Management of Thyroglossal Fistula and Recurrent Thyroglossal Duct Remnants: A New Concept for Surgical Approach

Background: Surgery for thyroglossal duct cysts has a high cure rate, however, surgery for recurrent cases (thyro-glossal fistulas) has less success rate and there are still recurrences despite a competently performed procedure. In addition, many patients who present with thyroglossal fistula without history of previous surgery have lower cure rates. All these patients present a surgical challenge since no standard treatment exists. Surgery for such cases may encounter some difficulties due to abnormal anatomy as a result of previous surgery or infection leading to fibrosis and adhesions in addition to the unexpected branching pattern of the tract. The management of the thyroglossal fistula could be as a pharyngeo-cutaneous fistula management with tight pharyngeal closure after proper excision of the identified tract with the central hyoid (if not excised before) and to avoid wide area of dissection and excision which has a considerable risk of complications. Aim of the Work: To evaluate and discuss the outcome of tight pharyngeal closure by hyoid gap closure and layered closure in the management of thyroglossal fistula and recurrent thyroglossal duct remnants. Methods: A retrospective study conducted from March 2014 to January 2016 including 27 patients suffering from thyroglossal fistula having 16 patients as a primary presentation without surgical history and 11 patients of recurrent disease after Sistrunk operation for thyroglossal cyst. All patients have been presented and managed at the Department of Otolaryngology, Hearing and Speech Institute and El-Sheihk Zayed Specialized Hospital. All patients have undergone tight pharyngeal closure by hyoid gap closure and layered closure. Regular follow-up visits were done every two months for at least one year. Results: The operative time ranged from 1 to 2 hours with a mean of 1.2 hours. Blood loss has a range of 55-170 ccms with a mean of 90 ccms. Hospitalization was one day in all patients with discharge in the second postoperative day. As regards complications, there were no major complications in the form of injury to important adjacent structures or massive hemorrhage. Other complications in the form of wound infection in one patient was evident 1 week after surgery and well controlled by parentral antibiotics and local antiseptic meas¬ures. Return to normal life activity or work was possible in all patients after 10 days. As regards the final outcome, all patients were doing well throughout the follow-up period. There was no recurrence in 26 patients of the study except one male patient who suffered recurrence of discharging fistula after nine months of our surgery. In this case the recurrence was most probably due to infrahyoid remnants. This patient was re operated by central neck dissection after 11 months of the first surgery and doing well until the time of writing. Conclusion: Tight hyoid closure and layered closure have successfully managed thyroglossal fistula and recurrent thy-roglossal duct remnants. Understanding the anatomy and pathophysiology is important in treating these challenging cases.