The Laryngoscope
C 2012 The American Laryngological,
V
Rhinological and Otological Society, Inc.
Thyroglossal Duct Cysts in Adults Treated by Ethanol Sclerotherapy:
A Pilot Study of a Nonsurgical Technique
Tam-Lin Chow, FRCS (Edin), FHKAM (Surgery); Chi-Yee Choi, FRCS (Edin), FHKAM (Surgery);
Joyce Yee-Hing Hui, FRCR, FHKAM (Radiology)
Objectives/Hypothesis: To investigate the effect of ethanol sclerotherapy on the thyroglossal duct cyst (TDC).
Study Design: Prospective case series.
Methods: Patients with primary TDC were enrolled. The volume of the TDC was calculated using the following formula:
length width height p/6. Under sonographic guidance, ethanol was slowly instilled into the TDC cavity after the cyst
fluid was aspirated. The procedure was performed in an outpatient setting.
Results: A total of eight patients were recruited for this study, but two of them did not receive sclerotherapy. One
patient refused treatment after obtaining initial consent, and another patient was not treated due to a technical issue. The
median follow-up duration was 21 months. The median cyst volume was 3.5 mL. Of the six patients given sclerotherapy,
recurrent TDC occurred in one patient. As expected, the TDC persisted in the two patients who had not undergone sclerotherapy. Two patients experienced moderate pain after the procedure that was well controlled with oral analgesics. No major
complications arose, and no patient needed hospitalization because of treatment complications.
Conclusions: Percutaneous ethanol sclerotherapy is an effective minimally invasive modality of therapy for TDC. Further
studies with longer follow-up are warranted.
Key Words: Ethanol, sclerotherapy, thyroglossal duct cyst.
Level of Evidence: 4
Laryngoscope, 122:1262–1264, 2012
INTRODUCTION
Thyroglossal duct cyst (TDC) is a congenital problem caused by the persistent embryonal thyroglossal
duct remnant. The patients can present with asymptomatic upper anterior neck lumps, which sometimes might
be complicated with infection. The classical treatment is
the Sistrunk operation,1 in which the TDC, middle onethird of the hyoid bone, and part of the tongue base
around the foremen caecum are removed. The recurrence rate is about 3%. The Sistrunk operation has stood
the test of time and remained the operation of choice for
TDC.2,3 A recent anatomic study discovered that the thyroglossal duct arborizes with the formation of multiple
side tracts,4 which can account for the uncommon recurrence after the classic Sistrunk operation. Therefore, the
extended Sistrunk operation, in which a central core of
soft tissue is dissected and removed at the anterior neck
compartment, from the thyroid gland to tongue base in
addition to the hyoid bone and fibrous tract, has been
From the Department of Surgery (T.-L.C., C.-Y.C.) and Department of
Diagnostic Radiology and Organ Imaging (J.Y.-H.H.), United Christian
Hospital, Kowloon, Hong Kong.
Editor’s Note: This Manuscript was accepted for publication
January 30, 2012.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Dr. Tam-Lin Chow, Department of Surgery, United Christian Hospital, 130 Hip Wo Street, Kowloon, Hong
Kong. E-mail: [email protected]
DOI: 10.1002/lary.23254
Laryngoscope 122: June 2012
1262
advocated to prevent recurrence. Kim et al.5 and Patel
et al.6 reported encouraging outcomes by adopting the
extended approach for patients with a prior failed
Sistrunk procedure. However, we should be cautious in
applying it as the primary surgery for TDC to balance
against the increased morbidity of the extended
resection.5
Minimally invasive intervention had been successfully practiced for different benign head and neck
cystic lesions (e.g., branchial cyst, plunging ranula, lymphangioma, and TDC).7,8 The lesions were treated by
percutaneous sclerotherapy with OK-432. Because OK432 is not available in our locality, we investigated the
effect of sclerotherapy of the TDC with ethanol.
MATERIALS AND METHODS
The diagnosis of TDC relies on the unequivocal tongue tug
sign of the anterior midline neck cystic nodule. All adult
patients with primary TDC were invited to participate in this
study after obtaining informed consent. This prospective study
was approved by our institutional review board.
Apart from conventional magnetic resonance imaging
sequences, axial 0.7-mm-thick T2-weighted gradient-echo
(3DFT-CISS) magnetic resonance examination (Seimens Medical
Solutions, Erlangen, Germany) of the neck was performed to
rule out the existence of a patent tract in communication with
the oropharynx. Sclerotherapy was then arranged on an outpatient basis. For sonography, an iU22 ultrasound scanner
(Philips Healthcare, Andover, MA) was performed using a 5 to
12 MHz linear probe. The volume of the TDC was calculated
using the following formula: length width height p/6. For
Chow et al.: Ethanol Sclerotherapy for TDC
TABLE I.
Patient Demographics, Clinical Characteristics, and Ethanol Sclerotherapy Outcome.
Case
Gender
Age, yr
TDC Size, cm3
Sclerotherapy
Follow-Up, mo
TDC Relapse
Complication
1
Female
44
1.7
Yes 1
21
Nil
Nil
2
Female
49
1.7
Nil*
21
NA
NA
3
4
Male
Female
61
42
9.1
2.0
Yes 1
Yes 1
53
23
Nil
Nil
Nil
Nil
5
Female
37
1.5
Yes 1
17
Nil
Nil
6
7
Male
Female
48
52
5.5
4.9
Yes 1
Nil†
21
13
Nil
NA
Nil
NA
8
Female
37
9.8
Yes 3
72
Yes
Nil
*Patient refused sclerotherapy.
†
Cyst fluid too viscous.
TDC ¼ thyroglossal duct cyst; NA ¼ not applicable.
a complex cyst, volume was calculated as the volume of the
cystic component rather than solid areas. Under sonographic
guidance, a 20- to 22-gauge needle was introduced into the TDC
without local anesthesia, and the cyst fluid was aspirated as
completely as possible. The aspirates were sent to the laboratory for cytology examination. After that, ethanol was slowly
instilled into the TDC cavity at a rate of approximately 2 to 5
mL/min. A volume of 50% to 90% of the original volume of aspirated fluid was injected. Injection of ethanol was stopped if
ethanol was seen leaking out from the nodule under ultrasound
or if the patient complained of pain.
Follow-up ultrasonography was arranged at 3 months, 6
months, and 1 year after the procedure. Sclerotherapy could be
repeated if considerable residual/recurrent fluid collection was
noted. The data were prospectively collected.
RESULTS
A total of eight patients were recruited for this
study (Table I). However, ethanol sclerotherapy was not
given to two patients. One patient (case 2) refused the
procedure after consent was obtained. In another patient
(case 7), the cyst fluid was too viscous to be aspirated,
Fig. 1. Preablation ultrasound depicts thyroglossal cyst with some
echogenic debris.
Laryngoscope 122: June 2012
and thereby sclerotherapy was not carried out due to a
technical issue. The median follow-up duration was 21
months (range, 13–72 months)
The demographic data and outcome are summarized in Table I. There were six female and two male
patients. Their median age was 46 years (range, 37–61
years). The TDCs were asymptomatic in five patients,
whereas three patients experienced mild pain. Past
infection of the TDC occurred in one patient. The
median cyst volume was 3.5 mL (range, 1.7–9.8 mL).
For those six patients who had undergone sclerotherapy,
one session of treatment was given in five patients,
whereas three sessions were required in the remaining
patient. No patient suffered from hoarseness or hemorrhage after therapy. Two patients experienced moderate
pain after the procedure that was well controlled with
oral non-narcotic analgesics (paracetamol) for 2 days. No
patient needed hospitalization because of treatment
complications.
Of the six patients given sclerotherapy, recurrent
TDC occurred in one patient. The recurrent nodule was
only 1 cm and painless. The patient refused further sclerotherapy or surgical extirpation. As expected, the TDC
persisted in the two patients without sclerotherapy. Both
of them declined the Sistrunk operation. Of those five
patients with successful ablation without recurrence, the
cysts vanished completely (Fig. 1 and Fig. 2).
Fig. 2. Postablation ultrasound shows complete disappearance of
the thyroglossal cyst.
Chow et al.: Ethanol Sclerotherapy for TDC
1263
DISCUSSION
In general, benign neck cysts are treated by surgical excision. Percutaneous sclerotherapy has gained
popularity in the past decade. In 2005, Taguchi et al.9
reported one case of neonatal branchial cleft cyst treated
by intralesional injection with OK-432. Subsequently,
Roh et al.10 reported a series of 12 branchial cleft cysts
managed with intracystic injection of OK-432. There
was no recurrences in their series. The use of OK-432
sclerotherapy has expanded to plunging ranula, lymphangioma, and TDC.7,8
Akin to OK-432, ethanol can be used as a sclerosing
agent for benign cysts. Ethanol sclerotherapy for thyroid
cysts is well documented.11–14 The merit of ethanol over
OK-432 is the absence of post-treatment fever or flu-like
symptoms. Moreover, OK-432 is not licensed in our locality. Therefore, we used ethanol as the sclerosing agent
in our study.
Percutaneous ethanol sclerotherapy was well tolerated by the patients. Only two patients in our series
complained of moderate pain after therapy. The pain
was well controlled with a non-narcotic analgesic (paracetamol). There were no complications of hoarseness or
bleeding. All of the procedures were performed easily in
an outpatient setting.
The outcome was very positive in this study. Only
one patient suffered a small TDC relapse out of the six
patients who had undergone the sclerotherapy. Conversely, the two patients who did not undergo
sclerotherapy after enrollment had persistent disease.
The recurrent case (case 8) was the first trial case, and
the cyst was the biggest (9.8 cm3). Whether the relapse
was due to the learning curve or large cyst volume is
uncertain due to the small sample size of this study.
Further studies with more patients are needed to investigate the parameters for treatment failure. The median
follow-up in our series was 21 months, which indicates
that the therapeutic effect is sustaining. Likewise, Fukumoto et al.15 reported their experience of ethanol
sclerotherapy in two patients with TDC. Both patients
were cured with the follow-up duration around
30 months. The instilled ethanol can migrate to the secondary tracts of the TDC, which could explain the
effectiveness of sclerotherapy on TDC despite tract
arborization.
Laryngoscope 122: June 2012
1264
General anesthesia is necessary when performing
the Sistrunk operation. The surgical complications
include bleeding, infection, and scar formation. The
patients undergoing surgical treatment also need hospitalization. Therefore, the advantages of percutaneous
ethanol sclerotherapy for TDC are that it is less invasive
than surgery, there is minimal pain, it has a lower cost,
and it provides a better cosmetic outcome.
CONCLUSION
Percutaneous ethanol sclerotherapy is an effective
minimally invasive modality of therapy for TDC.
Further studies with longer follow-up are warranted.
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Chow et al.: Ethanol Sclerotherapy for TDC