Mid-neck cyst

Congenital anomalies of development in children are quite rare, benign tumors, cysts, which are included in the category of pathologies of embryogenesis, according to statistics make up no more than 5% of tumors of the maxillofacial region (MFR), but are quite serious diseases that are asymptomatic, in addition, difficult to diagnose. A median cyst of the neck can form at an early stage of embryonic development - from the 3rd to the 5th week of pregnancy, clinically manifests itself at any age, but most often during intensive growth or during hormonal changes in the body. In medical practice, a median cyst is often called thyroglossal, this is due to its etiology and pathogenetic specificity of development.

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Causes of Median Neck Cyst

The etiology of the median cyst is still a subject of scientific debate, apparently, this is due to the fact that such a congenital anomaly is quite rare. Statistically, the median cyst occupies no more than 2-3% of the total number of tumors of the neck, respectively, the possibility of studying the neoplasm in full and confirming its etiology by multiple clinical observations is not possible. It is believed that thyroglossal benign tumors are a pathology of the embryonic basis for the formation of the maxillofacial region, that is, an anomaly of the gill apparatus.

1. Some doctors support the version that claims that the causes of the median cyst of the neck are rooted in unhealed

In due time ductus thyreoglossus – thyroglossal duct or thyroid gland duct. This theory was put forward in the 19th century by the famous German doctor, anatomist, specialist in the study of embryogenesis, Wilhelm His. His name was given to a specific channel connecting the embryo of the thyroid gland and the oral cavity, which is reduced in the last period of intrauterine development. The His channel or thyroglossal duct can be a source of formation of cysts and median, thyroglossal fistulas.

2. The causes of the median cyst of the neck can be explained by another version, which also deserves attention. At the end of the 19th century, the outstanding surgeon Venglovsky proposed his own version explaining the etiology of the development of thyroglossal tumors, according to which they are formed from the cells of the epithelium of the oral cavity, while the thyroglossal duct is replaced by a cord.

Obviously, these two hypotheses need further study and clinical confirmation, and the causes of median neck cyst will be clarified soon.

However, the first variant of His is more reliable in a statistical sense - more than 55% of diagnosed cases showed a close connection of the median cyst with the hyoid bone and foramen cecum linguae - the blind opening of the tongue, which is completely consistent with the topography of the ductus thyreoglossus - the thyroid rudiment.

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Symptoms of a median neck cyst

Clinical manifestations of congenital neck defects are almost always hidden in the initial period of development. It is extremely rare to see cases when the symptoms of a median neck cyst are visible to the naked eye in the first months after birth. Much more often, the cyst manifests itself at the age of 5 to 14-15 years and older. A feature of almost all types of benign neck tumors is an asymptomatic course, which can last for many years. A median cyst in a latent state does not manifest itself with pain, does not provoke dysfunction of nearby structures. Its development can be triggered by an acute inflammatory disease, as well as periods of hormonal changes in the body, for example, puberty. Even when it manifests itself, the cyst grows very slowly, upon palpation it is determined as a round elastic formation on the midline of the neck, the tumor is not fused with the skin, during swallowing it can move upward along with the hyoid bone and nearby tissues. Objective complaints from the patient begin when the cyst becomes infected, inflamed and interferes with food intake. The tumor can open outward, less often into the oral cavity, releasing purulent exudate, but the fistula never heals on its own and remains as a permanent channel for the outflow of inflammatory secretory fluid. The release of exudate helps to reduce the size of the cyst, but does not contribute to its resorption. Moreover, a tumor that is not diagnosed and removed in a timely manner can provoke serious problems with swallowing food, speech impairment (diction), and in rare cases - malignancy, that is, development into a malignant process.

Median neck cyst in a child

Despite the fact that, according to statistics, a median cyst on the neck of a child is extremely rare - only 1 case per 3000-3500 newborn babies, this disease remains one of the serious congenital pathologies that require differential diagnosis and inevitable surgical treatment.

Symptoms of a median cyst in a child rarely appear in the first years of life; more often, the tumor is diagnosed during the period of intensive growth – at the age of 4 to 7-8 years and later, during puberty.

The etiology of median cysts is presumably due to incomplete fusion of the thyroglossal duct and close association with the hyoid bone.

As a rule, in the initial period of development, a median cyst on the neck of a child is diagnosed during random examinations, when an attentive doctor carefully palpates the lymph nodes and neck. Palpation is painless, the cyst is felt as a dense, clearly defined rounded formation of small size.

The clinical picture, which more clearly shows the signs of a thyroglossal cyst, may be associated with an inflammatory, infectious process in the body, the cyst increases in size and may become purulent. Such development is manifested by visible symptoms - an increase in the area of the neck in the middle, subfebrile body temperature, transient pain in this area, difficulty swallowing food, even liquid consistency, hoarseness of the voice.

A suppurating cyst is clinically very similar to an abscess, especially if it opens and releases purulent contents. However, unlike a classic abscess, a median cyst is not capable of resorption and healing. In any case, the tumor requires careful differential diagnostics when it is separated from atheromas, cysts of the subgenital area, dermoid, and lymphadenitis, which have similar symptoms.

Thyroglossal cyst in a child is treated surgically, just like a cyst in an adult patient. Cystectomy is performed under local anesthesia, the capsule and contents of the tumor are completely removed, resection of a separate part of the hyoid bone is also possible. If the cyst suppurates, it is first drained, inflammatory symptoms are removed, and the operation is performed only in a state of remission. Surgical treatment of a median cyst in children is indicated from the age of 5, but sometimes such operations are performed at an earlier period, when the pathological formation interferes with the process of breathing, eating, and with cysts larger than 3-5 centimeters.

Median neck cyst in adults

In adult patients, lateral cysts are most often diagnosed among congenital pathologies of the neck, however, thyroglossal tumors also pose a certain threat in terms of the risk of malignancy. The percentage of transformation of the cystic process and malignancy is very small, however, untimely diagnosis and treatment can carry the risk of developing phlegmon of the neck and even cancer.

A median neck cyst in adults develops without clinical manifestations for a very long time, its latent state can last for decades. Traumatic factors provoke an increase in the cyst - blows, bruises, as well as inflammations associated with ENT organs. The cyst increases in size due to the accumulation of inflammatory exudate, often pus. The first noticeable clinical sign is swelling in the median zone of the neck, then pain appears, difficulty swallowing food or liquid, less often - changes in the timbre of the voice, shortness of breath, and impaired diction. A serious complication of a median neck cyst is compression of the trachea and the degeneration of tumor cells into atypical, malignant ones.

Thyroglossal cyst is treated exclusively by surgery, puncturing, conservative methods are ineffective and even delay the process, provoking various exacerbations. The sooner the operation to remove the cyst is performed, the faster the recovery occurs. The prognosis for the treatment of median cysts in adult patients is generally favorable, provided that the tumor is detected in time and radically removed.

Diagnosis of median cyst of the neck

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How is a median cyst diagnosed?

Thyroglossal congenital anomalies in 75-80% develop without obvious clinical signs. Diagnosis of a median cyst of the neck may initially be aimed at examining the ENT organs, lymph nodes, in which case the neoplasm is diagnosed in passing, with careful palpation.

Primary observations and data are confirmed by the following methods:

• Ultrasound of the neck, lymph nodes.
• X-ray.
• Fistulography (probing and use of contrast dye).
• Computed tomography as indicated.
• Puncture.

Since the diagnosis of a median neck cyst is quite difficult due to the similarity of the symptoms of many diseases of the maxillofacial region (MFR), the doctor is required to have not only theoretical knowledge, but also extensive practical experience. The choice of treatment method depends on how accurately the diagnosis is made.

The median cyst should be distinguished from such diseases of the parotid region and neck:

• Congenital dermoid cyst of the neck.
• Atheroma.
• Lymphadenitis.
• Adenophlegmon.
• Struma of the tongue.

Treatment of median neck cyst

Treatment of congenital cystic tumors of the neck is currently performed exclusively by surgery. The median cyst is also subject to cystectomy regardless of its size and condition. An inflamed cyst containing pus is first treated symptomatically, the purulent exudate is drained. After neutralization of the acute process, adult patients are shown surgery. Surgical treatment of a median cyst on the neck in a child can be postponed for several years until reaching a more mature age and the ability to adequately undergo surgery. This is possible only if the cyst does not increase in size and does not interfere with the functioning of the entire maxillofacial region.

A median cyst in remission is subject to radical removal, regardless of its location - above or below the hyoid bone. Cystectomy is performed under local anesthesia by layer-by-layer tissue dissection and resection of the tumor itself together with the body or part of the hyoid bone. Often, a thyroglossal cyst is combined with a fistula, which is also excised, having been previously filled with a contrast agent to visually determine the fistula tract. The complexity of treating a median cyst of the neck lies in its close location to important organs - the larynx, pharynx, large vessels. Difficulties can also be caused by fistula branches that are not visible during surgery. Incomplete removal of all structural parts of the cyst can provoke a relapse, when the operation must be repeated after 3-4 months. Therefore, preliminary examinations of the tumor are so important, including a fistulogram using contrast agents showing all possible fistula tracts.

When all diagnostic procedures are carried out, and the operation is correct and precise, recovery occurs very quickly. In addition, such operations are classified as "minor surgery" and have a virtually 100% favorable prognosis.

Removal of the median neck cyst

The median cyst of the neck is subject to removal - this is considered a standard method, excluding any option of conservative therapy or puncture. Removal of the median cyst of the neck is performed surgically, by radical excision of the capsule and contents of the tumor. Operations are indicated for all patients - adults and children, starting from the age of three. Less often, cystectomy is performed on infants, for which there are certain indications - a threat to life with a large cyst and compression of the trachea, an extensive purulent inflammatory process and the risk of general intoxication of the child's body.

The preference for removal rather than resorption therapy is associated with the etiology of cyst formation - they are all considered congenital anomalies of embryogenesis, so the only way to eliminate the consequences of impaired reduction of the gill apparatus is surgery.

Thyroglossal cyst removal is performed under endotracheal or intravenous anesthesia. Careful excision of all parts of the cyst, as well as the fistula, fistula tract and a certain area of the hyoid bone, guarantees almost 100% relapse-free recovery. Unlike the removal of lateral cysts, cystectomy of median neoplasms is considered less traumatic and has a favorable prognosis.

Surgery for median neck cyst

How is surgery performed for a median neck cyst:

1. After a thorough examination, the patient undergoes an anesthesia procedure, usually local anesthesia.
2. After the anesthetic is administered, a layer-by-layer incision is made in the cyst localization area. The incisions run along natural folds, so postoperative scars are virtually invisible.
3. The walls and capsule of the cyst are enucleated, and the contents of the tumor are drained or washed out, depending on the consistency.
4. If an accompanying fistula is detected, part of the hyoid bone is also resected, since the fistula cord is located in this area.
5. The fistula is removed simultaneously with the cyst, and is first visualized using methylene blue.
6. The surgical wound is sutured with neat cosmetic stitches.

Modern surgical technologies, methods and equipment allow the removal of a median cyst to be performed as safely and minimally invasively as possible. Sutures are applied from the inside of the wound, which allows achieving a good cosmetic effect, when after six months the patient has virtually no external postoperative scars or scars on the neck.

The operation for a median cyst lasts on average from 30 minutes to an hour and a half in extreme, complicated cases. The complexity of the surgical intervention and the scope of the procedure may depend on the size of the tumor and its contents. A purulent median cyst is removed longer, as it requires drainage and careful postoperative revision. If parts of the cyst or fistula are not completely excised, relapses are possible, so a favorable outcome of the operation depends on the doctor's attentiveness. But even relapses are not considered a threatening complication, as a rule, a repeat operation is indicated 2-4 months after the primary one and ends 100% successfully. The recovery period lasts no more than a week, after which the patient can return to normal life and perform all necessary functions, both household and work. Swelling at the incision site is possible for a month, but it disappears without a trace if all doctor's recommendations are followed. Complete recovery depends on the general health and regenerative properties of the body.

Prevention of median neck cyst

Unfortunately, it is impossible to say that the development of a median cyst can be prevented. Preventive measures are not taken for various reasons, but the main one is congenital etiological factors. Developmental anomalies in the prenatal period are generally considered difficult to predict; geneticists deal with these issues. Some scientists have put forward a version about the inheritance of congenital tumors of the maxillofacial region (MFR), but this information is controversial and has not been statistically confirmed. Prevention of a median cyst of the neck can consist of standard recommendations that apply to any disease in principle:

• Dispensary examinations should be systematic and regular.
• All children should be examined from the moment of birth.
• Early detection of tumor formations helps to take timely measures to stop the process and plan surgical intervention.
• Early diagnosis of a median cyst allows one to avoid extensive surgery, which is indicated when removing large, inflamed tumors of the neck.
• Self-examination can also help in detecting a cyst at an early stage of development. In this sense, even the so-called "false alarm" is much better than the late detection of a purulent, developed cyst.
• Thyroglossal cyst has a tendency to malignancy. The percentage of such cases is small, however, the risk of developing a malignant process exists. Therefore, a visit to an ENT doctor, dentist should be planned in the regime - once every six months.
• In some cases, the enlargement and suppuration of the median cyst are provoked by injuries to the neck, which is a complex and vulnerable part of the body. Therefore, preventing injuries, bruises and blows in this area helps to reduce the risk of development and inflammation of hidden latent neoplasms.

Prognosis of median neck cyst

Almost 100% of operations to remove a median cyst on the neck end successfully. Of course, surgical intervention in this anatomical area cannot be considered completely safe, but modern equipment, the use of the latest techniques, medical experience and developments in the field of otolaryngology allow us to talk about a favorable outcome of treatment.

The prognosis of a median cyst of the neck is usually favorable. The risk of tumor malignancy is possible only in rare cases when the neoplasm is clinically manifested but not treated. A neglected process, accompanying inflammations, and infection of the cyst can lead to the transformation of tumor cells into malignant ones. There are no confirmed and indisputable statistics on this issue; it is believed that a median cyst extremely rarely degenerates into cancer, according to some information, only in 1 case out of 1,500 diagnoses. The most dangerous thyroglossal cyst is in infancy, especially if it reaches large sizes and compresses the respiratory tract.

The median cyst of the neck is a congenital anomaly, which is currently successfully operated and does not present any difficulties in terms of treatment. The only "dark spot" in its history is the not fully understood etiology and pathogenesis. However, the study process has not stopped, and currently many geneticists and doctors continue to accumulate clinically reliable information in order to come to a consensus in determining the root cause of congenital tumors, and therefore to new, more advanced methods of their treatment.