Anterior Midline Neck Mass in an Adolescent

A 12-year-old boy presented with a slow-growing, asymptomatic, midline neck lesion, which had been present since he was 3 years old. The lesion was initially more superior in the neck and over the years had migrated inferiorly. The patient denied any respiratory distress, pain, or difficulty with swallowing. Findings of the physical examination revealed a 2.0- × 1.5-cm smooth, nontender, mobile, subcutaneous nodule on the anterior midline neck (Figure 1) that moved anteriorly with swallowing and tongue protrusion (Video; available at www.jpeds.com). Findings of the ultrasound scan revealed a homogenous, mildly hyperechoic, well-circumscribed lesion in the subcutaneous soft tissues with no internal vascularity or communication with the thyroid gland. The diagnosis of thyroglossal duct cyst (TGDC) was established. TGDC is a congenital neck abnormality that arises from an embryologic remnant called the thyroglossal duct. TGDC are the most common congenital cysts in the neck, accounting for approximately 70% of cases.1Thompson L.D. Herrera H.B. Lau S.K. A clinicopathologic series of 685 thyroglossal duct remnant cysts.Head Neck Pathol. 2016; 10: 465-474Crossref PubMed Scopus (58) Google Scholar During embryologic development, the thyroid gland originates from the foramen cecum at the tongue base and descends caudally into the neck, forming the thyroglossal duct.1Thompson L.D. Herrera H.B. Lau S.K. A clinicopathologic series of 685 thyroglossal duct remnant cysts.Head Neck Pathol. 2016; 10: 465-474Crossref PubMed Scopus (58) Google Scholar The duct normally regresses before birth, but failure of obliteration allows for cysts to develop along its path.1Thompson L.D. Herrera H.B. Lau S.K. A clinicopathologic series of 685 thyroglossal duct remnant cysts.Head Neck Pathol. 2016; 10: 465-474Crossref PubMed Scopus (58) Google Scholar The cyst is usually detected during early childhood as a painless, soft or firm midline neck mass that moves superiorly during swallowing or tongue protrusion.1Thompson L.D. Herrera H.B. Lau S.K. A clinicopathologic series of 685 thyroglossal duct remnant cysts.Head Neck Pathol. 2016; 10: 465-474Crossref PubMed Scopus (58) Google Scholar TGDC is often embedded within the strap muscles (infrahyoid muscle) near the posterior hyoid bone.1Thompson L.D. Herrera H.B. Lau S.K. A clinicopathologic series of 685 thyroglossal duct remnant cysts.Head Neck Pathol. 2016; 10: 465-474Crossref PubMed Scopus (58) Google Scholar TGDC can be a single cyst or multiple cysts.1Thompson L.D. Herrera H.B. Lau S.K. A clinicopathologic series of 685 thyroglossal duct remnant cysts.Head Neck Pathol. 2016; 10: 465-474Crossref PubMed Scopus (58) Google Scholar Enlarging cysts from infection or inflammation may lead to abscess formation, dysphagia, pain, or respiratory distress.1Thompson L.D. Herrera H.B. Lau S.K. A clinicopathologic series of 685 thyroglossal duct remnant cysts.Head Neck Pathol. 2016; 10: 465-474Crossref PubMed Scopus (58) Google Scholar TGDC is a clinical diagnosis. Imaging modalities including ultrasonography, computed tomography, or magnetic resonance imaging can confirm the diagnosis and help determine the cyst’s size and proximity to the thyroid gland, larynx, and hyoid bone.2Patel S. Bhatt A.A. Thyroglossal duct pathology and mimics.Insights Imaging. 2019; 10: 12Crossref PubMed Scopus (35) Google Scholar,3Jackson D.L. Evaluation and management of pediatric neck masses: an otolaryngology perspective.Physician Assist Clin. 2018; 3: 245-269Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Up to 70% of TGDCs present with ectopic thyroid gland tissue within the cyst or in the surrounding tissues.1Thompson L.D. Herrera H.B. Lau S.K. A clinicopathologic series of 685 thyroglossal duct remnant cysts.Head Neck Pathol. 2016; 10: 465-474Crossref PubMed Scopus (58) Google Scholar To rule out any cancer, fine-needle aspiration cytology can be performed.3Jackson D.L. Evaluation and management of pediatric neck masses: an otolaryngology perspective.Physician Assist Clin. 2018; 3: 245-269Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Elective surgical excision with the Sistrunk procedure is recommended to prevent infection.2Patel S. Bhatt A.A. Thyroglossal duct pathology and mimics.Insights Imaging. 2019; 10: 12Crossref PubMed Scopus (35) Google Scholar Complications of TGDC excision include recurrence if surgery fails to remove the entire thyroglossal duct tract, infection, bleeding, and damage to underlying structures, including subsequent thyroid dysfunction.1Thompson L.D. Herrera H.B. Lau S.K. A clinicopathologic series of 685 thyroglossal duct remnant cysts.Head Neck Pathol. 2016; 10: 465-474Crossref PubMed Scopus (58) Google Scholar,2Patel S. Bhatt A.A. Thyroglossal duct pathology and mimics.Insights Imaging. 2019; 10: 12Crossref PubMed Scopus (35) Google Scholar The location and associated physical examination findings of pediatric neck masses can help guide diagnosis (Figure 2). Although dermoid cysts present as painless midline neck masses, they are often located near the suprasternal notch.2Patel S. Bhatt A.A. Thyroglossal duct pathology and mimics.Insights Imaging. 2019; 10: 12Crossref PubMed Scopus (35) Google Scholar,3Jackson D.L. Evaluation and management of pediatric neck masses: an otolaryngology perspective.Physician Assist Clin. 2018; 3: 245-269Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Lipomas are characteristically soft masses but typically occur at the lateral rather than midline neck.3Jackson D.L. Evaluation and management of pediatric neck masses: an otolaryngology perspective.Physician Assist Clin. 2018; 3: 245-269Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar,4Jain G. Tyagi I. Pant L. Nargotra N. Giant anterior neck lipoma with bleeding pressure ulcer in an elderly man: a rare entity.World J Plast Surg. 2017; 6: 365-368PubMed Google Scholar Both lipomas and dermoid cysts are more superficial and readily mobile than TGDC.3Jackson D.L. Evaluation and management of pediatric neck masses: an otolaryngology perspective.Physician Assist Clin. 2018; 3: 245-269Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Branchial cleft cysts can be differentiated by their location at the lateral neck, anterior to the sternocleidomastoid muscle. Dermoid cysts, lipomas, and branchial cleft cysts do not typically move with swallowing or tongue protrusion.3Jackson D.L. Evaluation and management of pediatric neck masses: an otolaryngology perspective.Physician Assist Clin. 2018; 3: 245-269Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Cystic hygromas present as ill-circumscribed masses at the posterior cervical triangle of the neck.3Jackson D.L. Evaluation and management of pediatric neck masses: an otolaryngology perspective.Physician Assist Clin. 2018; 3: 245-269Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar The authors declare no conflicts of interest. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhMjQyNzY4NjE1ZTI4MTUzYmRiNDVjMGQ3OGViODY2OCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNzA0NDk2NDEyfQ.nEXg6n0Kdx0qkXNk6nyiGYDXkOLqmb6bjzrmRLhskXNeL63cmVlW-BaVxD-h3e9tkkFCrdgG50mOqRALV6EJgE3JijGB6D6KJ_o7LDxvzm9R0JBNmt3Q1Xg7aEKWItobncwKVastPfStXGIxEBwLJnfbTR5wftmGCgDQSUAg1woMph5eBSX4ntgY6relZfAGKC2U08o0zr6Kz0vE400H6Sb5yIO9ThA0OGKnT-dQTYD_JO5B8Xj3uRJs-1kMdhogjxIQgvXCG2IF9iMozPn7tKEvniIrF3oN52Kt8s8Lq79hcSVH6SFMirydmTalcQxTEzSdt1-99-esOsdhD7Xj2w Download .mp4 (10.32 MB) Help with .mp4 files Video 1A midline neck mass that moves superiorly during swallowing or tongue protrusion.