American Journal of Otolaryngology - Head and Neck Medicine and Surgery
Volume 32, Issue 1 , Pages 71-74, January 2011

Endoscope-assisted intra-oral resection of the external thyroglossal duct cyst

  • Yoon Kyoung So, MD
    • ,
  • Jong In Jeong, MD
    • ,
  • Hye-Youn Youm, MD
    • ,
  • Han-Sin Jeong, MD, PhD

      Affiliations

    • Corresponding Author InformationCorresponding author. Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Gangnam-gu, 135-710, Seoul, South Korea. Tel.: +82 2 3410 3579; fax: +82 2 3410 6987.

Received 23 July 2009 published online 09 November 2009.

Article Outline

Abstract 

Objective

Surgical removal of a thyroglossal duct cyst (TGDC) and its tract is usually accomplished through an external neck incision, including the removal of the middle part of hyoid bone and a block of tissues extending to the foramen cecum. However, this procedure inevitably results in neck scarring. We implemented a modified approach to TGDC removal in a 28-year-old woman through the floor of the mouth using an endoscope system.

Case report

Here, we describe the detailed procedure of the endoscope-assisted intra-oral resection for TGDC. The total operative time was 130 minutes. The patient complained of swelling and pain in the floor of the mouth for 2 days, but did not require any intervention. Follow-up imaging studies confirmed no recurrence (18 months) without any sequelae, and the patient was satisfied with her surgical outcome.

Conclusion

The intra-oral approach through the floor of the mouth is a technically feasible alternative surgical option that allows for complete removal of a TGDC without the neck scar.

 

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1. Introduction 

Cysts arising from thyroglossal tract remnants often occur in pediatric patients. However they can also present in the second decade of life and later in adulthood [1]. It has been reported that the age distribution of patients with thyroglossal duct cysts (TGDC) and fistula is one third younger than 10 years, one third in their second and third decade, and one third older than 30 years [2]. Until now, the Sistrunk operation is the treatment of choice for symptomatic or clinically apparent TGDCs, which includes the removal of the mid-portion of the hyoid bone in continuity with the TGDC along with excision of a block of tissue between the hyoid bone and the foramen cecum [3], [4], [5], [6], [7], [8]. Although major complications are rare in the Sistrunk operation (recurrence develops in <10% of patients) [1], [4], [5], [6], [7], [9], [10], [11], [12], this operation inevitably results in the external scar, usually 5 to 10 cm in length, in the midline of the neck.

Considering that most patients who undergo surgical resection are young (<30 years), it is desirable to develop a surgery avoiding the external neck scar for TGDC. Thanks to advancements in medical technology, we were able to develop a modified endoscope-assisted approach through the floor of the mouth. In this report, we describe this new technique as well as surgical outcomes.

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2. Case report 

The patient was a 28-year-old woman who complained of an anterior bulging TGDC. She was uncomfortable during swallowing due to the sensation of a lump in throat. She noted a bulging mass in her anterior neck two months before presentation. She had a cystic mass located just inferior to the level of the hyoid bone, which had grown slightly over 1 month. The mass (diameter = 2 cm) was nontender, and it moved on tongue protrusion and swallowing. The patient's medical history was unremarkable; she had no history of thyroid disease.

Laryngoscope examination revealed no protruding mass at the base of the tongue. Aspiration cytology and computed tomographic scans (non–contrast-enhanced, due to a history of hypersensitivity to contrast material) suggested an external infrahyoid TGDC (Fig. 1). Considering the increase in size of the mass and the patient's desire to remove the mass, we decided to pursue the surgical excision of the TGDC and its tract. The patient provided written informed consent to trial of endoscope-assisted intra-oral TGDC resection.

  • View full-size image.
  • Fig. 1. 

    Initial findings of the external thyroglossal duct cyst. (A) A 2-cm-diameter mass was found just inferior to the level of the hyoid bone. (B) Computed tomography confirmed the infrahyoid thyroglossal duct cyst (arrow).

2.1. Surgical technique 

The patient was placed in the supine position with her neck fully extended. Her mouth was kept open with a retractor and her tongue was held back to expose the floor of the mouth. Initially, we made a 3-cm-sized vertical incision in the midline of the floor of the mouth between the papillae of Wharton's duct (Fig. 2). After careful dissection of the soft tissues in the floor of the mouth, we found the genioglossus muscles, separated them in the midline, and retracted them bilaterally. With the assistance of the endoscope (rigid, 10 mm, 0 degrees, Karl Storz, Tuttlingen, Germany), we identified the hyoid bone and the suprahyoid muscles (Fig. 3). We transected the geniohyoid and mylohyoid muscles with ultrasonic scissors (Harmonic scalpel 300, Ethicon Johnson & Johnson Company, Cincinnati, OH, USA) approximately 0.5 cm apart from the hyoid bone. To remove the possible tract of the cyst, we included some midline tissues extending from the midline of the hyoid bone toward the foramen cecum in the dissection. We then cut the body of the hyoid bone out with long-curved scissors. We also transected the infrahyoid muscles attached to the body of the hyoid bone. While pulling the hyoid bone upward, we were able to identify the cystic mass immediately inferiorly; it was attached to the hyoid bone by a stalk. We removed it along with the hyoid bone en bloc through careful dissection of the cyst. After irrigation of the surgical field, we inserted a suction drain from the floor of the mouth and sutured it to the edge of the opened mucosa. We approximated the genioglossus muscles in the midline and closed the wound with 4-0 Vicryl sutures.

  • View full-size image.
  • Fig. 2. 

    Intra-oral approach through a midline incision of the floor of the mouth. A vertical incision was made in the midline of the floor of the mouth between the papillae of Wharton's duct. After careful dissection of soft tissues in the mouth floor, the genioglossus muscles were separated in the midline, and retracted bilaterally.

  • View full-size image.
  • Fig. 3. 

    Endoscopic view of the intraoral approach to external thyroglossal duct cyst. (A) Initially, we made a 3 cm-sized vertical incision in the midline of the floor of the mouth, between the papillae of Wharton's duct. (B) With the endoscope assistance, we identified the hyoid bone and the suprahyoid muscles. We then cut the body of the hyoid bone out with long-curved scissors. (C) While pulling the hyoid bone upward, we could dissect the cystic mass attached to the hyoid bone by a stalk en bloc by careful cyst dissection. Arrow indicates the mid portion of the hyoid bone.

The total operative time was 130 minutes. Recovery was uneventful, and the amount of drainage during the first 24 hours after surgery was 46 mL. The patient complained of swelling and pain in the floor of the mouth for 2 days but did not require any intervention. The drain was removed on postoperative day 2. We encouraged frequent oral gargling with 0.02% chlorhexidine and allowed a normal diet on postoperative day 3. The patient was discharged home on postoperative day 5.

She was followed up for 18 months with clinical examinations and ultrasonography. The mucosa of the floor of the mouth was completely healed without any sequelae or discomfort and there was no external scar on the neck. There were no signs of recurrence or complications during the follow-up period. The patient was quite satisfied with the surgical outcome.

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3. Discussion 

Most patients with symptomatic or clinically apparent TGDCs successfully undergo the Sistrunk operation. However, this operation requires a transcervical approach, which results in an external neck scar. There have been several reports of endogenous TGDCs located in the base of the tongue or larynx, which have been treated through transoral endoscopic surgery [13], [14], [15], [16]. To our knowledge, this is the first report detailing surgical removal of an external TGDC (manifesting as a central midline neck mass) via the transoral approach. The transoral approach has been attempted in the removal of dermoid cysts in the floor of the mouth [17], [18], [19]. In contrast to surgical removal of dermoid cysts, TGDC surgery should include removal of TGDC and its possible tract. This means the middle part of hyoid bone and a block of tissue extending to the foramen cecum must be removed. This technique became technically feasible with the advancements in endoscope system and ultrasonic scissors (harmonic scalpel).

The approach through a midline incision in the floor of the mouth uses the natural midline dehiscence between the genioglossus and geniohyoid muscles. Thus, it provides a relatively avascular dissection plane. When we reached the hyoid bone, we cut the geniohyoid and mylohyoid muscles attached to the middle portion of the hyoid bone (1.5 cm in width). To remove the possible TGDC tracts, we traced the virtual tract from the middle portion of the hyoid bone to the foramen cecum, which was located on the inferior side of the endoscopic surgical view. We used the ultrasonic scissors (harmonic scalpel) to remove a cuff of tissue (5 mm in width) in the middle portion of the hyoid bone. The tissue under the foramen cecum was removed without interrupting the mucosa of the base of the tongue. This method was concordant with the modified Sistrunk operation [4], [5], [7], [8].

The patient was quite satisfied with the surgical outcome. The most serious symptom during the postoperative period was swelling in the floor of the mouth. This symptom was possibly due to the loose connective tissues in the floor of the mouth. The swelling totally resolved by 5 days. We placed a suction drain through the mucosa of the floor of the mouth to avoid accumulation of fluid or blood in the surgical wound, which may exacerbate swelling of the floor of the mouth. We removed the drain at postoperative day 2, without any complications. We also paid close attention to the swelling in the floor of the mouth, so as to avoid airway compromise.

Our approach was technically feasible and provided an adequate surgical field in an adult patient. However, this does not mean the surgical safety in children. More experience is required in adult patient before this approach is applied to pediatric patients. In addition, coexisting TGDC infection can impede safe and clear dissection of the TGDC, and its tract from the surrounding tissues. In such cases, it is reasonable to delay surgery until the infection subsides completely. Because of these considerations, our institutional review board approved our surgical trial (phase I) in only a small number of adult patients who had symptomatic TGDCs but no recent history of infection (within 3 months).

We followed up our patient for 18 months, during which she developed no signs of recurrence or complications. This indicated complete extirpation of the TGDC and its tracts. However, long-term follow-up is needed to confirm the results of our new surgical approach. Nevertheless, our approach was made technically feasible by advancements in surgical instruments and technology. This report suggests a possible approach through the floor of the mouth to the neck, as a kind of natural orifice transluminal endoscopic surgery.

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4. Conclusion 

The intra-oral approach through the floor of the mouth may be a technically feasible alternative surgical option that allows for complete removal of TGDCs without leaving the external neck scar.

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Acknowledgment 

The authors thank Dr Junsun Ryu (Head and Neck Oncology Clinic, Center for Special Organs, National Cancer Center, Ilsan, Korea) for his beautiful illustration (Fig. 2).

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References 

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PII: S0196-0709(09)00206-3

doi:10.1016/j.amjoto.2009.09.001

American Journal of Otolaryngology - Head and Neck Medicine and Surgery
Volume 32, Issue 1 , Pages 71-74, January 2011

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