.png){kind=small}
.png){kind=small}
BackTable / ENT / Article
Thyroglossal Duct Cysts: Patient Presentation & Treatment Decision-Making
Megan Saltsgaver • Updated Nov 6, 2024 • 75 hits
Thyroglossal duct cysts are rare, benign, congenital neck masses that form from a persistent thyroglossal duct. They usually appear in young children, though occasionally an adult may present with one.
Thyroglossal duct cysts develop during the formation of the thyroid gland in utero. A tract extends from the base of the fetus’s tongue to where the thyroid gland will eventually reside, allowing for gland formation. This tract normally closes after the thyroid forms, but if it remains open, fluid can accumulate in the tract, sometimes leading to infection.
Pediatric otolaryngologist Dr. Christopher Liu explains how a patient with a thyroglossal duct cyst presents in his practice and how he determines which treatment is appropriate. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Thyroglossal duct cysts are a common congenital midline neck mass in children and are often detected when parents notice a bump or infection with symptoms like redness, pain and swelling.
• A differential evaluation is required to determine if a neck mass is a thyroglossal duct cyst. Patient history of recurring infections and movement of the mass when swallowing are particularly indicative of a thyroglossal duct cyst.
• Drainage of the infected cyst can be done in an outpatient setting or can be done in the operating room under anesthesia as an incision and drainage (I&D).
• Viable antibiotic treatments include Clindamycin, Augmentin, Omnicef, or IV Unasyn if hospitalized.
• The treatment of a thyroglossal duct cyst is a surgery called The Sistrunk Procedure. This will help to prevent infections. The surgery is normally done following a child’s first infection, but can be delayed as these cysts are not life threatening.
Table of Contents
(1) Thyroglossal Duct Cyst Symptoms & Patient Presentation
(2) Physical Examination of Thyroglossal Duct Cyst
(3) Thyroglossal Duct Cyst Treatment without Surgery
(4) Thyroglossal Duct Cyst Surgery
Thyroglossal Duct Cyst Symptoms & Patient Presentation
Thyroglossal duct cysts are the most common congenital neck masses, typically presenting as a midline neck mass that moves with swallowing. Patients tend to present to ENT offices in one of two ways. In about half of cases, parents notice a small bump on their child’s neck. In the other half, the cyst is first identified when it becomes infected, presenting with symptoms like sudden swelling, redness, pain, fever, or abscess formation. Although they are most commonly seen in children aged 2 to 6, they can occur at any age and are sometimes discovered in adults incidentally on imaging, such as an ultrasound, done for unrelated reasons.
Thyroglossal duct cysts are considered random occurrences without a clear pattern, though very rarely multiple children in a family may have one. There is typically little to note in the patient’s history, except for recurrent infections. Parents often report that the cyst has previously become red, swollen, or fluctuated in size, sometimes requiring drainage or antibiotics. These recurring signs strongly suggest a thyroglossal duct cyst.
[Dr. Ashley Agan]
How do patients with a thyroglossal duct cyst usually present to you? Is it the textbook, a midline neck mass? What are you seeing?
[Dr. Christopher Liu]
Actually, I think it's more of a 50/50 breakdown, but half of the kids that we see, parents bring them in because they notice a bump on the neck. It's never bothered the child and never been infected, and it's just been there. A lot of times parents will assume that it's an Adam's apple of some sort, because it's just right in that spot. They don't really think much of it until they mention it to the pediatrician, and the pediatrician sends them to us. That's half of the patients that we see.
The other half are patients who don't know they have a cyst until they have their first infection. Those patients will come in with an abscess or sudden increase in size, redness, pain, fever, swelling. That's the second type of thyroglossal duct cyst patient that we see. Usually, that's how they present. It's usually in those two kinds of scenarios that we see them.
[Dr. Gopi Shah]
Yes, I feel like you're right, it's either the consult and the ED or the hospital, as you said, because they're actively infected or they're coming to you. Sometimes they start pretty young. Have you noticed that, Chris? Sometimes they might get referred early. What do you find is the age range in your practice?
[Dr. Christopher Liu]
I think most of the kids that I see are between two and six years old. That's probably the average. Occasionally I've seen kids less than a year, and those kids are a bit difficult, I would say, trying to decide when the good time it is to do the surgery. It's odd, very rarely will I see teenagers. Teenagers are not very common at all. I'd say that maybe only 10% of that practice is teenagers. We don't see very many of them.
[Dr. Gopi Shah]
In your practice, have you noticed any common risk factors or anything? To me, it's random, unless, I don't know, have you noticed any risk factors or patterns for the kids who have them and the kids who don't?
[Dr. Christopher Liu]
No, I have not seen a pattern. It does feel very random. I've had one or two families who've had multiple siblings with it, so maybe there's something going on there, but that's maybe 1 or 2 out of 100 kids that I see. As far as I can tell, the pattern is fairly random. There's no family history usually, and the parents don't ever recall anyone that they know that's had the same problem.
[Dr. Ashley Agan]
Yes, it is the most common congenital neck mass, right? That's pretty common.
[Dr. Christopher Liu]
Yes, it is. I think there have been cadaver studies in the past showing that there's probably a lot more people out there that also have thyroglossal duct cysts, small ones that are never symptomatic, and so we don't ever know about them. Those are the patients that we never see since we're only seeing the ones that are visible and/or infected.
[Dr. Ashley Agan]
Yes. I feel like on the adult side, I'll get patients who have incidentally found very small cysts that have never caused any problems, but they were getting an ultrasound for something else. I saw one paper in the radiology literature that said just a little under 1% of adults can have incidentally-found thyroglossal duct cysts. I think you're right, I think there's probably more people walking around out there with them than we even know.
[Dr. Christopher Liu]
Yes, I've definitely seen a few kids in my practice where they're getting an MRI of the brain or the neck for another reason. Oftentimes it's for sleep apnea or autism or something like that. They're getting an MRI head and radiology will mention that there's possibly a thyroglossal duct cyst right next to the hyoid or in the foramen cecum. Those patients can be a little awkward because you're like, "Well, that's the textbook answer is excision, but you probably would have never known you'd had this unless you had gotten the MRI, so it's really up to you what you want to do."
[Dr. Ashley Agan]
Yes, and we'll get into that decision-making momentarily. Before we get there, as we walk through the patient visit and before moving on to the physical exam, is there anything else in your history-taking that's important to know? You want to ask about has it ever been infected, has it ever been drained or I&D'd? Anything else that you're asking about?
[Dr. Christopher Liu]
I feel like with thyroglossal ducts, a lot of it is going to be based on your physical exam. Your diagnosis, a lot of it is going to be based on your physical exam. I think one of the most important details to me, honestly, is the history of infection because things that can show up in that area or in that vicinity, not necessarily midline, but in that submental, submandibular area, potentially maybe a little lower than that, those tend not to get infected. Dermoid cysts don't usually have a history of infection, ranulas don't usually have a history of infection.
Same thing with lymphatic malformations too, you can have exacerbations but those are not very frequent. There's just a look to how these thyroglossals get infected. If a parent comes in and tells me that this bump in their child's neck has been infected in the past, has been drained, needed antibiotics, fluctuates in size, gets red, then the first thing I do think of is thyroglossal duct cyst. That shoots to the top of my differential. That's the one key part of the history that clues me in to whether I think this is a thyroglossal duct cyst or not.
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
Physical Examination of Thyroglossal Duct Cyst
Physical examination of a thyroglossal duct cyst is straightforward, though it’s essential to differentiate it from other potential neck masses, such as dermoid cysts, which also tend to present in the midline of the neck. Sometimes, definitive identification can only be made in the operating room when the cyst capsule is visualized.
In children with prior infections of a thyroglossal duct cyst, there may be scarring from chronic inflammation. Fistulas or ulcers can occasionally develop, typically after a cyst has spontaneously ruptured or been drained.
Routine physical examination of a suspected thyroglossal duct cyst does not usually involve laryngoscopy to assess the airway. However, if there are symptoms of airway obstruction or dysphagia, scoping may be considered.
[Dr. Gopi Shah]
In terms of your physical exam, so we think of the midline neck mass, we might have them stick their tongue out and see if it moves, that pathognomonic finding for that, when a child doesn't have a history of an infection and you have a midline neck mass, do you have a way to help yourself lean more towards thyroglossal versus dermoid versus a lymph node? Because without that history, sometimes for me, the dermoid versus the thyroglossal in the midline can be a little tricky.
[Dr. Christopher Liu]
Yes, I'm sure we're going to talk about surgical technique later on, but I think dermoids, they tend to be really smack dab in the center. There is usually no history of infection, but oftentimes what I tell families is that I think this is a dermoid. We're going to do the surgery like a dermoid, but if it starts to look like a thyroglossal duct cyst, because the contents of the two entities are different, then we are going to convert to a sistrunk because that's going to be the appropriate surgery.
A lot of times what I'll do, if I'm not 100% sure, at least intraoperatively, and this is a little different than how I'd normally do my sistrunks, but if I think that there's a dermoid, I will actually expose the capsule of the cyst. If it looks like a dermoid, I'll take it out and then incise the cyst off the table to prove that the contents are dermoid before saying, "Your child only needs a simple incision." Because oftentimes it's really hard to tell. They look the same on ultrasound, they look the same on imaging, and they look the same on physical exams, so it's really tough sometimes.
[Dr. Gopi Shah]
Yes, when they come to your clinic, that midline, if there's no infection history, I agree, it can be really tricky.
[Dr. Christopher Liu]
Basically just prepare the family for the bigger operation and be pleasantly surprised when you do the simple one, and I don't think I've ever had a family upset about me doing the simpler one.
[Dr. Gopi Shah]
For sure.
[Dr. Ashley Agan]
Anything else for your exam, other than just being able to palpate the neck and feel the mass?
[Dr. Christopher Liu]
Yes, outside of just the location, I think there's a couple of things, and this is more relevant to the patients that have had infections in the past. Outside of a bump, you can also have basically an ugly-looking scar there or a hypertrophic-looking scar. Probably, I think those tend to form with our glossals because after the infection is gone, you can still get some chronic inflammation from that mucoid drainage that tends to want to leak out through that area. You can have a fistula, you can have an ulcer. These are later findings after an infection has been drained or let's say a cyst has spontaneously ruptured.
Oftentimes when I see that, a lot of times parents are really worried about it because of the appearance, but I tell them, "Look, now that it's draining, it's probably not going to get infected again. It might be a hygiene issue until we have our surgery, but at least there is something there for me to follow. The worst-case scenario is that it completely heals and disappears and then I can't really help you until it shows up again, but as long as it's draining and there's an ulcer or something there for me to follow, then we're good to go."
[Dr. Gopi Shah]
Is there ever a reason to scope these kids? The rare thyroglossal that has maybe some more swelling posterior to the hyoid or do you ever have symptoms? I've never had a child that had trouble swallowing with this, but I would imagine in a higher volume practice, you might see something like that, I don't know.
[Dr. Christopher Liu]
Personally, I have not routinely scoped patients for this problem, even when they're infected. I have only had one patient that had a foramen cecum component that was significant enough that was causing airway symptoms. In the absence of airway symptoms or dysphagia or anything of that matter, I don't routinely scope these patients.
Thyroglossal Duct Cyst Treatment without Surgery
When a child presents with an infected thyroglossal duct cyst, there are a few approaches to management. Some ENT’s are taught not to drain the cyst, but Dr Liu likes to take a more aggressive approach and drain the infection, stating that operating on a child with an active infection is out of the question. He does give the family the option to try a day or two of antibiotics if the family is wanting to avoid surgery.
Clindamycin is often chosen for these infections, as the bacteria found in the cyst frequently resemble those in upper respiratory infections. However, Dr. Liu typically starts with Augmentin or Omnicef to cover gram-negative bacteria, as Haemophilus influenzae can sometimes be present in these cases. If hospitalization is necessary, he opts for IV Unasyn.
For drainage, some physicians perform incision and drainage in the OR, but Dr. Liu prefers to drain in-office with a needle, allowing outpatient management. Using topical Emla for numbing, he finds most children tolerate the small needle well. Collected pus is sent for aerobic and anaerobic cultures to guide further antibiotic treatment.
[Dr. Gopi Shah]
For the kids that present to you with an infected thyroglossal duct cyst, so the child in the ER or the child that's been admitted, usually we do the IV antibiotics and see, but my question for you is, what do you usually like from empirics? When it's not getting better, the peds, ENT, we love the 48 hours, let's say nothing's really changed, but there's warmth and fluctuance, how do you usually manage that?
[Dr. Christopher Liu]
Honestly, I think there's a lot of controversy. It's a bit of a gray area in terms of just generally how to deal with an infected congenital cyst. I think as residents we're taught don't drain the cyst because once you violate the capsule, it makes the subsequent surgery harder. When I first started my practice, that's the attitude I took, but over the last couple of years, I have found myself being much more aggressive about draining these infections and not letting them fester for too long. Because, at the end of the day, you can't operate on a kid that has an infection.
The goal is, and this is why I tell families when they come in, I'm okay doing a day or two of antibiotics because obviously no parent really wants their child to have surgery, go under anesthesia too many times. I tell them, "Look, we can do antibiotics for a few days, but if they're not getting better, we don't need to keep doing the same thing. Let's just go ahead and get it drained, get them over the hump, treat the infection so then we can move on to the next step, which is drainage."
Part of the reason I have changed that practice is because when you think about how thyroglossal ducts look, there's actually a lot of data that supports the idea that these cysts are not solitary cysts. What people see is the large one, the large cyst, the one that got infected or the one that's most visible, but oftentimes, behind that cyst, there's a network of ducts and network of small cysts or thyroglossal elements that can also cause problems in the future. For me, when we do the surgery, it doesn't really matter to me whether the cyst wall is intact because I'll do the surgery at the same time.
With thyroglossal at least, I have a very low threshold to drain these, just to get these kids over the hump, so that we can move on to the next step. In terms of antibiotics, I know a lot of people like to use clindamycin, and I haven't done a study on this, so I'm not going to say that I'm the world's expert on this, but what I have noticed is that a lot of times the infections, the bacteria that are identified in these thyroglossal duct infections tend to mirror the bacteria that you find in upper respiratory infections.
This is purely anecdotal, but there have been a lot of cases where we have kids get put on clinda because they assume or the pediatrician assumes that the skin and soft tissue infection doesn't get better and the child actually comes back positive for H flu. Nowadays, I usually will start patients on Augmentin and if not Augmentin, I'll do Omnicef instead of clindamycin, just for that gram-negative coverage.
[Dr. Gopi Shah]
In terms of antibiotics for IV, your first line usually is Unasyn then if they're admitted for IV?
[Dr. Christopher Liu]
Yes, something that at least covers H flu or something that is more directed towards what you would normally give for sinusitis or OME.
[Dr. Gopi Shah]
I find that I used to wait and wait and wait for the IV antibiotics, but it didn't really make a difference because after about 48 hours, if it's not better, it didn't get better after the 72 or longer. I agree, I've been a little bit more just like, "Okay." When you do take them for the I&D, how aggressive are you in terms of opening things up? How aggressive are you when you wash out? Do you leave anything in, like a Penrose or a drain?
[Dr. Christopher Liu]
Can I be honest with you? I have not done an I&D on a thyroglossal in a long time. I think part of it actually is because I tend to drain them in clinic with a needle. It's funny, nowadays with the thyroglossals, unless they're really young or just look really infected, so where it's just huge, the entire neck is swollen, I feel like a lot of these kids nowadays we manage as an outpatient. If it's just isolated swelling or redness over the area, they'll go to the ER, ER will see them, give them the antibiotics, tell them to follow up with ENT in a few days. Then usually they end up in my practice.
If they're doing better, obviously I say, "Okay, keep doing the antibiotics." If they're not, I give the parents a choice, like, "Look, we can plan to do it the next day as an add-on. You can go home, but then we'll bring you in and get it done. Or I can tap it with a needle in the clinic, drain it, and it may recollect, but there's a good chance it won't. Then you spare yourself a trip to the OR." I would say most parents want it tapped. They're so ready for this thing to go away, they're just like, "Do it there, do it now." If it's a young kid, we'll papoose them and drain it.
If it's an older kid, usually the older kids are perfectly fine. They don't usually have any trouble with it. It's not that common, at least as far as I'm aware. We haven't had to drain any of these frequently, let's put it that way. I don't want to say never because I recently just did a kid that somebody else had drained, but the kid was a year old and they got 30 ccs out of the neck, so that kid needed an OR drain. If it's an isolated area, I don't think it's absolutely necessary to do an I&D with packing.
[Dr. Ashley Agan]
When you're doing this needle drainage in clinic, do you just clean the skin with an alcohol wipe and then poke it with an 18-gauge?
[Dr. Gopi Shah]
Do you numb it up at all with Emla or anything like that?
[Dr. Christopher Liu]
Yes, I do use Emla. Then I tell the parents it's usually just one stick. Most of these kids, if they're already on the verge of getting an abscess drained, that thing is–
[Dr. Ashley Agan]
Yes, ready to pop.
[Dr. Christopher Liu]
You're not going to miss. It's right there, so I tell them it's usually just one stick. "We get it out, they're going to fuss. They're going to cry, but at least you get to go home today and it's going to feel a lot better by tonight." I've actually not had any parents, at least in the last year, decline that offer, which is good.
[Dr. Ashley Agan]
Do you send off your pus for any reason?
[Dr. Christopher Liu]
Yes, I do send it for aerobic and anaerobic. Going back to how my practice has slowly changed over the last couple of years in terms of what antibiotic to recommend, I had a run of kids come back with Haemophilus. We've had to change their antibiotic from clindamycin to something else.
Thyroglossal Duct Cyst Surgery
After in-office drainage of the cyst, Dr. Liu always advises families that a Sistrunk procedure will eventually be necessary to prevent future infections. If parents are ready to proceed, he schedules a follow-up within a week to check for any fluid reaccumulation. Dr. Liu prefers to perform surgery within 6 to 8 weeks following infection, if possible.
A neck ultrasound is an effective imaging tool to assess the area’s anatomy, including the thyroid gland, and confirm that the mass is indeed a cyst. CT or MRI imaging is not routinely needed and should generally be avoided due to radiation exposure risks with CT scans in young children; however, an MRI can be ordered in special cases.
Because thyroglossal duct cysts are not life-threatening, families may choose to delay surgery, particularly if their child is very young (such as one or two years old) and they feel surgery is too invasive at that age.
For cysts incidentally discovered on imaging, such as MRI or CT, surgery is optional. In these cases, patients or families can decide based on personal preference, as the cyst may never have caused issues had it not been found incidentally.
Podcast Contributors
Dr. Christopher Liu
Dr. Christopoher Lieu is an associate professor at UT Southwestern Medical Center and practices at Children's Health in Dallas, Texas.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, August 6). Ep. 184 – Thyroglossal Duct Cysts in Children: A Comprehensive Approach [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
The Sistrunk Procedure: A Step by Step Guide to Thyroglossal Duct Cyst Surgery