A 9-year-old girl is evaluated due to a neck mass. The patient first noticed the swelling 2 weeks ago after a viral respiratory illness. The lesion is mildly tender and is not enlarging. She has not had heat or cold intolerance or recent change in appetite or weight. The patient has no other medical conditions. Vital signs are within normal limits. Physical examination shows a 2x2 cm, soft mass in the midline just above the thyroid cartilage. The mass moves superiorly when she is instructed to swallow. There are no other palpable neck masses. The remainder of the examination reveals no abnormalities. Serum TSH is within normal limits. Imaging is performed and confirms a cystic midline mass superior to the thyroid gland. Which of the following statements is most appropriate regarding the management of this mass?

Question

A 9-year-old girl is evaluated due to a neck mass.  The patient first noticed the swelling 2 weeks ago after a viral respiratory illness.  The lesion is mildly tender and is not enlarging.  She has not had heat or cold intolerance or recent change in appetite or weight.  The patient has no other medical conditions.  Vital signs are within normal limits.  Physical examination shows a 2x2 cm, soft mass in the midline just above the thyroid cartilage.  The mass moves superiorly when she is instructed to swallow.  There are no other palpable neck masses.  The remainder of the examination reveals no abnormalities.  Serum TSH is within normal limits. Imaging is performed and confirms a cystic midline mass superior to the thyroid gland.  Which of the following statements is most appropriate regarding the management of this mass?

Quizplus · Accepted Answer

Explanation: 11ec2b69_beab_4b19_8f63_b1a96c6b9391_MD0005_00 Due to the risk of recurrent infections, a thyroglossal duct cyst (TDC) should be surgically removed (Choice E). Resection should remove the entirety of the cyst as well as any fibrous tract remnants. The thyroglossal duct passes just posterior to the hyoid bone; therefore, the central portion of the hyoid is typically resected along with the tract to decrease the chance of recurrence. Occasionally, the TDC may contain the only functioning thyroid tissue; identification (eg, via preoperative imaging) is necessary to avoid iatrogenic hypothyroidism resulting from inadvertent removal of the only functioning thyroid tissue during resection of the TDC. (Choice A) Incision and drainage (I&D) is appropriate for an abscess, which can cause a neck mass but usually presents with significant pain and fever. I&D of a TDC should be avoided if possible because it increases the risk of recurrence after definitive resection (likely due to disruption of tissue planes making the tract more difficult to identify and remove). (Choice B) TDCs are benign and do not undergo malignant transformation. Rarely, patients may develop thyroid cancer from ectopic thyroid tissue trapped in the TDC but not from malignant degeneration of the cyst itself. (Choice C) Levothyroxine has no impact on the size of a TDC. Should the patient develop hypothyroidism either before or after surgery, levothyroxine should be used to maintain a euthyroid state. Educational objective: A thyroglossal duct cyst should be surgically excised. Infection of the cyst leads to increased rates of recurrence. References: Congenital neck masses. (http://www.ncbi.nlm.nih.gov/pubmed/30396417) Surgical management outcomes of recurrent thyroglossal duct cyst in children-a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/25890397) Thyroglossal duct cyst and ectopic thyroid: surgical management. (http://www.ncbi.nlm.nih.gov/pubmed/25439547)

A 9-Year-Old Girl Is Evaluated Due to a Neck Mass