1016/j.jpedsurg.2017.11.019 0022-3468/© 2017 Published by Elsevier Inc.

requiring thyroxine therapy [7,8]. We also sought to determine whether preoperative thyroid imaging was appropriately ordered and reported.

1. Methods All children undergoing surgery for an anterior midline neck swelling at our institution over a 15 year period from April 2000 to May 2015 were identified retrospectively. Patients who had surgery for other reasons, such as thyroid cancer, were excluded. Data are collected from electronic medical records, radiology and histopathology reports. Information collected included patient demographics, preoperative infection, type of operation performed (simple excision versus Sistrunk procedure), histopathological diagnosis and whether or not there was a recurrence. We also recorded whether a preoperative USS had been performed. Recurrence rates between the noninfected versus preoperative infection groups and between the simple excision versus Sistrunk groups were compared using Chi-square test for independence. A P value of b0.05 was accepted as significant. Data are presented as median (interquartile range).

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Table 1 Recurrence by operation type; Chi-square two-tailed P b 0.0001. Recurrence Yes Hyoid Total

Yes No

12 14 26

Total

Table 2 Recurrence in the simple excision and Sistrunk procedure groups following preoperative infection; Chi-square two-tailed P b 0.0003 vs P = 0.09.

No 163 34 197

175 48 223

P b 0.0001.

2. Results A total of 227 (115 male) children were identified with a median age at operation of 4.5 (2.7–7 .2) years. Preoperative USS was performed in 169 (74%) children. The requesting surgeon had specifically enquired about the presence of a thyroid gland in their request in 64 (38%) cases. Overall, 133/169 (79%) reports confirmed the presence of a thyroid gland increasing to 59/64 (92%) when specifically requested. Initial imaging was unsatisfactory in 14 and required further imaging to confirm presence of a thyroid. One child had their procedure cancelled on the day owing to lack of a suitable preoperative scan. Surgery was defined as a simple excision (n = 48, 22%) or a Sistrunk procedure (n = 175, 78%). Histopathological reports were available for 223 children (4 unobtainable). Histopathological diagnoses were: TGDC n = 153, dermoid/epidermoid cyst n = 44, other n = 18, inconclusive n = 8. In those TGDCs who recurred (n = 26), 14 followed a simple excision and 12 followed a Sistrunk procedure. The recurrence rate was higher in the simple excision group compared with the Sistrunk group (14/48, 29% vs 12/175, 6.9%; P b 0.0001) [Table 1]. The histopathology report at the first resection had either been inconclusive or indicated an alternative diagnosis in 9 /26 (36%) TGDC recurrences. Recurrence was higher in the preoperative infection group in children who underwent simple cyst excision (n = 10/15, 67% vs n = 4/ 33, 12%; P b 0.0003). There was no significant difference however in recurrence where preoperative infection was present in the Sistrunk group (n = 6/47, 13% vs n = 6/128, 5%; P = 0.09) [Table 2]. 3. Discussion We believe that this study shows that all children with an anterior midline neck swelling should have a preoperative USS to confirm the presence of a normally situated thyroid gland distinct from the swelling, though this wasn't shown in practice with only about 75% actually having one and only a minority of the requests mentioning the reason. Obviously some clinicians may be unaware of the indications for imaging or consider it unnecessary where clinical assessment is strongly suggestive of a diagnosis other than a TGDC. Preoperative infection increases the likelihood of TGDC recurrence [9,10]. However, in our study this was only shown in those having the

Preoperative infection Total

Yes No

Simple excision

Sistrunk procedure

Recurrence

No recurrence

Recurrence

No recurrence

10 4 14

5 29 34

6 6 12

41 122 163

Total

62 161 223

P N 0.0003. P = 0.09.

lesser operation of simple cyst excision not those having Sistrunk's procedure. The data may be erroneous as it was based on retrospective notes evaluation and rates may therefore have been somewhat underestimated. The differential of a child presenting with an anterior midline neck swelling usually lies between a TGDC or a dermoid cyst [4,5] and clinical assessment and USS cannot reliably make the distinction. It is likely that, in a number of the simple excision cases, the intraoperative appearance of the swelling convinced the surgeon that the diagnosis was not a TGDC and led them to abort the planned Sistrunk procedure. The data in this study, however, show that the surgeon cannot reliably differentiate a TGDC from alternative pathology intraoperatively. Nevertheless TGDC is a diagnosis to make as it has a high risk of recurrence if only a simple excision is performed [5]. Thus, we believe that in a child presenting with an anterior midline neck swelling, a Sistrunk procedure is the gold standard operation to minimize the risk of recurrence [2,3,5,11].

References [1] Foley DS, Fallat ME. Thyroglossal duct and other congenital midline cervical anomalies. Semin Pediatr Surg 2006;15:70–5. [2] Chou J, Walters A, Hage R, et al. Thyroglossal duct cysts: anatomy, embryology and treatment. Surg Radiol Anat 2013;35:875–81. [3] Sistrunk WE. The surgical treatment of cysts of the thyroglossal tract. Ann Surg 1920;71:121–4. [4] Shah R, Gow K, Sobol SE. Outcome of thyroglossal duct cyst excision is independent of presenting age or symptomatology. Int J Pediatr Otorhinolaryngol 2007;71: 1731–5. [5] Radkowski D, Arnold J, Healy GB, et al. Thyroglossal duct remnants. Preoperative evaluation and management. Arch Otolaryngol Head Neck Surg 1991;117:1378–81. [6] Tunkel DE, Domenech EE. Radioisotope scanning of the thyroid gland prior to thyroglossal duct cyst excision. Arch Otolaryngol Head Neck Surg 1998;124:597–9. [7] Gupta P, Maddalozzo J. Preoperative sonography in presumed thyroglossal duct cysts. Arch Otolaryngol Head Neck Surg 2001;127:200–2. [8] Lilley JS, Lomenick JP. Delayed diagnosis of hypothyroidism following excision of a thyroglossal duct cyst. J Pediatr 2013;162:427–8. [9] Ducic Y, Chou S, Drkulec J, et al. Recurrent thyroglossal duct cysts: a clinical and pathologic analysis. Int J Pediatr Otorhinolaryngol 1998;44:47–50. [10] Brereton RJ, Symonds E. Thyroglossal cysts in children. Br J Surg 1978;65:507–8. [11] Ellis PD, van Nostrand AW. The applied anatomy of thyroglossal tract remnants. Laryngoscope 1977;87:765–70.