RAKSHITH AVB

Name NaveenAge 10 YearsSex Male

Chief Complaints Swelling in the midline, in front of the upper part of neck for last 3 years

History of Prestning Swelling – Insidious onset.Illness Progression – Gradually increasing in size No History of Pain over the swelling.

No History of any discharge from swelling.

Examination Site - In the Midline of neck, in front of Thyroid Cartilage

Size - 2cm in diameterShape – Round in ShapeSurface – Smooth

Margins are Rounded, free from underlying Skin and Structures

Fluctuation PositiveTrans illumination Negative

Swelling Moves up and down with deglutition and also moves up

with protrusion of tongue.

Examination of Regional - Lymph Nodes Not Enlarged Lymph Nodes

Examination of the - No Ectopic Thyroid Tissue PresentBase of the tongue

Summary of the Case

This ten year old Child Presented with swelling in the midline in front of the upper part of the neck for the last three years which is gradually increasing in size, there is no pain over the swelling. There is no history of any discharge from the swelling.

Swelling Moves up on Protrusion of the thongue.

Diagnosis

This is a case of thyroglossal syst situated in the prelaryngeal region

Differential Diagnosis

Differential diagnosis: These cysts should be differentiated from

1. Dermoid cyst - cheesy secretion

2. Infected lymph node (Delphian) -

purulent secretion

3. Lipoma - slippery edges

4. Sebaceous cyst - doughy feel

5. Thyroid isthmus tumour

Thyroglossal Cyst Thyroglossal Cyst is a cystic swelling which develops from the thyroglossal duct. It is a type of tubolodermoid.

The Fate of Thyroglossal Duct

•Lower part forms the isthmus and two lateral lobes of thyroid gland.• Part form foramen caecum to the thyroid isthmus Disappears.• Part from hyoid bone to the isthmus of thyroid gland may persist as a fibrous cord to form levator glandulae thyroidae.

Relation of thyroglossal Duct with the hyoid bone

• A long the course of the duct ectopic thyroid tissue may develop in deferent sites – lingual thyroid, ectopic thyroid tissue in sub mental and sub hyoid or prelaryngeal region.

• A portion of the thyroglossal duct may remain unobliterated and accumulation of secretion may occur leading to formation of thyroglossal cyst.

The thyroglossal Duct descend usually in front of the hyoid bone. The duct however may form a retro hyoid loop and then descends downwards. Rarely the duct may pass through the hyoid bone.

Site of occurrence: 1. Hyoidal - 60%

2. Suprahyoidal - 25%

3. Infrahyoid - 13%

4. Intralingual - 2%

Pathology

The thyroglossal cyst in lined by columnar or cuboidal epithelium. The cyst epithelium is surrounded by a rim of lymphoid tissue. The cyst contains thick jelly like fluid which may contain Cholestrol crystals.

Clinical Features

Asymptomatic small mass in midline in front of neck

Infected: tenderness, swelling & redness

Fistula: Opening in skin with discharge of mucous from cyst

Difficulty in swallowing or breathing

Investigations

I would like to do a 131I Scan of thyroid gland to exclude any ectopic thyroid tissue in the swelling. In case ectopic thyroid tissue this may be this may be the only functioning thyroid tissue and no other tissue will be seen.

Ultra sonography Used to Determine the nature of thyroid nodule. Ability to determine nodule has a cystic component.

Purely cystic masses are always be benign.Mixed – Solid Cystic components - Malignant.Can also help FNA when Thyroid Nodules are small and difficult

to palpate.

Operation

I will do a Sistrunk operation. This is a operation involves complete excision of cyst along with thyroglossall tract. The operation is done under local anesthesia. The neck is extended by placing a sand bag in between the shoulder blades and head rests on a heads ring. An elliptical incisions made around the cyst and the cyst is dissected all around. The thyroglossal duct Attached to the cyst is dissected upwards. The body of hyoid bone is excised. The excision of the body of the hyoid bone helps in excision of any retro hyoid part of the thyroglossal tract and also complete excision of the thyroglossal tract up to the foramen caecum.

Complications

• Recurrent Infection• Fistula Formation • Rarely Papillary Carcinoma may develp in thyroglossal cyst.

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