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Call
(630) 938-6161
to Schedule a Consultation

25 N Winfield Rd Ste 505
Winfield IL 60190-1295

Miscellaneous Thyroid Topics

Thyroglossal Duct Cyst & Ectopic Tissue

Central Neck Dissection

Thyroglossal Duct Cyst (TGDC)

The formation of the thyroid gland begins in the tongue (foramen cecum) when you are a fetus.

As a fetus develops, the thyroid travels down from the tongue, closely around the hyoid bone, along the midline front of the neck, to its eventual final location just above the chest plate.

  • The path that the thyroid travels down is called the thyroglossal duct tract (Thyro = thyroid; glossal = tongue).

The thyroglossal duct tract seals off shortly after the thyroid reaches its final destination.

  • 7% of the time, a small portion of the tract remains intact and a cyst (pocket of fluid) forms.
    • This is called a Thyroglossal Duct Cyst (TGDC).

Image Source: Aleksey Dvorzhinskiy

TGDC’s most commonly present as an asymptomatic mass, just below the chin, in the midline of the neck.

  • More commonly present in childhood but sometimes can present later in life in adulthood.
  • TGDC’s are usually not noticed until after an Upper Respiratory Infection that caused the previously tiny cyst to enlarge and become visible / palpable.

On exam, a TGDC will rise in the neck when the patient sticks out their tongue.

Sometimes a TGDC can be infected causing severe swelling, pain, redness of the overlying skin, and rarely drainage of fluid from the skin.

  • This typically resolves after a course of oral antibiotics.
  • Rarely is needle drainage and/or hospital admission for IV antibiotics necessary.

When a TGDC is suspected on exam, an ultrasound of the neck should be obtained.

  • This will help confirm the diagnosis of a TGDC and rule out any other possible causes for a midline mass in the neck.
  • Confirms the presence of normal thyroid tissue.
    • Rarely can the thyroid gland not fully travel down the front of the neck.
    • This results in ectopic thyroid tissue (see below) that can present similar to a TGDC.
    • Presence of a thyroid gland in its normal (eutopic) location rules out ectopic thyroid tissue.
    • Removal of ectopic thyroid tissue will likely result in permanent hypothyroidism (low thyroid hormone) requiring lifelong daily thyroid hormone replacement medication.
      • For this reason, it is very important to distinguish between a TGDC and ectopic thyroid tissue, especially when considering surgery.
  • Rules out high-risk features that could suggest cancer.
    • Cancer in a TGDC is very rare, occurs < 1% of the time.
    • When cancer is present, atypical features will be noticed on ultrasound:
      • Calcifications, irregular borders, and/or solid portions.
      • FNA (biopsy) should be performed if atypical features are noted on ultrasound.
        • Otherwise FNA’s are not indicated in the work-up of TGDC.

Observation

  • Can be considered for small TGDC’s not causing compressive symptoms or cosmetic concerns, and in very young children.
  • Consider ultrasounds every 6-12 months until stability is confirmed over a period of 1-2 years.
    • Can then be repeated as needed thereafter (i.e. change in exam or symptoms).
  • There is risk of growth and/or future infection if observation is elected.

Ethanol ablation

  • Office procedure that uses an ultrasound to guide a needle into cyst (pocket of fluid).
    • The fluid is then aspirated (or sucked out) with the needle.
    • Using the same needle, Ethanol (special kind of alcohol) is then injected into the cyst.
      • The Ethanol helps to promote scarring inside the cyst in order to decrease the chance of the fluid returning and make the mass go away indefinitely.
  • Should not be performed if cancer is present or suspected.
  • May fail if the fluid is too thick to aspirate with a needle.
  • There is a risk of the fluid coming back, completely or partially, requiring repeat Ethanol ablation or surgery.

Surgery to remove a TGDC should be considered when:

  • FNA is + for cancer.
    • Excision of the TGDC alone is sufficient unless work-up of the thyroid gland reveals cancer or high suspicion for cancer in one of its nodules, or spread of cancer to a lymph node is confirmed on FNA.
  • The TGDC is large or steadily growing causing compressive symptoms (pressure on the throat) or cosmetic concerns.
  • Repeat infections requiring antibiotics.

Surgery of choice is a Sistrunk procedure performed under general anesthesia.

Central Neck Dissection

Ectopic Thyroid

Presence of functional thyroid tissue outside (ectopic) its normal expected location.

  • Most commonly somewhere along the thyroid’s path of embryologic decent in the thyroglossal duct tract (see above in Thyroglossal Duct Cyst – TGDC).
    • 90% lingual (in the tongue at the foramen cecum; back 2/3 of the tongue).
    • In the front of the neck along the midline.
      • Important to obtain ultrasound to differentiate from TGDC.
        • Will not elevate when the tongue sticks out.
  • Occasionally the thyroid travels farther down.
    • In the neck:
      • Small ‘island’ of thyroid tissue that broke off the mainland of the thyroid.
        • Incidentally seen on ultrasound of the thyroid, CT of the Neck or Chest, or encountered during surgery.
          • Risk for cancer is very low and often FNA (biopsy) is not needed unless high risk features are present (i.e. calcifications or irregular borders).
    • Into the chest (mediastinum):
      • Appears as a large mass separate from or abutting the normal thyroid.
      • Can be confused for a substernal goiter.

Imaging – depends on the location of the ectopic thyroid tissue:

  • Ultrasound is preferred for masses in the neck.
  • CT Neck or MRI of the Neck with contrast if lingual (tongue) thyroid tissue is suspected.
  • CT of Neck with contrast if ectopic thyroid is in the mediastinum (chest).

Biopsy (FNA):

  • Considered only if high risk features such as calcifications or irregular borders are present.
  • Consider for large ectopic thyroid mases in the mediastinum when it is not clear / obvious that it is thyroid tissue.
    • If standard FNA approach with ultrasound via neck is not possible, may consider CT guided FNA performed by interventional radiology or Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) performed by a Pulmonologist.

Observation

  • Can be considered if there is no concern for cancer and there are no compressive symptoms.
  • Repeat imaging can be performed typically on a yearly basis until stability is ensured over a 1-3 year period, then less frequently or as needed thereafter.
    • Preferred imaging depends on the location of the ectopic thyroid tissue as discussed above.
    • If steady growth is noted during observation or compressive symptoms do develop, there should be a low threshold to consider surgery.

Surgery should be considered if:

  • There is a biopsy confirming cancer or highly concerning for cancer.
  • The ectopic thyroid tissue is causing compressive symptoms.
    • Lingual thyroid – may cause difficulty swallowing, breathing, or speaking.
    • In the mediastinum – may compress the trachea causing difficulty breathing, the esophagus causing difficulty swallowing, or compressing the large blood vessels to and from the heart.
      • May require the assistance of a Thoracic surgeon to either open the sternum (aka sternotomy, similar to open heart surgery) or make an incision through the ribs (thoracotomy or thoracoscopy) if the ectopic thyroid tissue cannot be accessed through the neck.
  • The ectopic thyroid tissue is steadily enlarging overtime and will likely cause symptoms in the future.

To learn more about the Thyroid, head back to the Thyroid main page here.

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