|Year : 2013 | Volume
| Issue : 2 | Page : 61-63
Thyroglossal duct cyst: Unusual presentation in an adult
W.V.B.S. Ramalingam, Rajeev Chugh
Department of ENT and Head & Neck Surgery, BL Kapur Super Speciality Hospital, Pusa Road, Behind Rajendra Place Metro Station, New Delhi - 110 005, India
|Date of Web Publication||7-May-2014|
Military Hospital, Trimulgherry, Secunderabad, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Thyroglossal duct cyst is a congenital lesion of the neck resulting from the remnant of the thyroglossal tract. A 59-year-old male patient presented with a progressive cystic swelling in the neck which moved on swallowing and protrusion of tongue. Investigations were inconclusive and thyroid profile was normal. Sistrunk's operation was performed and histopathological examination revealed it as thyroglossal duct cyst. There were no post-operative complications and no evidence of malignancy. The objective of this article is to emphasize on the importance of considering thyroglossal duct cyst as differential in an unusually large cystic neck swelling in adults with no conclusive evidence on investigations. Complete excision of the cyst with the tract and part of the body of hyoid (Sistrunk's operation) will significantly improve the outcome with reduced risk of recurrence.
Keywords: Cystic neck swelling, Sistrunk′s operation, thyroglossal duct cyst
|How to cite this article:|
Ramalingam W, Chugh R. Thyroglossal duct cyst: Unusual presentation in an adult. J Laryngol Voice 2013;3:61-3
| Introduction|| |
Thyroglossal tract arises from the site of tuberculum impar and descends in the neck to form the thyroid gland at its terminal part. Any part of the tract may persist and this results in thyroglossal duct cyst.  Thyroglossal duct cyst typically occurs before 20 years of age and a substantial minority of patients over 20 at the time of diagnosis.  Mean age is 5 years (4 months-70 years). Occurrence in the elderly is rare and only 28% occur over 50 years and 10% over 60 years. , Most patients present with a symptomless lump in the neck, which rises on swallowing and protrusion of tongue usually, 1-3 cm in diameter in the midline below the hyoid bone. Infected neck mass is a common presentation in adults.  Differential diagnosis includes dermoid cyst; branchial cyst; pyramidal lobe hyperplasia; teratoma; hamartoma; lipoma; sebaceous cyst; cavernous hemangioma; lymph nodes, etc.  Since the differential diagnosis among adults is broader, likelihood of misdiagnosis is greater. Thyroglossal cyst, if not considered as a differential diagnosis in cystic neck swelling may result in incomplete excision and recurrence. 
Neck ultrasound is the most common pre-operative diagnostic procedure along with thyroid profile. 
Radionuclide scanning is justified in cases of lingual thyroid and where a normally located thyroid gland cannot be detected. 
Treatment is Sistrunk's operation described in 1920. This includes excision of the tract running from the cyst to the foramen caecum along with the central part of the body of hyoid with which the tract is intimately related. Surgery using the technique based on anatomy of hyoid bone region is essential. Indications for surgery include cosmesis; malignant degeneration; recurrent infection; rarely intermittent upper airway obstruction. ,,,,
| Case Report|| |
A 59-year-old male patient presented with insidious onset gradually progressive lump in the neck of 5 years duration. No features of hypothyroidism, hyperthyroidism or compression. On examination of the neck, there was an 8 cm × 7 cm cystic swelling on the left side extending from the level of hyoid to the lower border of thyroid cartilage and from midline to the posterior border of the sternocleidomastoid. There was no discharge from the swelling. Swelling moved on deglutition and on protrusion of tongue. On laryngoscopy, epiglottis was pushed to the right with shift of supraglottis to right and distortion of the laryngeal introitus.
Ultrasonography revealed an 8 cm × 6 cm × 5 cm well-defined cystic lesion from the left submandibular region to the midline displacing thyroid inferiorly and carotid and internal jugular vein to left. Thyroid gland was normal. Fine needle aspiration cytology was inconclusive. Computed tomography (CT) scan revealed a large cystic lesion on the left side pushing the laryngeal framework to the right [Figure 2]. Thyroid profile was normal. Radionuclide scanning was not performed in view of the normal thyroid gland on ultrasound of the neck.
Sistrunk's operation was performed to remove the cyst. A large cyst was noticed causing scalloping of the superior border of the thyroid ala on the left side with concavity of the left ala due to pressure. Tract was identified and dissected up to the base of tongue along with the central part of body of hyoid [Figure 3].
Histopathology revealed cyst lined partially by pseudo-stratified ciliated epithelium and squamous epithelium. Subjacent stroma showed few thyroid follicles. Stroma shows fibrosis with predominant lymphocytic infiltration and a final diagnosis of thyroglossal cyst was made. There was no evidence of malignancy noted on histopathology.
Patient was followed-up in the post-operative period for 6 months. There was no complication like fistula or recurrence noted.
| Discussion|| |
Thyroglossal duct cysts are one of the most common pediatric midline neck lesions. Although uncommon in adults, thyroglossal duct cysts should be a part of the surgeon's differential diagnosis when presented with a neck mass. An infected neck mass is the common presentation of thyroglossal duct cysts in adults. 
In a study by Ren et al. it was observed that the incidence of thyroglossal duct cyst was equal in males and females and had a bimodal distribution with similar incidence in children and adults. Adults were significantly more likely than children to present with a complaint other than mass or infection. 
A study by Lin et al. showed that compared with children, more adult patients have left sided and infra-hyoid cyst locations. The cyst sizes were significantly larger in adults. Sistrunk's procedure is recommended as the surgery of choice, especially in adults in whom a more extended tract resection should be performed. 
Thyroglossal duct cysts that occur off the midline may be difficult to differentiate from branchial cleft cysts, an important factor in their surgical excision. 
Our patient was a 59-year-old adult with an unusually large cystic swelling in the neck [Figure 1]. With no definitive diagnosis on the basis of ultrasonography, CT scan and fine needle aspiration cytology. It was essential to keep thyroglossal duct cyst as a differential and proceed with an excision of the cyst along with the central part of body of hyoid up to the base of tongue.
|Figure 3: Sistrunk's operation - cyst being removed along with hyoid. Scalloping of thyroid cartilage seen|
Click here to view
| Conclusion|| |
Thyroglossal duct cyst is a common cystic lesion of the neck in the pediatric age. Adults may present with an unusually large cystic swelling in the neck. Even when there is no conclusive evidence of a thyroglossal cyst on investigation, it is still wise to keep this as differential diagnosis and treat accordingly with a Sistrunk's operation in order to ensure complete excision of the tract and reducing the incidence of recurrence.
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[Figure 1], [Figure 2], [Figure 3]