Thyroglossal duct cysts

Thyroglossal duct cysts

Thyroglossal Duct C'ysts A Thirty Year Experience With Emphasis on Occurrence in Older Patients Alfred D. Katz, M D and M a r k Hachigian, MD, Los An...

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Thyroglossal Duct C'ysts A Thirty Year Experience With Emphasis on Occurrence in Older Patients

Alfred D. Katz, M D and M a r k Hachigian, MD, Los Angeles, California

A thyroglossal duct cyst is a congenital anomaly resulting from r e t e n t i o n of an epithelial t r a c t between the thyroid and its origin, the foramen cecum, at the floor of the pharynx. This t r a c t is nearly always invested by the hyoid bone, which forms later during embryonic life [1-2]. Cysts t h a t arise from a persistent thyr0glossal d u c t are discovered most f r e q u e n t l y in the pediatric age g r o u p , b u t m a y become s y m p t o m a t i c at a n y age. T h e r e p o r t e d incidence of thyroglossal d u c t cysts in patients over 60 years of age is 0.6 to 5 percent [3-6]. Since we encountered thyroglossal d u c t cysts in the older patient more frequently, we decided t o compile the present series b y reporting on all cases of thyrogl0ssal d u c t cysts in a large private practice during a 30 year period. Material and Methods

All the private charts of one of us (ADK) for the past 30 years were reviewed. There were approximately 2,000 thyroid and Parathyroid operations performed, and 79 resections of thyroglossal duct cysts (3.95 percent). There was no sex predilection in the present study with 40 male an d 39 female patients. Twenty-eight percent of the patients were over the age of 50 and 10 percent were over 60. The youngest patient was 16 months and the oldest was 82 years of age. Figure 1 demonstrates the unusually large number of older patients in our series when compared with the numbers reported in the Engl!sh literature [4,6l. The most common presentation was painless swelling in the midline of the neck. This initial presentation frequently occurred after a severe upper respiratory tract infection. Seventy-six patients had symptoms for less than 1 year, but most for a few weeks only. All masses moved with tongue protrusion or deglutition. Three of the masses were submental whereas the rest were infrahyoid. The masses ranged in size from 3 mm to 3 cm in 76 of the patients, and the cystic neck masses were 6 to 7 cm in the other 3 patients. Patients with much larger masses were symptomatic for many years but refused surgical attention until much later in their course. Three patients iniFrom the Departmentof Surgery, Cedars-SinalMedical Center, Los Angeles, California. Requestsfor reprints shouldbe addressedto Alfred D. Katz, MD, 8635 West Third Street, Suite 695-W, Los Angeles, California 90048. "

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tially presented with a recurrent midline neck mass. In all of these patients, the original surgeon did not remove the center of the hyoid bone. Papillary carcinoma in the thyroid tissue of a thyroglossal duct cyst was discovered in two patients. In one patient, it was an incidental finding, and the patient refused to undergo any further operation. In the other patient, it was diagnosed preoperatively by needle biopsy. In this patient, a total thyroidectomy was performed along with resection of the thyroglossal duct cyst and center of the hyoid bone. Only one other total thyroidectomy was performed in conjunction with the Sistrunk operation, which was in a woman who had a cold nodule found on the thyroid scan during workup of her thyroglossal duct cyst. Her final pathologic diagnosis was papillary carcinoma of the thyroid and a benign thyroglossal duct cyst. One patient had a parathyroid adenoma resected along with a thyroglossal duct cyst. ~ Seventy-eight patients had a local resection of their cysts and removal of the center of the hyoid bone with the Sistrunk procedure [7,8]. Drains were placed in all of the patients and removed on the first postoperative morning. Most patients were discharged by the second postoperative morning and experienced mild dysphagia for 2 to 3 days which resolved spontaneously. Patients were followed weekly or biweekly until solid wound healing occurred. The older patients tended to have wound drainage for longer periods postoperatively. In all cases, the incisions were healed and free of drainage by the sixth postoperative week. There were no known recurrences and no deaths; however, there were three complications. The postoperative course' of three young patients was comPlicated by the development of obstructive masses at the tongue base [9]. These children proved to have lingual thyroids that enlarged after the functioning ect0pic thyroid within their thyroglossal duct cysts was removed. In all three patients, the lingual thyroid masses regressed with medical Suppressive therapy. These complications occurred before thyroid scans were performed routinely as part of the preoperative evaluation. Comments

T h e present s t u d y resembles most o t h e r studies in every regard except age distribution [4-6,10-:17]. We have no explanation for the large p r o p o r t i o n of

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older patients we saw with thyroglossal duct cysts. This may simply reflect the age characteristics of our total patient population which tended to be 40 years and older. These older patients posed no special management problems, but did tend to have drainage from the operative wounds for a longer duration than the younger patients. There was no sex predilection for thyroglossal duct cysts. All patients presented with midline neck masses and a variable history of infection and drainage. Based on our experience, our evaluation of the midline neck mass was the same in all age groups. First, a careful history and physical examination, including indirect laryngoscopy, was performed. All of the thyroglossal duct cysts moved with deglutition or tongue protrusion. Second, thyroid scans were performed preoperatively as a routine in nearly all patients after we recognized the growth of occult lingual thyroids in the three patients who had their only functioning thyroid tissue removed with their thyroglossal duct cysts. Now, if a lingual thyroid is diagnosed, and there is no thyroid in the patient's neck other than in the thyroglossal duct cysts, thyroid medication is started preoperatively. We suggest that a thyroglossal duct cyst be resected even if the ectopic thyroid contained within the cyst is the patient's only thyroid tissue. The cyst is prone to infection and progressive enlargement. Also, the thyroid tissue in the cyst is frequently abnormal or insufficient for adequate hormonal production. The patient can be better controlled by exogenous thyroid replacement and avoid a growing or infected neck mass. Finally, we found that preoperative fineneedle aspiration biopsy aids greatly in the management of midline cervical masses [18-22]. With the advent of fine-needle aspiration of all head and neck masses, the techniques and magnitude of head and neck surgery have changed. Two patients originally thought to have thyroglossal duct cysts had midline dermoid tumors diagnosed preoperatively by needle biopsy [23]. These patients had their tumors excised under local anesthesia as outpatients. Moreover, 742

Figure 1. Comparison of age distribution of patients with thyroglossal cyst~ Data on 1,044 patients ( 1890 to 1976) were compiled from the English literature [4, 6] and data on 79 patients ( 1955 to 1985) were compiled by the authors.

fine-needle biopsy can be an excellent adjunct to other clinical considerations. Needle aspiration is an assistance in deciding for or against surgery in patients with increased operative risks. A chronically ill 68 year old man had refused surgery for his duct cyst. However, with the needle diagnosis of carcinoma, the operation was performed. There was not only papillary carcinoma in the thyroid remnant of the duct cyst but papillary carcinoma in both lobes of the thyroid. We now have two chronically ill patients with thyroglossal duct cysts who are being followed with serial aspirations. We also suggest surgery in patients whose cysts have been decompressed by fine-needle biopsy and have not refilled. At operation, these large collapsed cysts have been easily identified and removed. Without infection, the hospital stay and postoperative care in these patients have been minimal. Intraoperative decision-making is frequently aided by the information gained in a thoroughpreoperative workup. Additionally, at operation, we open and may obtain a frozen section of a presumed thyroglossal duct cyst before embarking on a hyoid bone resection. If a mass is a dermoid tumor, the preservation of the hyoid bone greatly reduces the magnitude of the surgery. In thyroglossal duct surgery, we believe the Sistrunk operation (resection of the cyst and center of the hyoid bone) is the procedure of choice [7,8]. We have had no known recurrences with this procedure, although the three patients referred to us for recurrences did not have the center of the hyoid bone excised. Carcinoma in a thyroglossal duct cyst is very rare [24-31]. The types may include squamous cell carcinoma usually arising from ectopic thyroid remnants in the cyst wall [25-31]. Papillary carcinoma within thyroglossal duct cysts appears to be biologically similar to papillary neoplasms arising from the main gland. The higher incidence of thyroid cancer in women is less striking in thyroglossal duct cyst cancer. The prognosis of the papillary carcinoma is usually very favorable [25-31]. We treated our paThe American Journal of Surgery

Thyroglossal Duct Cysts in Older Patients

tient with a preoperative diagnosis of carcinoma with total thyroidectomy and resection of the thyroglossal duct cyst. This is the same method we use for carcinoma of the thyroid [32,33]. This treatment may be in contrast to the management of thyroid cancers in some other parts of the United States [34]. In reviewing the literature, we found several reports of patients with small papillary carcinomas within thyroglossal duct cysts treated only with local resection who survived [26,31]. However, this does not change our opinion that a papillary carcinoma in a thyroglossal duct cyst is a cancer of the thyroid and should be treated with total thyroidectomy and follow-up adjuvant therapy. The patient should be placed on thyroid replacement to tolerance. In conclusion, our study of 79 patients with thyroglossal duct cysts demonstrated that these cysts may be found at any age and have no sex predilection. Careful preoperative evaluation includes a thorough history and physical examination, thyroid scan, and fine-needle aspiration biopsy. Intraoperative examination of the gross specimen and frozen section may be useful in planning operative therapy. Carcinoma within thyroglossal duct cysts is a rare occurrence, and if it is of thyroid cell origin, we treat it as we would a cancer of the thyroid. Summary

A total of'79 patients (39 female and 40 male) underwent the Sistruck procedure for thyroglossal duct cysts. Twenty-eight percent of the patients were over 50 years of age and 10 percent were over 60. The age range was 16 months to 82 years. Three patients had thyroidectomies, two of which were for carcinoma, along with resection of a thyroglossal duct cyst. Two patients, one diagnosed preoperatively by needle biopsy, had papillary carcinoma in thyroid tissue of the cyst wall. The length of time from cyst discovery to surgery was the same for patients over 10 years of age. We suggest needle biopsy of all neck masses and also elective operation in a patient of any age, once a diagnosis of thyroglossal duct cysts is made. The Sistrunk procedure is the operation of choice. References 1. Moore KL. The developing human. Clinically oriented embryology, 2nd ed. Philadelphia: WB Saunders, 1977: 179-80. 2. Patten BM. Human embryology. Philadelphia: Blakiston, 1946: 540-1. 3. AllardRHB. The thyroglossal duct cyst. Head NeckSurg 1982; 5: 134-46. 4. Murphy JP, Budd DC. Thyroglossal duct cysts in the elderly. South Med J 1977; 70: 1247-58. 5. Shanmugham MS, Todd GB. Thyroglossal cyst in the elderly patient. Ear Nose Throat J 1983; 62: 67-70. 6. Sammarco GJ, McKenna J. Thyroglossal duct cysts in the elderly. Geriatrics 1970; 25: 98-101.

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7. Sistrunk WE. The surgical treatment of cysts of the thyroglossal tract. Ann Surg 1920; 71: 121-4. 8. Sistrunk WE. Technique of removal of cysts and sinuses of the thyroglossal duct. Surg Gynecol Obstet 1928; 46: 109-12. 9. Katz AD, Zager WJ. The lingual thyroid. Its diagnosis and treatment. Arch Surg 1971; 102: 582-5. 10. Noyek AM, Friedberg J. Thyroglossal duct and ectopic thyroid disorders. Otolaryngo! Clin North Am 1981; 14: 187-201. 11. Hawkins DB, Jacobsen BE, Klatt EG. Cysts of the thyroglossal duct. Laryngoscope 1982; 92: 1254-8. 12. Dulgaard JB, Wetteland P. Thyrogtossal anomalies. A followUp study of 58 cases. Acta Chir Scand 1956; 111: 444-55. 13. Larocelle D, Arcand P, Belzile M, Gagnon ND. Ectopic thyroid tissue. A review of the literature. J Otolaryngol 1979; 8: 523-30. 14. Marshall SF. Thyroglossal cysts and sinuses. Surg Clin North Am 1953; 33: 633-44. 15. Wampler HW, Krolls SO, John PJ. Thyroglossal tract cyst. Oral Surg Oral Med Oral Pathol 1978; 45: 32-6. 16. Ward PH, Strahan RW, Acquarelli M, Harris PF. The many faces of the thyroglossal duct. Trans Am Acad Ophthalmol Otolaryngol 1970; 74: 310-8. 17. Batsakis JG. Tumors of the head and neck: clinical and pathological consideration. 2nd ed. Baltimore: Williams & Wilkins 1979: 235-8. 18. Griffies WS, Donegan E, Abel ME. The role of fine needle aspiration in the management of the thyroid nodule, laryngoscope 1985; 95: 1103-6. 19. Ramacciotti CE, Pretorius HT, Chu EW, Basky SH, Brennan MF, Robbins J. Diagnostic accuracy and use of aspiration biopsy in the management of thyroid nodules. Arch Intern Med 1984; 144:1169-73. 20. Ashcraft MW, Van Herle AJ. Management of thyroid nodules: I1. Scanning techniques, thyroid suppressive therapy and fine needle aspiration. Head Neck Surg 1981; 3: 297-322. 21. Willems JS, Lowhagen T. Fine-needle aspiration cytology in thyroid disease. Clin Endocrinol Metab 1981; 10: 247-66. 22. Hamburger JL, Hamburger SW. Declining role of frozen section in surgical planning for thyroid nodules. Surgery 1985; 98: 307-12. 23. Katz AD. Midline dermoid tumors of the neck. Arch Surg 1974; 109: 822-3. 24. White IL, Talbert WM. Squamous cell carcinoma arising in thyroglossal duct remnant cyst epithelium. Otolaryngol Head Neck Surg 1982; 90: 25-31. 25. Kristensen S, Juul A, Moesner J. Thyroglossal cyst carcinoma. J Laryngol Otol 1984; 98: 1277-80. 26. Roses DF, Snively SL, Phelps RG, Cohen N, Blum M. Carcinoma of the thyroglossal duct. Am J Surg 1983; 145: 266-9. 27. Maxwell WC, Marchetta FE. Papillary adenocarcinoma of the thyroglossal duct tract. Arch Surg 1960; 80: 224-5. 28. Massalin R, Diener C, Jawali H. Thyroglossal cyst carcinoma. A case report and review of the literature. Kans Med 1982; 83: 426-7. 29. Nussbaum M, Buchwald RP, Ribno A. Anaplastic carcinoma arising from median ectopic thyroid (thyroglossal duct remnant). Cancer 1981; 48: 2724-8. 30. Joseph TJ, Komorowski RA. Thyroglossal duct carcinoma. Hum Pathol 1975; 6: 717-29. 31. Page CP, Kemmerer WT, Haft RC, Mazzaferri EL. Thyroid carcinomas arising in thyroglossal ducts. Ann Surg 1974; 180i 799-803. 32. Katz AD, Bronson D. Total thyroidectomy. The indications and results of 630 cases. Am J Surg 1978; 136: 450-4. 33. Katz AD. Thyroid and associated polyglandular neoplasms in patients who received head and neck irradiation during childhood. Head Neck Surg 1979; 1: 417-22. 34. Tollesen HR, Shah JP, Huvos AG. Papillary carcinoma of the thyroid: recurrence in the thyroid gland after initial surgical treatment. Am J Surg 1972; 124: 468-73.

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