Thyroglossal cyst

Last updated
Thyroglossal cyst
Thyreoglossal duct cyst.jpg
Thyroglossal cyst
Specialty Medical genetics

A thyroglossal cyst is a fibrous cyst that forms from a persistent thyroglossal duct. Thyroglossal cysts can be defined as an irregular neck mass or a lump which develops from cells and tissues left over after the formation of the thyroid gland during developmental stages. [1]

Contents

Thyroglossal cysts are the most common cause of midline neck masses and are generally located caudal to (below) the hyoid bone. These neck masses can occur anywhere along the path of the thyroglossal duct, from the base of the tongue to the suprasternal notch. [2] Other common causes of midline neck masses include lymphadenopathy, dermoid cysts, and various odontogenic anomalies. [2]

Thyroglossal cysts develop at birth. Many diagnostic procedures may be used to establish the degree of the cyst.

Signs and symptoms

Thyroglossal duct cysts most often present with a palpable asymptomatic midline neck mass usually below [65% of the time] the level of the hyoid bone. The mass on the neck moves during swallowing or on protrusion of the tongue because of its attachment to the tongue via the tract of thyroid descent. Some patients will have neck or throat pain, or dysphagia.[ citation needed ]

The persistent duct or sinus can promote oral secretions, which may cause cysts to become infected. Up to half of thyroglossal cysts are not diagnosed until adult life. The tract can lie dormant for years or even decades, until some kind of stimulus leads to cystic dilation. Infection can sometimes cause the transient appearance of a mass or enlargement of the cyst, at times with periodic recurrences. Spontaneous drainage may also occur. Differential diagnosis are ectopic thyroid, enlarged lymph nodes, dermoid cysts and goiter.[ citation needed ]

Thyroglossal cyst usually presents as a midline neck lump (in the region of the hyoid bone) that is usually painless, smooth and cystic, though if infected, pain can occur. There may be difficulty breathing, dysphagia (difficulty swallowing), or dyspepsia (discomfort in the upper abdomen), especially if the cyst becomes large.[ citation needed ]

The most common location for a thyroglossal cyst is midline or slightly off midline, between the isthmus of the thyroid and the hyoid bone or just above the hyoid bone. A thyroglossal cyst can develop anywhere along a thyroglossal duct, though cysts within the tongue or in the floor of the mouth are rare.[ citation needed ]A thyroglossal cyst will move upwards with protrusion of the tongue.[ citation needed ]Thyroglossal cysts are associated with an increased incidence of ectopic thyroid tissue. Occasionally, a lingual thyroid can be seen as a flattened strawberry-like lump at the base of the tongue. [3]

Complications

Infection

Post surgery infection on a Thyroglossal Cyst, reaction from stitches. Infected site.jpg
Post surgery infection on a Thyroglossal Cyst, reaction from stitches.
Post removal of stitches from surgery on a Thyroglossal Cyst infection Post stitches infection.jpg
Post removal of stitches from surgery on a Thyroglossal Cyst infection

An infected thyroglossal duct cyst can occur when it is left untreated for a certain amount of time or simply when a thyroglossal duct cyst hasn't been suspected. The degree of infection can be examined as major rim enhancement has occurred, located inferior to the hyoid bone. Soft tissue swelling occurs, along with airway obstruction and trouble swallowing, due to the rapid enlargement of the cyst. [2] With infections, there can be rare cases where an expression of fluid is projected into the pharynx causing other problems within the neck. [4]

Thyroglossal Fistula

A thyroglossal duct cyst may rupture unexpectedly, resulting in a draining sinus known as a thyroglossal fistula. [2] Thyroglossal fistula can develop when the removal of the cyst has not been fully completed. This is usually noticed when bleeding in the neck occurs, causing swelling and fluid ejection around the original wound of removal. [5]

Thyroglossal duct cyst carcinoma

Rarely, cancer may be present in a thyroglossal duct cyst. These tumors usually arise from the ectopic thyroid tissue within the cyst. [6] [7]

Causes

Thyroglossal Duct Cysts are a birth defect. During embryonic development, the thyroid gland is being formed, beginning at the base of the tongue and moving towards the neck canal, known as the thyroglossal duct. Once the thyroid reaches its final position in the neck, the duct normally disappears. In some individuals, portions of the duct remain behind, leaving small pockets, known as cysts. During a person's life, these cyst pockets can fill with fluids and mucus, enlarging when infected, presenting the thyroglossal cyst. [1]

Embryology

The thyroglossal tract arises from the foramen cecum at the junction of the anterior two-thirds and posterior one-third of the tongue. Any part of the tract can persist, causing a sinus, fistula or cyst. Most fistulae are acquired following rupture or incision of the infected thyroglossal cyst. A thyroglossal cyst is lined by pseudostratified, ciliated columnar epithelium while a thyroglossal fistula is lined by columnar epithelium.[ citation needed ]

Diagnosis

Ultrasound image of thyroglossal duct cyst Thyroglossal Duct Cyst 150117131348265.jpg
Ultrasound image of thyroglossal duct cyst

Diagnosis of a thyroglossal duct cyst requires a medical professional, and is usually done by a physical examination. It is important to identify whether or not the thyroglossal cyst contains any thyroid tissue, as it can define the degree of cyst that is being dealt with. [1]

Diagnostic procedures for a thyroglossal cyst include: [1]

TypeDefinition
Blood Test Blood testing of thyroid function.
Ultrasound Image capture of the degree of mass and its surrounding tissues.
Thyroid ScanRadioactive iodine or technetium (a radioactive metallic element) is used in this procedure to show any abnormalities of the thyroid.
Fine Needle AspirationThe removal of cells for biopsy, using a needle

Clinical features

Clinical features can be found in the subhyoid portion of the tract and 75% present as midline swellings. The remainder can be found as far lateral as the lateral tip of the hyoid bone.[ citation needed ]

Typically, the cyst will move upwards on protrusion of the tongue, given its attachment to the embryonic duct, as well as on swallowing, due to attachment of the tract to the foramen caecum.[ citation needed ]

Treatment

Although generally benign, the cyst must be removed if the patient exhibits difficulty in breathing or swallowing, or if the cyst is infected. Even if these symptoms are not present, the cyst may be removed to eliminate the chance of infection or development of a carcinoma, [8] or for cosmetic reasons if there is unsightly protrusion from the neck.

Thyroid scans and thyroid function studies are ordered preoperatively; this is important to demonstrate that normally functioning thyroid tissue is in its usual area.[ citation needed ]

Surgical management options include the Sistrunk procedure, en bloc central neck dissection, suture-guided transhyoid pharyngotomy, and Koempel's supra-hyoid technique. [9] Cystectomy is an inadequate approach. [10]

Sistrunk Procedure

The Sistrunk procedure is the surgical resection of the central portion of the hyoid bone along with a wide core of tissue from the midline area between the hyoid and foramen cecum. [11] It involves excision not only of the cyst but also of the path's tract and branches, and removal of the central portion of the hyoid bone is indicated to ensure complete removal of the tract. The original Sistrunk papers (the "classic" procedure described in 1920, and the "modified" procedure described in 1928) are available on-line with a modern commentary. [12] [13]

In general, the procedure consists of three steps:

  1. incision
  2. resection of cyst and hyoid bone
  3. drainage and closure

There are several versions of the Sistrunk procedure, including:

The procedure is relatively safe. In a study of 35 pediatric patients, Maddalozzo et. al found no major complications, but did observe minor complications (6 patients presented with seroma and 4 patients with local wound infections). [15] A more recent paper analyzed 24 research studies on different treatment complications of thyroglossal cyst, and reported a total minor complications rate of 6% for the Sistrunk operation (classical or modified) and simple cystectomy treatment modalities. [16] The Sistrunk procedure also showed better outcomes concerning the rate of overall recurrence, i.e. has the lowest rate of recurrence. [16]

Sistrunk procedure results in a 95% cure rate and 95–100% long-term survival. [17]

Epidemiology

  1. 90% of cases are presented in children before the age of 10 [18]
  2. 70% of neck anomalies are from Thyroglossal cysts [18]
  3. Thyroglossal Duct Cysts are the second most common neck abnormalities after lymphadenopathy [18]
  4. A person can live with a Thyroglossal Duct Cyst without any problems, until a pathology develops. [18]
  5. Approximately 7% of the population has thyroglossal duct remnants [19]
  6. Thyroglossal duct carcinoma occurs in approximately 1 to 2% of Thyroglossal cyst cases. [20]

See also

Related Research Articles

Otorhinolaryngology Surgical subspeciality concerned with ear, nose, and throat conditions

Otorhinolaryngology is a surgical subspecialty within medicine that deals with the surgical and medical management of conditions of the head and neck. Doctors who specialize in this area are called otorhinolaryngologists, otolaryngologists, head and neck surgeons, or ENT surgeons or physicians. Patients seek treatment from an otorhinolaryngologist for diseases of the ear, nose, throat, base of the skull, head, and neck. These commonly include functional diseases that affect the senses and activities of eating, drinking, speaking, breathing, swallowing, and hearing. In addition, ENT surgery encompasses the surgical management and reconstruction of cancers and benign tumors of the head and neck as well as plastic surgery of the face and neck.

Thyroid Endocrine gland in the neck; secretes hormones that influence metabolism

The thyroid, or thyroid gland, is an endocrine gland in the neck consisting of two connected lobes. The lower two thirds of the lobes are connected by a thin band of tissue called the thyroid isthmus. The thyroid is located at the front of the neck, below the Adam's apple. Microscopically, the functional unit of the thyroid gland is the spherical thyroid follicle, lined with follicular cells (thyrocytes), and occasional parafollicular cells that surround a lumen containing colloid. The thyroid gland secretes three hormones: the two thyroid hormones – triiodothyronine (T3) and thyroxine (T4) – and a peptide hormone, calcitonin. The thyroid hormones influence the metabolic rate and protein synthesis, and in children, growth and development. Calcitonin plays a role in calcium homeostasis. Secretion of the two thyroid hormones is regulated by thyroid-stimulating hormone (TSH), which is secreted from the anterior pituitary gland. TSH is regulated by thyrotropin-releasing hormone (TRH), which is produced by the hypothalamus.

Tongue Muscular organ in the mouth of most vertebrates

The tongue is a muscular organ in the mouth of most vertebrates that manipulates food for mastication and is used in the act of swallowing. It has importance in the digestive system and is the primary organ of taste in the gustatory system. The tongue's upper surface (dorsum) is covered by taste buds housed in numerous lingual papillae. It is sensitive and kept moist by saliva and is richly supplied with nerves and blood vessels. The tongue also serves as a natural means of cleaning the teeth. A major function of the tongue is the enabling of speech in humans and vocalization in other animals.

Gallbladder Organ in humans and other vertebrates

In vertebrates, the gallbladder is a small hollow organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath the liver, although the structure and position of the gallbladder can vary significantly among animal species. It receives and stores bile, produced by the liver, via the common hepatic duct, and releases it via the common bile duct into the duodenum, where the bile helps in the digestion of fats.

Fistula An abnormal connection between two epithelialized surfaces, often organs

A fistula is an abnormal connection between two hollow spaces, such as blood vessels, intestines, or other hollow organs. Fistulas are usually caused by injury or surgery, but they can also result from an infection or inflammation. Fistulas are generally a disease condition, but they may be surgically created for therapeutic reasons.

Cholecystitis cholangitis that is characterized by an inflammation that is located in the gallbladder

Cholecystitis is inflammation of the gallbladder. Symptoms include right upper abdominal pain, nausea, vomiting, and occasionally fever. Often gallbladder attacks precede acute cholecystitis. The pain lasts longer in cholecystitis than in a typical gallbladder attack. Without appropriate treatment, recurrent episodes of cholecystitis are common. Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, or inflammation of the common bile duct.

Pilonidal disease Hair-containing cyst or sinus, occurring chiefly in the coccygeal region

Pilonidal disease is a type of skin infection which typically occurs as a cyst between the cheeks of the buttocks and often at the upper end. Symptoms may include pain, swelling, and redness. There may also be drainage of fluid, but rarely a fever.

Orbit (anatomy) Cavity or socket of the skull in which the eye and its appendages are situated

In anatomy, the orbit is the cavity or socket of the skull in which the eye and its appendages are situated. "Orbit" can refer to the bony socket, or it can also be used to imply the contents. In the adult human, the volume of the orbit is 30 millilitres, of which the eye occupies 6.5 ml. The orbital contents comprise the eye, the orbital and retrobulbar fascia, extraocular muscles, cranial nerves II, III, IV, V, and VI, blood vessels, fat, the lacrimal gland with its sac and duct, the eyelids, medial and lateral palpebral ligaments, check ligaments, the suspensory ligament, septum, ciliary ganglion and short ciliary nerves.

Dermoid cyst tissue disease

A dermoid cyst is a teratoma of a cystic nature that contains an array of developmentally mature, solid tissues. It frequently consists of skin, hair follicles, and sweat glands, while other commonly found components include clumps of long hair, pockets of sebum, blood, fat, bone, nail, teeth, eyes, cartilage, and thyroid tissue.

Thyroglossal duct

The thyroglossal duct is an embryological anatomical structure forming an open connection between the initial area of development of the thyroid gland and its final position. It is located exactly mid-line, between the anterior 2/3 and posterior 1/3 of the tongue.

Maxillary sinus Largest of the paranasal sinuses, and drains into the middle meatus of the nose

The pyramid-shaped maxillary sinus is the largest of the paranasal sinuses, and drains into the middle meatus of the nose through the osteomeatal complex.

Oral mucocele

Oral mucocele is a clinical term for two related phenomena: mucus extravasation phenomenon and mucous retention cyst. Other names include mucous extravasation cyst, mucous cyst of the oral mucosa, and mucous retention and extravasation phenomena.

Ranula human disease

A ranula is a mucus extravasation cyst involving a sublingual gland and is a type of mucocele found on the floor of the mouth. Ranulae present as a swelling of connective tissue consisting of collected mucin from a ruptured salivary gland caused by local trauma. If small and asymptomatic further treatment may not be needed, otherwise minor oral surgery may be indicated.

Persistent thyroglossal duct

A persistent thyroglossal duct is a usually benign medical condition in which the thyroglossal duct, a structure usually only found during embryonic development, fails to atrophy. The duct persists as a midline structure forming an open connection between the back of the tongue and the thyroid gland. This opening can lead to fluid accumulation and infection, which necessitate the removal of the duct.

Branchial cleft cyst tumor derived from branchial epithelium or branchial rests

A branchial cleft cyst is a cyst as a swelling in the upper part of neck anterior to sternocleidomastoid. It can, but does not necessarily, have an opening to the skin surface, called a fistula. The cause is usually a developmental abnormality arising in the early prenatal period, typically failure of obliteration of the second, third, and fourth branchial cleft, i.e. failure of fusion of the second branchial arches and epicardial ridge in lower part of the neck. Branchial cleft cysts account for almost 20% of neck masses in children. Less commonly, the cysts can develop from the first, third, or fourth clefts, and their location and the location of associated fistulas differs accordingly.

Thyroid dysgenesis human disease

Thyroid dysgenesis is a cause of congenital hypothyroidism where the thyroid is missing, ectopic, or severely underdeveloped.It should not be confused with iodine deficiency, or with other forms of congenital hypothyroidism, such as thyroid dyshormonogenesis, where the thyroid is present but not functioning correctly.

Odontogenic cyst are a group of jaw cysts that are formed from tissues involved in odontogenesis. Odontogenic cysts are closed sacs, and have a distinct membrane derived from rests of odontogenic epithelium. It may contain air, fluids, or semi-solid material. Intra-bony cysts are most common in the jaws, because the mandible and maxilla are the only bones with epithelial components. That odontogenic epithelium is critical in normal tooth development. However, epithelial rests may be the origin for the cyst lining later. Not all oral cysts are odontogenic cyst. For example, mucous cyst of the oral mucosa and nasolabial duct cyst are not of odontogenic origin.
In addition, there are several conditions with so-called (radiographic) 'pseudocystic appearance' in jaws; ranging from anatomic variants such as Stafne static bone cyst, to the aggressive aneurysmal bone cyst.

Ectopic thymus is a condition where thymus tissue is found in an abnormal location. It is thought to be the result of either a failure of descent or a failure of involution of normal thymus tissue.

A cyst is a pathological epithelial lined cavity that fills with fluid or soft material and usually grows from internal pressure generated by fluid being drawn into the cavity from osmosis. The bones of the jaws, the mandible and maxilla, are the bones with the highest prevalence of cysts in the human body. This is due to the abundant amount of epithelial remnants that can be left in the bones of the jaws. The enamel of teeth is formed from ectoderm, and so remnants of epithelium can be left in the bone during odontogenesis. The bones of the jaws develop from embryologic processes which fuse together, and ectodermal tissue may be trapped along the lines of this fusion. This "resting" epithelium is usually dormant or undergoes atrophy, but, when stimulated, may form a cyst. The reasons why resting epithelium may proliferate and undergo cystic transformation are generally unknown, but inflammation is thought to be a major factor. The high prevalence of tooth impactions and dental infections that occur in the bones of the jaws is also significant to explain why cysts are more common at these sites.

In CT scan of the thyroid, focal and diffuse thyroid abnormalities are commonly encountered. These findings can often lead to a diagnostic dilemma, as the CT reflects the nonspecific appearances. Ultrasound (US) examination has a superior spatial resolution and is considered the modality of choice for thyroid evaluation. Nevertheless, CT detects incidental thyroid nodules (ITNs) and plays an important role in the evaluation of thyroid cancer.

References

  1. 1 2 3 4 University of Rochester Medical Center. (2015). Thyroglossal duct cyst. Retrieved from http://www.urmc.rochester.edu
  2. 1 2 3 4 Deaver M. J.; Silman E. F.; Lotfipour S. (2009). "Infected thyroglossal duct cyst". Western Journal of Emergency Medicine. 10 (3): 205. PMC   2729228 . PMID   19718389.
  3. SRB's Manual of Surgery 3rd edition 2009;405;406.
  4. Stahl W.M.; Lyall D. (1954). "Cervical cysts and fistulae of thyroglossal Tract Origin". Annals of Surgery. 139 (1): 123–128. doi:10.1097/00000658-195401000-00018. PMC   1609283 . PMID   13114863.
  5. The State of Queensland. (2011) Thyroglossal cysts/fistuka. Retrieved from http://www.health.qld.gov.au
  6. Ali M.; Abussa A.; Hashmi H. (2007). "Papillary thyrpid carcinoma formation in a thyroglossal cyst. A case report". Libyan Journal of Medicine. 2 (3): 148–149. doi:10.4176/070611. PMC   3078210 . PMID   21503216.
  7. Sabra, M. (2009). Clinical thyroidology for patients. American Thyroid Association. 3(2), 12. Retrieved from http://www.thyroid.org
  8. McNicoll MP, Hawkins DB, England K, Penny R, Maceri DR (1988). "Papillary carcinoma arising in a thyroglossal duct cyst". Otolaryngology–Head and Neck Surgery. 99 (1): 50–54. doi:10.1177/019459988809900109. PMID   3140182. S2CID   27041672.
  9. Ibrahim, Farid F.; Alnoury, Mohammed K.; Varma, Namrata; Daniel, Sam J. (2015-06-01). "Surgical management outcomes of recurrent thyroglossal duct cyst in children--A systematic review". International Journal of Pediatric Otorhinolaryngology. 79 (6): 863–867. doi:10.1016/j.ijporl.2015.03.019. ISSN   1872-8464. PMID   25890397.
  10. 1 2 3 Geller, Kenneth A.; Cohen, David; Koempel, Jeffrey A. (2014-02-01). "Thyroglossal duct cyst and sinuses: a 20-year Los Angeles experience and lessons learned". International Journal of Pediatric Otorhinolaryngology. 78 (2): 264–267. doi:10.1016/j.ijporl.2013.11.018. ISSN   1872-8464. PMID   24332664.
  11. Gioacchini, FM (January 2015). "Clinical presentation and treatment outcomes of thyroglossal duct cysts: a systematic review". International Journal of Oral and Maxillofacial Surgery. 44 (1): 119–126. doi:10.1016/j.ijom.2014.07.007. PMID   25132570.
  12. 1 2 Sistrunk, W.E. (1928). "Technique of removal of cysts and sinuses of the thyroglossal duct". Surg. Gynecol. Obstet. 46: 109–112.
  13. 1 2 Sistrunk, Walter Ellis (2016-11-23). "The Surgical Treatment of Cysts of the Thyroglossal Tract". Annals of Surgery. 71 (2): 121–122.2. doi:10.1097/00000658-192002000-00002. ISSN   0003-4932. PMC   1410396 . PMID   17864229.
  14. Ryu, Yoon-Jong; Kim, Dong Wook; Jeon, Hyoung Won; Chang, Hyun; Sung, Myung Whun; Hah, J. Hun (2015-06-01). "Modified Sistrunk operation: New concept for management of thyroglossal duct cyst". International Journal of Pediatric Otorhinolaryngology. 79 (6): 812–816. doi:10.1016/j.ijporl.2015.03.001. ISSN   1872-8464. PMID   25829321.
  15. Maddalozzo, J.; Venkatesan, T. K.; Gupta, P. (2001-01-01). "Complications associated with the Sistrunk procedure". The Laryngoscope. 111 (1): 119–123. doi:10.1097/00005537-200101000-00021. ISSN   0023-852X. PMID   11192879. S2CID   24852015.
  16. 1 2 Gioacchini, F. M.; Alicandri-Ciufelli, M.; Kaleci, S.; Magliulo, G.; Presutti, L.; Re, M. (2015-01-01). "Clinical presentation and treatment outcomes of thyroglossal duct cysts: a systematic review". International Journal of Oral and Maxillofacial Surgery. 44 (1): 119–126. doi:10.1016/j.ijom.2014.07.007. ISSN   1399-0020. PMID   25132570.
  17. Carter, Yvette; Yeutter, Nicholas; Mazeh, Haggi (2014-09-01). "Thyroglossal duct remnant carcinoma: beyond the Sistrunk procedure". Surgical Oncology. 23 (3): 161–166. doi:10.1016/j.suronc.2014.07.002. ISSN   1879-3320. PMC   4149934 . PMID   25056924.
  18. 1 2 3 4 Weerakkody, Y., & Gaillard F. (2015). Thyroglossal duct cyst. UBM Medica Network. Retrieved from http://radiopaedia.org
  19. Karmakar S.; Saha A.; Mukherjee D. (2012). "Thyroglossal cyst: An unusual presentation". Indian Journal of Otolaryngology and Head & Neck Surgery. 65 (1): 185–187. doi:10.1007/s12070-011-0458-5. PMC   3718931 . PMID   24427642.
  20. Forest V.; Murali R.; Clark JR. (2011). "Thyroglossal duct cyst carcinoma: Case series". Journal of Otolaryngology - Head & Neck Surgery = le Journal d'Oto-Rhino-Laryngologie et de Chirurgie Cervico-Faciale. 40 (2): 151–156. PMID   21453651.

Further reading

Classification
D
External resources