Intralingual Thyroglossal Duct Cyst Excision

Intralingual thyroglossal duct cyst is a rare presentation of this congenital anomaly, accounting for approximately 0.5% to 2% of cases of thyroglossal duct cysts.1 The most common presentations include airway obstruction and dysphagia.2-5 While the Sistrunk procedure remains the preferred method of excision in cases of cervical thyroglossal duct cyst, several studies have demonstrated the feasibility of transoral endoscopic excision in intralingual thyroglossal duct cyst without significant recurrence rates.5, 6 In this article, we comprehensively describe our technique of endoscopic intralingual thyroglossal duct cyst excision. To date we have successfully managed six infants (range 1–5 months of age) using this technique. All patients with suspected intralingual thyroglossal duct cyst based on flexible laryngoscopy findings of a submucosal mass in the base of the tongue should undergo cross-sectional imaging in order to further characterize the lesion and confirm the presence of a cervical thyroid gland. Magnetic resonance imaging (MRI) is preferred in infants who can be fed and swaddled without the need for sedation. Computerized tomography (CT) may be considered in older children who would require sedation for MRI, however, parents must be counseled on the risks of radiation exposure. Nasotracheal intubation is preferred to allow for maximum exposure of the operative field. This will allow for complete access to the airway for instrumentation. One dose of intravenous steroids (in our case decadron 0.5 mg/kg up to 10 mg maximum dose) and antibiotics are given prior to the start of the procedure. In children with teeth, a protective tooth guard is used to avoid dental injury. In infants, an unfolded moist 4 × 8 gauze is used to protect the maxilla from the laryngoscope. Exposure of the base of tongue, vallecula, and epiglottis is established with a Lindholm laryngoscope (Karl Storz Endoscopy-America, Inc., El Segundo, CA) of appropriate size for the patient. The laryngoscope is placed in suspension with the aid of a self-retaining laryngoscope holder (Karl Storz Endoscopy-America, Inc.) secured to a Mayo stand over the patient. During the procedure, a timer is set to go off after 15 minutes of suspension after which the suspension is released for at least 60 seconds to prevent compression injury to local neurovascular structures. Standard laser safety precautions are employed throughout the case including eye protection for all non–microscope-using staff in the room. The patient's eyes are covered with moistened eye patches and the entire exposed area of the face and neck covered with wet sterile towels (Fig. 1). The endotracheal tube is covered with wet pledgets to ensure additional laser safety. A Hopkins rod telescope or microscope with 400-mm focal length may be used for visualization during the case. If excellent visualization can be achieved with the microscope, then this method is preferred because it allows the operating surgeon to use both hands. The Hopkins telescope sometimes offers superior visualization because unlike a microscope it does not rely on line-of-sight; however, its utilization limits the surgeon to a single hand for operating if there is no assistant. Alternatively, an operative assistant may be used to maintain a view with the telescope (Fig. 1). Use of a 30o angled Hopkins telescope positioned outside of the laryngoscope is an option and allows for less crowding in the lumen of the laryngoscope. If using the microscope, one can use the micromanipulator attachment for laser use. An angled Omniguide handpiece is used when using a Hopkins telescope (Video S1). Following adequate exposure (Fig. 2), the surface of the cyst is ablated with the CO2 laser fiber (Lumenis Inc., San Jose, CA) on 3 to 5 W at a distance with a diffuse beam to ensure hemostasis on manipulation. It is then entered using the laser or microlaryngeal scissor and decompressed with a microlaryngeal suction (Fig. 3). Following decompression, the cyst wall is dissected free of the vallecula and base of tongue using the CO2 laser on a 3- to 5-W setting in pulsed mode with the assistance of microlaryngeal grasping and cutting instruments (Fig. 4). It is important to not divide the glossoepiglottic fold to avoid retroflexion of the epiglottis. Care is taken to remove the cyst in its entirety. A laryngeal spreader secured to the suspension using two sterile rubber bands is used to expose the resection cavity (Fig. 4), and the CO2 laser is used to achieve hemostasis and ablate the entire surface of the resection cavity. This ensures ablation of all microscopic mucosal tissue in order to prevent recurrence. The resection cavity is left open to heal by secondary intention in order to decrease anesthetic time, leave the native anatomy undistorted, but more importantly to decrease the risk of burying mucosalized tissue with closure. The base of tongue heals very well and there is a little risk of postoperative bleeding. Prior to withdrawing the laryngoscope, the cavity is carefully examined for any areas of shiny appearing mucosalized tissue (Fig. 4). The laryngoscope is then withdrawn. A tongue stitch is placed at the conclusion of the procedure and left in place overnight as a fail-safe mechanism to open the patient's airway should there be postoperative obstruction due to edema. It is removed the following morning if there are no respiratory issues or significant lingual edema. The patient is extubated at the end of the procedure and is admitted to the intensive care unit for at least 24 hours postoperatively for airway observation. Perioperative antibiotics are employed as most children undergo the procedure in infancy, and an infection in the base of tongue in this age group could be catastrophic. Given the immature infant immune system and large mucosal defect, the author prefers to use 5 days of perioperative antibiotics (amoxicillin), the typical time for re-mucosalization of the defect. A clinical swallow evaluation is obtained on postoperative day 1. If this evaluation is normal, the patient may resume oral intake, including thin liquids. If the clinical swallow evaluation on the first postoperative day demonstrates coughing during feeds, a video swallow study is obtained that same day. Postoperative pain is initially managed with intravenous acetaminophen with morphine pushes as needed and transitioned to oral acetaminophen as tolerated. Steroids are also given for 24 hours postoperatively to decrease pain and inflammation. The patient is discharged from the hospital once oral intake is safe and adequate. Flexible fiberoptic laryngoscopy is performed in the office at 1 week, 4 week, 3 months, and 6 months postoperatively to evaluate the surgical site and to ensure that there is no recurrence of the cyst. Following the 6-month visit, the patient is seen again at 1 year and then as needed. Hemostasis is usually achieved with oxymetazoline soaked pledgets and the CO2 laser. A suction bovie electrocautery may be utilized if this is not successful. The bilateral lingual arteries are avoided by staying in the midline of the base of tongue. Patients are seen at the intervals previously described in order to monitor for possible recurrence. In the unlikely event of a recurrence, early re-intervention is advised. Anna Cornelius-Schecter for the voiceover in the accompanying video. Surgical Video can be viewed in the online issue which is available at www.laryngoscope.com. Video S1. Video of intralingual thyroglossal duct cyst CO2 laser excision demonstrating the operative techniques as described in this article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.