Excision of Congenital Neck Masses
Thyroglossal duct cyst excision
Please see thyroglossal duct cysts in CONGENITAL NECK MASSES for additional information on this topic.
What are the indications for thyroglossal duct cyst removal?
Thyroglossal duct cysts (and/or tracts) that do NOT contain thyroid gland tissue and are NOT infected when identified are candidates for excision. If the cyst is infected the infection is treated first, then surgery can by performed.
What are the treatment options for thyroglossal duct cysts that contain thyroid tissue?
Thyroglossal duct remnants that contain THYROID GLAND (ectopic) tissue can also be candidates for removal if a normal functioning thyroid gland is identified, so removal of the ectopic tissue will not cause the patient to become HYPOTHYROID (have too little thyroid hormone).
If the only thyroid tissue found in the patient is located in the thyroglossal duct cyst, the treatment options are as follows:
- Remove the thyroglossal duct cyst and thyroid tissue, and start lifelong thyroid hormone replacement therapy (under a specialist’s supervision)
- Attempt keep the ectopic thyroid tissue in place, while stopping further growth of the tissue with medications (thyroxine – a thyroid hormone). Unfortunately, if the ectopic thyroid gland continues to cause symptoms in the patient (breathing or swallowing problems, bleeding or repeated infections), it will ultimately be recommended for removal. For those patients unable to tolerate surgery and who have failed a thyroid hormone trial, radiation therapy may be an option.
What is involved with thyroglossal duct remnant removal?
Prior to a thyroglossal duct cyst removal, thyroid function tests (to measure thyroid hormone levels in the body), as well as an imaging study (such as ultrasound, CT scan, thyroid scan) may be acquired to check for a normal thyroid gland. Many times, a normal physical exam and an ultrasound showing a normal thyroid gland is all that is required before surgery. Any infection detected will be treated with antibiotics before removal.
The surgery is performed under general anesthesia (the patient is fully asleep).
A skin incision (surgical cut) is made in the center of the neck near the lump in a natural skin crease (to decrease the scar). The entire thyroglossal duct cyst, along with a small portion of the hyoid bone (a small bone in the neck) and the cyst tract is then removed. The name of this procedure is called the Sistrunk operation. This operation results in a 10-fold decrease in recurrences of the cyst compared to other types of surgical techniques. The surgical site is then sutured using plastic surgery techniques to minimize any visible scarring.
This operation takes about 45 minutes to one hour and is usually performed as an outpatient procedure.
What are the complications of this procedure?
Wound infections and bleeding are complications of any surgical procedure. These complications are minimized using antibiotics and cautery (application of heat to bleeding areas).
An additional complication of the surgery could be creating an opening into the throat. This would be repaired immediately if recognized. Complications are more likely with repeat or revision surgeries.
Recurrence of a thyroglossal duct remnant is also a risk.
Finally, HYPOTHYROIDISM, is an expected concern in those patients with all the body’s thyroid tissue located in the thyroglossal duct remnant. An endocrinologist (gland specialist) will be required with the follow up of these patients.
Please see “lymphangioma” in CONGENITAL NECK MASSES for more information on lymphangiomas and cystic hygromas.
What are the indications for excision of a lymphangioma?
All lymphangiomas are candidates for surgical removal as soon as they are identified unless removal would put normal structures (nerves, blood vessels, etc.) at risk, or if surgery would likely cause a significant cosmetic deformity (abnormality of appearance).
In some very small infants, who do not have symptoms associated with a cystic hygroma, the excision of the cyst should be performed promptly, before the cyst becomes larger and involves other structures. Removal is also performed as soon as possible if a cyst blocks the airway and causes BREATHING DIFFICULTIES; occasionally a TRACHEOTOMY (breathing tube placed into the neck below the obstruction) will need to be placed until the cyst is removed.
What is involved with the excision of a cystic hygroma?
Prior to surgical removal, the extent of the cyst is evaluated by imaging (picture taking) studies such as MRI (study of choice) and chest x-ray. A CT scan may also be used to evaluate these cysts.
Lymphangiomas are excised under general anesthesia (patient is fully asleep).
A surgical incision is made in the area of the cyst. As the size of these cysts can be very large and can extend in to multiple different head, neck and chest areas, the location of the incision varies among patients. These cysts also do not have a very defined capsule and often wrap around vital structures in the neck (blood vessels, nerves, muscles). For this reason, the surgeon will need to carefully perform a neck “dissection”, removing the growth from normal neck structures before the rest of the cyst can be removed.
If part of a cyst is too close to a vital structure, part of the cyst may not be able to be removed. If part of a cyst can not be removed, the surgeon will often cauterize (use heat) to cause scarring in that area, which may help prevent recurrence.
The length of this potentially complex surgery varies with the extent of the cyst.
Usually all surgeries for these growths require a hospital stay.
If part of the cyst is unable to be removed, regular follow up is necessary to check for recurrence. This may be done simply by physical exams (looking to see if a lump reappears). However, cysts removed in areas of the body that can’t be seen will require periodic MRI studies.
If surgery is not an option due to extent of the lesion, sclerotherapy may be considered. This would involve injecting chemicals into the cyst to create shrinkage and scarring. In patients with large cysts, this is sometimes very successful.
What are the complications of this procedure?
As with any surgery, infections of the surgical site and bleeding are potential complications.
Recurrence of the cystic hygroma is always a concern, even if it appears that the entire cyst has been removed successfully. Recurrence is assured if any of the cyst remains after surgery.
Also of concern is the fact that a cystic hygroma often is in close contact with important structures in the neck and complications can arise from damage to these structures. Some of these structures include the FACIAL NERVE, RECURRENT LARYNGEAL NERVE, and carotid artery (supplies blood to the head). It is important to remember that not all patients will have cysts close to these vital structures, decreasing this concern for those patients. Damage to these structures is also minimized during surgery by your surgeon, who has extensive training and expertise in locating these structures. Your surgeon will discuss with you at length the specific concerns associated with removing your child’s cyst prior to surgery.
Thomas M. Andrews
Dr. Andrews specializes in the medical and surgical treatment of ear, nose and throat disorders of children and adolescents. His accreditations include Florida State Medical License and Ohio State Medical License. He is also a board member of the National Board of Medical Examiners and American Board of Otolaryngology, Head and Neck Surgery