What the Anesthesiologist Should Know before the Operative Procedure
A thyroglossal duct cyst is the remnants of the passage of the thyroid from its original site in the tongue to its future site in the neck. Rarely, it can be associated with a median ectopic thyroid, which represents the only functional thyroid tissue present. These patients are typically hypothyroid.
Age at presentation appears to demonstrate a bimodal distribution, such that the average age of pediatric presentation is 6-7 years, whereas the age of adult presentation is typically in the fourth to sixth decades. Age may vary based on referral patterns.
There are case reports of malignant transformation of the duct remnants; more commonly, midline neck mass, infection of the cyst, or dysphagia/ dysphonia is the presenting complaint.
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1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
Treatment of an infected thyroglossal duct cyst should be completed before resection in order to reduce the risk of recurrence.
Emergent: Rarely, a thyroglossal cyst can present with airway obstruction.
Urgent: Rarely, a thyroglossal cyst can present with airway obstruction.
Elective: Negligible risk of delay.
2. Preoperative evaluation
In patients with median ectopic thyroid, there is no other functional thyroid tissue; excision of this mass will leave the patient hypothyroid. Identification of normal thyroid tissue via scintigraphy may be standard, or done only in patients where history, TSH levels, and ultrasound suggest median ectopic thyroid tissue. These patients will commonly present with hypothyroidism and should be made euthyroid prior to surgery.
3. What are the implications of co-existing disease on perioperative care?
Management of co-existing disease should follow previously published guidelines for patients having general anesthesia for a superficial procedure.
b. Cardiovascular system
N/A
c. Pulmonary
N/A
d. Renal-GI:
N/A
e. Neurologic:
N/A
f. Endocrine
Patients who present with hypothyroidism due to a median ectopic thyroid should be medically managed, such that they are euthyroid on the date of surgery.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
N/A
4. What are the patient's medications and how should they be managed in the perioperative period?
Management of patient medications should follow guidelines for any surgical patient. In particular, if thyroid replacement is taken, it should be continued in the perioperative period.
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
N/A
i. What should be recommended with regard to continuation of mediations taken chronically?
N/A
j. How To modify care for patients with known allergies –
Avoid allergen.
k. Latex allergy- If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
N/A
l. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics]
N/A
m. Does the patient have a history of allergy to anesthesia?
N/A
5. What laboratory tests should be obtained and has everything been reviewed?
Thyroid function tests should be within normal limits. Patients on thyroid replacement should have a TSH that indicates a euthyroid state. Other tests should be ordered based on co-existing disease, if any.
Common laboratory normal values will be same for all procedures, with a difference by age and gender.
a. Imaging
Ultrasound may reveal a mass rather than a cyst in the thyroglossal duct. This may indicate presence of ectopic thyroid tissue; symptoms and signs of hypothyroidism, and/or an elevated TSH, should also raise suspicion of this condition. Ultrasound may be accompanied by fine needle aspiration of any masses. CT/ MRI may be helpful in large cysts, cases of recurrence, and to rule out other conditions.
b. Other tests
Thyroid scintigraphy to rule out median ectopic thyroid tissue may have been done.
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
This procedure is done under general anesthesia. Due to the location of the initial incision, the extent of surgical dissection, and the proximity of vulnerable structures (trachea, major named vessels), other techniques provide an adverse risk-benefit ratio.
Monitored Anesthesia Care
MAC is not indicated for this procedure.
6. What is the author's preferred method of anesthesia technique and why?
a. What prophylactic antibiotics should be administered?
Antibiotics covering typical skin flora should be administered as per SCIP recommendations.
b. What do I need to know about the surgical technique to optimize my anesthetic care?
The Sistrunk procedure involves the resection of the entire tract, from the skin to the foramen cecum at the base of the tongue. A modified Sistrunk omits the dissection of the tract to the tongue base; it is not clear if this increases the risk of recurrence of the cyst. In patients with ectopic thyroid tissue in the tract and no other functioning thyroid tissue, the tissue may be autotransplanted.
c. What can I do intraoperatively to assist the surgeon and optimize patient care?
In the Sistrunk procedure, to ensure that the entire proximal tract is excised, either the surgeon or anesthesiologist places pressure on the base of the tongue with their finger.
d. What are the most common intraoperative complications and how can they be avoided/treated?
The above maneuver can cause movement of the endotracheal tube, which can lead to displacement of the endotracheal tube, as well as coughing and/ or bronchospasm. Vigilance at this point of the case is essential.
a. Neurologic:
N/A
b. If the patient is intubated, are there any special criteria for extubation?
No.
b. Postoperative management
1. What analgesic modalities can I implement?
Parenteral analgesics are typically sufficient.
2. What level bed acuity is appropriate?
No additional monitoring is required for this procedure.
3. What are common postoperative complications, and ways to prevent and treat them?
Wound infection, seroma, and recurrence.
What's the Evidence?
Ren, W, Zhi, K, Zhao, L, Gao, L. “Presentations and management of thyroglossal duct cyst in children versus aldults: a review of 106 cases”. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. vol. 111. 2011. pp. e1-e6. (Retrospective review of 47 pediatric and 59 adult thyroglossal duct cysts.)
Foley, DS, Fallat, ME. “Thyroglossal duct and other congenital midline cervical anomalies”. Seminars in Pediatric Surgery. vol. 15. 2006. pp. 70-5. (Review article; good discussion of management of median ectopic thyroid tissue.)
Brousseau, VJ, Solares, CA, Xu, M, Krakovitz, P, Koltai, PJ. “Thyroglossal duct cysts: presentation and management in children versus adults”. International Journal of Pediatric Otorhinolaryngology. vol. 67. 2003. pp. 1285-90. (Retrospective review of 21 pediatric and 41 adult thyroglossal duct cysts.)
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