Operative Techniques in Otolaryngology (2004) 15, 220-223
Excision of thyroglossal duct cyst: the Sistrunk procedure
Gisela Wagner, MD, Jesus E. Medina, MD
From the Department of Otorhinolaryngology, College of Medicine, The University of Oklahoma Health Sciences Center,
Oklahoma City, Oklahoma.
Before 1893, the removal of a thyroglossal cyst in- presence of the thyroid gland in its normal location and to
cluded simple incision and drainage. The recurrence rate confirm the cystic nature of the mass.5 Computed tomog-
after this procedure was ⬃50%. In 1893, Schlange1 pro- raphy or magnetic resonance imaging also may be useful
posed the excision of the cyst along with the central but are not routinely indicated. Some clinicians feel that
portion of the hyoid bone. This resulted in a drop in the a thyroid-stimulating hormone level must be obtained
recurrence rate to 20%. However, in 1920, Walter Sis- before surgery and, if the level is high, the thyroid should
trunk took this operation one step further and recom- be scanned. If, on the other hand, the level is normal, then
mended not only taking the central portion of the hyoid proceed with surgery.6
bone but also carving out a core or tissue one eighth of an
inch in radius from the hyoid bone to the foramen ce-
cum.2 He felt there was no point in identifying the su-
prahyoid portion of the duct, which it is usually hard to Surgical technique
do because the duct may be so small and friable that it
A horizontal incision about 2 inches long at or just below
breaks off easily and thus it is difficult to remove by
the level of the hyoid bone is made in the midline of the
itself. Today, the Sistrunk procedure is the standard op-
neck (Figure 2). The incision is carried down through the
eration to remove thyroglossal cyst, with reported recur-
subcutaneous tissue and platysma muscle.
rence rates between 0% and 8%.3,4
Once the skin and platysma are elevated, the cyst can be
found lying beneath the raphe connecting the sternohyoid
muscles (Figure 3).
Diagnostic evaluation The strap muscles are retracted laterally, and the cyst
is dissected free of the thyroid cartilage and surrounding
A thyroglossal cyst usually presents as a midline neck tissue until it is pedicled superiorly to the hyoid bone
mass that is not painful unless it is infected (Figure 1). A (Figure 4).
key to its diagnosis, which can be observed during phys- The muscles and soft tissue are then dissected off the
ical examination, is the elevation of the mass with swal- central segment of the hyoid bone, about 1.5 to 2 cm in
lowing or protrusion of the tongue. Sixty percent to 80% length. Dissecting superiorly or inferiorly to the hyoid bone
of thyroglossal duct cysts are located below the level of should be avoided because of the risk of transecting the
the hyoid bone.3 The differential diagnosis includes der- duct. The hyoid bone is then cut on each side of midline
moid and lingual thyroid. No general consensus is found (Figure 5).
in the literature on the extent of the diagnostic evaluation Without isolating the duct, tissue one eighth of an inch in
of a patient with a suspected thyroglossal duct cyst. Some radius is cored out through the tissues up to and including
clinicians feel that it is important to rule out the possi- the foramen cecum (Figure 6). The foramen cecum can be
bility that this midline mass may be the patient’s only reached by drawing a line backward and upward from the
source of thyroid hormone. To that end, an ultrasound of hyoid at a 45° angle through the intersection of the hori-
the neck is a simple and inexpensive test to look for the zontal and perpendicular lines at the center of the hyoid.
Placing a retractor through the mouth and into the vallecula
to pull the tongue base down into the wound may help with
Address reprint requests and correspondence: Jesus E. Medina,
MD, University of Oklahoma Health Sciences Center, Department of this part of the procedure. Placing a large needle from the
Otorhinolaryngology, PO Box 26901, WP 1360, Oklahoma City, OK hyoid into the foramen cecum may also aid in dissecting out
73190-3048. the core.
1043-1810/$ -see front matter © 2004 Elsevier Inc. All rights reserved.
doi:10.1016/[Link].2004.05.001
Wagner and Medina Excision of Thyroglossal Duct Cyst 221
Figure 1 Origination and descent of thyroglossal duct cyst.
Once the specimen in removed, the wound is irrigated,
and the opening into the pharynx at the foramen cecum is
closed with 2-3 absorbable sutures (Figure 7). The strap
muscles are approximated, a Penrose drain is placed in the
wound, and the subcutaneous tissues and the skin are closed
(Figure 8).
Complications
Major complications include recurrence, abscess or he-
matoma requiring surgical drainage, entry into the air-
way, the need for tracheotomy, nerve paralysis, hypothy-
roidism, and death. Reports of these major complications
Figure 3 After splitting strap muscles down the middle, the cyst
Figure 2 Skin incision is made midline overlying cyst and can be grabbed and lifted up as it is dissected free from the
thyroid cartilage. surrounding tissues.
222 Operative Techniques in Otolaryngology, Vol 15, No 3, September 2004
Figure 6 The tract can be followed to the foramen cecum and
excised.
Figure 4 Once freed up inferiorly, the cyst can be seen pedicled
to the hyoid bone superiorly. Also notice the close relationship
between the cyst and the underlying airway.
dissects too aggressively in the superior direction. Divid-
ing the hyoid medial to the lesser cornu and dissecting
are rare.7 By identifying the thyroid notch and the thy- superiorly medial to the anterior digastric muscle can
rohyoid membrane intraoperatively, one can decrease the avoid this type of injury. Hypothyroidism can be avoided
likelihood of entering the airway. The hypoglossal nerve with the proper preoperative evaluation to determine the
can be injured if one divides the hyoid too laterally or
Figure 5 The hyoid bone is then cut on each side of the midline. Figure 7 The opening at the foramen cecum is then closed.
Wagner and Medina Excision of Thyroglossal Duct Cyst 223
wound infection, and stitch abscess. All were treated with
conservative management and resolved without any fur-
ther sequela.7
References
1. Schlange H: Uber die fistual colli congenita. Arch Klin Chir 46:390-
392, 1893
2. Sistrunk WE: The surgical treatment of cysts of the thyroglossal tract.
Ann Surg 71:121-126, 1920
3. Allard R: The throglossal cyst. Head Neck Surg 5:134-146, 1982
Figure 8 The strap muscles are reapproximated and the skin 4. Pelausa M, Forte V: Sistrunk revisited: A 10-year review of revision
then closed. thyroglossal duct surgery at Toronto’s Hospital for Sick Children. J
Otolaryngol 18:325-333, 1989
5. Gupta P, Maddalozzo J: Preoperative sonography in presumed thyroglossal
duct cysts. Arch Otolaryngol Head Neck Surg 127:200-202, 2001
presence of a normal thyroid. Although Maddalozza re- 6. Radkowski D, Arnold J, Healy GB, et al: Thyroglossal duct remnants:
Preoperative evaluation and management. Arch Otolaryngol Head Neck
ported no major complications in his series of 35 patients Surg 117:1378-1381, 1991
undergoing a Sistrunk procedure, he did have a 29% 7. Maddalozzo J, Venkatesan TK, Gupta P: Complications associated with
occurrence of minor complications such as seroma, local Sistrunk procedure. Laryngoscope 111:119-123, 2001
