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.
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 . 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 . 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 . Although major complications are rare in the Sistrunk operation (recurrence develops in <10% of patients) , 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.
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.
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.
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.
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.
