Head and Neck Cancer Research

Keywords

Thyroglossal duct cyst; Neck mass; Sistrunk procedure; Sclerotherapy

Introduction

Cystic neck abnormalities can be broadly classified into congenital and acquired lesions. There are multiple diagnoses for these lesions but the thyroglossal duct cyst accounts for the majority of cases [1-3].

The diagnosis of a thyroglossal duct cyst is made after an appropriate history, physical examination and relevant radiological investigations. The standard treatment of choice is surgical removal following the Sistrunk procedure [4,5]. Only recently, sclerotherapy with OK 432 has become an alternative in selected cases [6,7].

In the past few years at the San Fernando General hospital, we have seen thyroglossal duct cysts with unusual presentations and in unusual locations. This has caused misdiagnosis and led to poor management in some cases. Due to these concerns, a retrospective study on thyroglossal duct cysts was undertaken to document how affected patients presented and also to document the location of the cysts.

Methods

An 11 year retrospective case series was conducted at the tertiary institution of the San Fernando General Hospital from January 1st 2004 – December 31st 2014. The operative logbooks of Otorhinolaryngology, Pediatric surgery and General surgery were examined and all patients who underwent excision of a thyroglossal duct cyst (initial or subsequent procedure) were documented.

The notes of these patients were then obtained through the Medical records department. The sole inclusion criteria for the study were that a thyroglossal duct excision/ removal or Sistrunk procedure had to be documented in the operative logbooks. The exclusion criteria were: no notes being recovered, no operative notes in recovered file and/or the final histology not confirming a thyroglossal duct cyst.

Information about gender, ethnicity, age, reason for seeking medical attention and location of the cyst (based on clinical, ultrasound and operative findings) were extracted from each file. The results were then analysed and compared to the international literature.

Results

Twenty five cases of thyroglossal duct cyst excisions were documented in the operative logbooks. However, eight cases had to be excluded. The notes for three cases were unable to be recovered, no operative notes were found in two files and three histologies documented histologies other than a thyroglossal duct cyst.

Of the seventeen confirmed cases, the departments of Otorhinolaryngology, Pediatric surgery and General Surgery managed 76.47%, 11.76% and 11.76% of patients respectively.

The male to female ratio was 7:10. East Indians accounted for 65% of cases while Africans made up the remaining 35% (Figure 1).

Figure 1: Comparison of age groups to actual age.

The ages ranged from birth to 51 years old. With respect to age, 2 peaks were noted at 5 – 10 years and 20 – 30 years. Below the age of ten, seven people had thyroglossal duct cysts. Within the age group 10 – 50, 9 patients had cysts. In this series, only one patient developed a cyst over the age of fifty.

The clinical presentation of the patients fell into one of five categories: infected cyst, asymptomatic, dysphagia/ shortness of breath, discharging sinus and a painful mass with rapid increase in size and compressive features. An infected cyst was the most common presentation (Table 1).

Table 1: Different clinical presentations of a thyroglossal duct cyst.

Midline thyroglossal duct cysts represented 71% of all cases. Right sided cysts accounted for 29% of all cases. There were no documented cases of left sided cysts. Within the midline thyroglossal duct cyst group, suprahyoid and thyrohyoid cysts occurred with frequencies of 7% and 60% respectively. There were no cases of intralingual or suprasternal cysts (Table 2). In the right sided cystic group, the suprahyoid level was the most common site (Table 3).

Table 2: The distribution of midline cysts.

Table 3: The distribution of lateral cysts.

Discussion

Cystic lesions of the neck include branchial cleft cysts, thyroglossal duct cysts, lymphangioma, dermoid cysts, epidermoid cysts, infections/inflammatory masses, cystic lesions of the thyroid, thymic cysts, laryngoceles, ranulas, cystic lesions of salivary glands, cystic metastatic lymph nodes, neurogenic tumours, rare vascular lesions and cervical bronchogenic cysts [8-10]. The thyroglossal duct cyst accounts for 70% of all congenital neck masses [1-3].

The thyroid gland descends from the base of the tongue at the level of the foramen caecum into the anterior neck through the thyroglossal duct [11,12]. This duct usually undergoes involution but in seven percent of patients it remains patent [1,13]. The ducts have an epithelial lining which - in the presence of infection or inflammation produces excess secretions that cause ductal dilatation and cyst formation [14,15]. The patient may seek medical attention for cosmetic concerns regarding an asymptomatic cyst or when the cyst becomes symptomatic.

In this small case series, the statistics reported in the age groups less than fifty years compared favorably to international statistics [2,16]. Ahura et al. and Fischer et al. also reported a greater percentage of patients over fifty years that developed cysts. No particular reason was found to account for this.

The M:F ratio was 7:10. Internationally no gender preference has been documented [17,18]. However in a recent review of 159 cases by Taimisto et al. a mild female predominance was noted [19]. Our case series also reports a mild female predominance.

The population of Trinidad and Tobago is divided as follows: East Indians: 40%, Africans: 37.5%, Mixed ethnicity: 20.5%, Others: 1.2% and Unspecified: 0.8% [20]. There appears to be a higher number of East Indians with thyroglossal duct cysts. However due to the small number of patients, it cannot be said with any certainty that this ethnic group is predisposed to cyst formation (Table 4).

Table 4: Age of patients at SFGH compared to international statistics.

The population of Trinidad and Tobago is divided as follows: East Indians: 40%, Africans: 37.5%, Mixed ethnicity: 20.5%, Others: 1.2% and Unspecified: 0.8% [20]. There appears to be a higher number of East Indians with thyroglossal duct cysts. However due to the small number of patients, it cannot be said with any certainty that this ethnic group is predisposed to cyst formation.

Patients with clinically evident thyroglossal duct cysts can be either asymptomatic or symptomatic. The literature has described cysts as being largely asymptomatic [14,21-23]. However, in this study, only 35% of patients were asymptomatic. The majority of patients were actually symptomatic and accounted for 65% of all cases. Notably, these patients all had head or neck infections before presentation. Six patients had a recent upper respiratory tract infection, one patient had cellulitis of the anterior neck and one patient had an infected cyst that developed a discharging fistula. The inflammation associated with infection could have increased secretions of the epithelium within the thyroglossal duct producing an obvious cystic swelling in the neck (Table 5) [14,15].

Table 5: Midline cysts – International vs SFGH statistics.

Within the subgroup of midline cysts, the thyrohyoid level was the most common location internationally and locally [3,14,24]. However, suprahyoid cysts only occurred in 6% of patients at the SFGH. There were no cases of intralingual or suprasternal cysts. A larger sample size may have included the latter two types.

Internationally, ten percent of patients have been reported to have lateral thyroglossal duct cysts [25-27]. The findings of this study therefore represents almost three times the normal occurrence. The suprahyoid location of the lateral cyst was the lowest international percentage published [27]. However, it was the most common level for occurrence in this series. There was also the description of a unique entity, a thyroglossal duct cyst that had suprahyoid, hyoid and infrahyoid components. Therefore, the low degree of suspicion for thyroglossal duct cysts in these lateral masses may be the reason why many of the cysts were being misdiagnosed as other entities at the San Fernando General Hospital (Table 6).

Table 6: Lateral cysts: International vs SFGH statistics.

Conclusion

There appears to be a mild female preponderance in patients with thyroglossal duct cysts at the San Fernando General Hospital. The ages of patients presenting to the hospital range from birth to 51 years. The majority of patients were symptomatic and cysts seemed to develop soon after head and neck infections. There is an increased incidence of right lateral thyroglossal duct cysts found at the suprahyoid level and a high degree of suspicion is necessary for accurate diagnosis of this entity.

Disclosure

The authors have nothing to disclose.

Acknowledgements

1. Dr M. Ashraph, Dr. R. Maharaj, Dr N. Armoogum- From the Department of Otorhinolaryngology - San Fernando General Hospital, Trinidad and Tobago

2. Dr. L. Roop, Dr. R Persad- From the Department of Pediatric Surgery - San Fernando General Hospital, Trinidad and Tobago

3. Dr V. Bheem, Dr S. Budhooram, Dr J Shah, Dr D. Dan, Dr. K. Sookhoo, Dr. T. Kuruvilla and Dr. Y. Maharaj- From the Department of General Surgery - San Fernando General Hospital, Trinidad and Tobago

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