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Reoperation for cysts of the thyroglossal duct
208
INTERNATIONAL
HEAD AND NECK Reoperation J.-M. Laberge,
for Cysts of the Thyroglossal L.T. Nguyen, et al. Can J Surg
Duct.
H. Flageole,
38:255-259, (June),
1989. The authors reviewed their experience at The Montreal Children’s Hospital with 121 children from 1974 to 1990. There were 70 boys and 51 girls (age range, 1 month to 18 years). There were 23 (19%) recurrences. Twelve children required only one reoperation, eight needed two further operations, and three had to have three more operations. Their mean age at presentation of the recurrence was 4.2 years. The mean interval between the initial surgery and the first reoperation was 8 months, with shorter intervals for subsequent procedures. The problem of recurrence is twofold: infection and incomplete removal of the entire tract. The recurrence rate after the initial Sistrunk procedure was 4% (4 of 94). In noninfected cysts, the recurrence rate after a Sistrunk operation was 1.4% (1 of 72), whereas in infected cysts it was 14% (3 of 22). In contrast, the recurrence rate after only excision of the cyst was 59% (10 of 17) and not significantly influenced by infection. Children who initially presented with infection had a reoperation rate of 42% (14 of 33). Among the 23 children who had reoperation for thyroglossal duct recurrence, only four (17%) had an initial Sistrunk procedure. Ten (43%) had only a simple cyst removal, because the diagnosis was thought to be either a dermoid cyst or a branchial cleft cyst. The authors believe that the majority of midline neck masses can be differentiated on clinical grounds; they did not routinely perform thyroid scanning. If an aberrant thyroid was suspected, ultrasonography was used to demonstrate a normal thyroid gland in its usual anatomic position. Therefore, the authors conclude that “when operating for a midline neck mass located near the hyoid bone that contains clear, glary fluid, the surgeon should proceed with a Sistrunk procedure, even if a tract is not clearly seen extending to the hyoid bone.” The increased morbidity associated with an infected cyst is well demonstrated by the linear relationship between infection and the number of surgical interventions needed to cure the problem. The overall rate of infection in the group with recurrence was 87%; the infection rate was 63% for those who needed two reoperations and 100% for the three who needed three reoperations. Twenty-one infected cysts were successfully treated by the first Sistrunk operation. However, in seven cases, infection was associated with recurrence of the cyst, even after a Sistrunk operation. Therefore, infection is best prevented by an early Sistrunk operation, which is associated with a much lower reoperation rate (92%) than incision and drainage. Entry into the cyst (22%) at the time of original surgery was not an independent risk factor. Thyroglossal duct cysts that did not recur seem to have been managed by a complete Sistrunk procedure in which a wide core of tissue was removed on each side of the tract.Sigmund Ein Ectopic A Case
Thyroid Report.
Gland A.K.C.
Simulating Leung, A.L.
a Thyroglossal Duct Cyst: Wang, and W.L.M. Robson.
Can J Surg 38:87-89, (February), 1995. There are a number of reports of the inadvertent surgical removal of an ectopic thyroid gland that was mistaken for a thyroglossal duct cyst. In spite of modern methods to differentiate these disorders, this mistake has been reported as recently as 1991. The child in this case report was 5 years old. The midline neck mass (more on the right) was first noted when she was 2 years old, and had grown slowly with her until the presenting size of 2 x 2% cm; the mass was smooth, firm, and nontender. She was euthyroid and asymptomatic. Her thyroid gland was not palpable. Results of thyroid function tests were normal. Ultrasonography and a techne-
ABSTRACTS
tium 99m pertechnetate scan showed a single focus of thyroid tissue conforming in size and position to the midline neck mass, with no evidence of functioning thyroid tissue in the lower neck. She was not operated on. Depending on the anatomic location, an ectopic thyroid gland may be lingual, sublingual, prelaryngeal, or substernal. It occurs in one of 100,000 to 300,000 persons and in one of 4,000 to 8,000 patients with thyroid disease. There are more females than males with an ectopic thyroid. The differential diagnosis is epidermal cyst, lymphadenopathy, lipoma, lymphangioma, sebaceous cyst, or midline bronchial cyst. Hypothyroidism has been reported in up to 33% of such patients, most commonly during periods of physiological stress such as, puberty, menstruation, pregnancy, infection, trauma, and surgery. The ectopic gland secretes a hormone that is chemically normal but may be insufficient in quantity. Goitre may develop in an ectopic thyroid gland when the circulating level of thyroid hormone becomes insufficient to meet the metabolic needs of the body. This will lead to increase TSH production and secondary hypertrophy of the ectopic thyroid gland. In an asymptomatic and euthyroid child with an ectopic thyroid gland, no treatment is necessary except for regular, longterm follow-up. Thyroid supplement is indicated in the children who have hypothyroidism, an elevated TSH, functional impairment (airway obstruction, dysphagia, or dysphonia), or an undesirable cosmetic appearance. Some authors have even suggested that all such children receive lifelong thyroxine suppression to prevent enlargement of the gland and hypothyroidism.-Sigmund Ein Postintubation H.C. Grille,
D.M.
Tracheal Donahue,
Stenosis-Treatment D.J. Mathisen,
and et al.
Results.
J Thorac Cardio-
vast Surg 109:486-493, (March), 1995. This important report details the outcome of 521 tracheal resections and reconstructions for postintubation tracheal stenosis over a 27-year period in the same institution. Most important for pediatric surgeons is that the outstanding results presented in this report are for patients older than 10 years (only one patient was under 10 years of age). Fifty-three patients had previous surgical attempts at tracheal surgical resection. Fifty-one had undergone laryngeal repair and 45 had undergone laser treatment. Sixty-two patients with major laryngeal injuries required complete resection of the anterior cricoid cartilage, with anastomosis of the trachea to the thyroid cartilage. One hundred seventeen underwent tracheal anastomosis to the cricoid. The cervical approach was used in 350 reconstructions, mediastinal in 145, and transthoracic in 8. The maximum length of resection was 7.5 cm. Only 49 patients required laryngeal release for anastomotic tension. Ninety-four percent of patients had good or satisfactory results. In 37 patients the operation failed, and 18 underwent a second reconstruction. Eighteen patients also required postoperative tracheostomy or T-tube insertion for multilevel disease. The mortality rate was 2.4%. Suture granulations occurred in nearly 10%. Despite widespread methods of prevention for postintubation injury, tracheal stenosis continues to appear because of overinflation of nonelastic plastic cuffs or leverage on tracheostomy tubes. Certainly, older children and adolescents can enjoy the same excellent results from reconstruction using the techniques and methods outlined in this report.Thomas
F. Tracy,
Jr
THORAX Bronchogenic Copin, and
Cysts
of
the
Mediastinum.
M.E.
Ribet,
M.C.
B. Gosselin. J Thorac Cardiovasc Surg 109:1003-1010, (April), 1995. During a 25-year period, 24 infants and children (age range, 1 day to 15 years) and 45 adults (age range, 15 to 64 years) were
INTERNATIONAL
HEAD AND NECK Reoperation J.-M. Laberge,
for Cysts of the Thyroglossal L.T. Nguyen, et al. Can J Surg
Duct.
H. Flageole,
38:255-259, (June),
1989. The authors reviewed their experience at The Montreal Children’s Hospital with 121 children from 1974 to 1990. There were 70 boys and 51 girls (age range, 1 month to 18 years). There were 23 (19%) recurrences. Twelve children required only one reoperation, eight needed two further operations, and three had to have three more operations. Their mean age at presentation of the recurrence was 4.2 years. The mean interval between the initial surgery and the first reoperation was 8 months, with shorter intervals for subsequent procedures. The problem of recurrence is twofold: infection and incomplete removal of the entire tract. The recurrence rate after the initial Sistrunk procedure was 4% (4 of 94). In noninfected cysts, the recurrence rate after a Sistrunk operation was 1.4% (1 of 72), whereas in infected cysts it was 14% (3 of 22). In contrast, the recurrence rate after only excision of the cyst was 59% (10 of 17) and not significantly influenced by infection. Children who initially presented with infection had a reoperation rate of 42% (14 of 33). Among the 23 children who had reoperation for thyroglossal duct recurrence, only four (17%) had an initial Sistrunk procedure. Ten (43%) had only a simple cyst removal, because the diagnosis was thought to be either a dermoid cyst or a branchial cleft cyst. The authors believe that the majority of midline neck masses can be differentiated on clinical grounds; they did not routinely perform thyroid scanning. If an aberrant thyroid was suspected, ultrasonography was used to demonstrate a normal thyroid gland in its usual anatomic position. Therefore, the authors conclude that “when operating for a midline neck mass located near the hyoid bone that contains clear, glary fluid, the surgeon should proceed with a Sistrunk procedure, even if a tract is not clearly seen extending to the hyoid bone.” The increased morbidity associated with an infected cyst is well demonstrated by the linear relationship between infection and the number of surgical interventions needed to cure the problem. The overall rate of infection in the group with recurrence was 87%; the infection rate was 63% for those who needed two reoperations and 100% for the three who needed three reoperations. Twenty-one infected cysts were successfully treated by the first Sistrunk operation. However, in seven cases, infection was associated with recurrence of the cyst, even after a Sistrunk operation. Therefore, infection is best prevented by an early Sistrunk operation, which is associated with a much lower reoperation rate (92%) than incision and drainage. Entry into the cyst (22%) at the time of original surgery was not an independent risk factor. Thyroglossal duct cysts that did not recur seem to have been managed by a complete Sistrunk procedure in which a wide core of tissue was removed on each side of the tract.Sigmund Ein Ectopic A Case
Thyroid Report.
Gland A.K.C.
Simulating Leung, A.L.
a Thyroglossal Duct Cyst: Wang, and W.L.M. Robson.
Can J Surg 38:87-89, (February), 1995. There are a number of reports of the inadvertent surgical removal of an ectopic thyroid gland that was mistaken for a thyroglossal duct cyst. In spite of modern methods to differentiate these disorders, this mistake has been reported as recently as 1991. The child in this case report was 5 years old. The midline neck mass (more on the right) was first noted when she was 2 years old, and had grown slowly with her until the presenting size of 2 x 2% cm; the mass was smooth, firm, and nontender. She was euthyroid and asymptomatic. Her thyroid gland was not palpable. Results of thyroid function tests were normal. Ultrasonography and a techne-
ABSTRACTS
tium 99m pertechnetate scan showed a single focus of thyroid tissue conforming in size and position to the midline neck mass, with no evidence of functioning thyroid tissue in the lower neck. She was not operated on. Depending on the anatomic location, an ectopic thyroid gland may be lingual, sublingual, prelaryngeal, or substernal. It occurs in one of 100,000 to 300,000 persons and in one of 4,000 to 8,000 patients with thyroid disease. There are more females than males with an ectopic thyroid. The differential diagnosis is epidermal cyst, lymphadenopathy, lipoma, lymphangioma, sebaceous cyst, or midline bronchial cyst. Hypothyroidism has been reported in up to 33% of such patients, most commonly during periods of physiological stress such as, puberty, menstruation, pregnancy, infection, trauma, and surgery. The ectopic gland secretes a hormone that is chemically normal but may be insufficient in quantity. Goitre may develop in an ectopic thyroid gland when the circulating level of thyroid hormone becomes insufficient to meet the metabolic needs of the body. This will lead to increase TSH production and secondary hypertrophy of the ectopic thyroid gland. In an asymptomatic and euthyroid child with an ectopic thyroid gland, no treatment is necessary except for regular, longterm follow-up. Thyroid supplement is indicated in the children who have hypothyroidism, an elevated TSH, functional impairment (airway obstruction, dysphagia, or dysphonia), or an undesirable cosmetic appearance. Some authors have even suggested that all such children receive lifelong thyroxine suppression to prevent enlargement of the gland and hypothyroidism.-Sigmund Ein Postintubation H.C. Grille,
D.M.
Tracheal Donahue,
Stenosis-Treatment D.J. Mathisen,
and et al.
Results.
J Thorac Cardio-
vast Surg 109:486-493, (March), 1995. This important report details the outcome of 521 tracheal resections and reconstructions for postintubation tracheal stenosis over a 27-year period in the same institution. Most important for pediatric surgeons is that the outstanding results presented in this report are for patients older than 10 years (only one patient was under 10 years of age). Fifty-three patients had previous surgical attempts at tracheal surgical resection. Fifty-one had undergone laryngeal repair and 45 had undergone laser treatment. Sixty-two patients with major laryngeal injuries required complete resection of the anterior cricoid cartilage, with anastomosis of the trachea to the thyroid cartilage. One hundred seventeen underwent tracheal anastomosis to the cricoid. The cervical approach was used in 350 reconstructions, mediastinal in 145, and transthoracic in 8. The maximum length of resection was 7.5 cm. Only 49 patients required laryngeal release for anastomotic tension. Ninety-four percent of patients had good or satisfactory results. In 37 patients the operation failed, and 18 underwent a second reconstruction. Eighteen patients also required postoperative tracheostomy or T-tube insertion for multilevel disease. The mortality rate was 2.4%. Suture granulations occurred in nearly 10%. Despite widespread methods of prevention for postintubation injury, tracheal stenosis continues to appear because of overinflation of nonelastic plastic cuffs or leverage on tracheostomy tubes. Certainly, older children and adolescents can enjoy the same excellent results from reconstruction using the techniques and methods outlined in this report.Thomas
F. Tracy,
Jr
THORAX Bronchogenic Copin, and
Cysts
of
the
Mediastinum.
M.E.
Ribet,
M.C.
B. Gosselin. J Thorac Cardiovasc Surg 109:1003-1010, (April), 1995. During a 25-year period, 24 infants and children (age range, 1 day to 15 years) and 45 adults (age range, 15 to 64 years) were