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K. Rajaram et al.
9.2 Clinical Features
Thyroglossal duct cysts occur equally in both sexes. Although
most develop in childhood, they may not become clinically
apparent until well into adulthood, so they show a bimodal
peak in the rst and fth decades of life [2].
The cysts almost always arise in the midline, but when
they are adjacent to the thyroid cartilage, they may lie slightly
to one side. Classically, the cyst moves upwards on swallowing, and notably with tongue protrusion, but this nding is
not pathognomonic of a thyroglossal duct cyst; it also may
occur with other midline cysts, such as dermoid cysts. As a
clinical nding, it suggests attachment to the hyoid bone. If a
patient has a midline mass in the neck that does not move
with swallowing, a pathologic entity other than a thyroglossal duct cyst should be considered [4].
Thyroglossal cysts may become infected and rupture into
the skin of the neck, presenting as a discharging sinus. This
presentation is more common in children but may also occur
in adults.
Thyroglossal cysts most often present as a lump in the
neck but may present incidentally. Additional symptoms are
usually related to the size of the cyst or infection [4]:
• Dysphagia
• Coughing
• Choking sensation
• Upper respiratory obstruction (in severe cases)
• Incidental nding
Thyroglossal duct cysts are on average 1–2cm in size, but
they may range up to 10cm. They are typically non-tender
with the skin freely movable over the cyst unless there is
active infection or a history of infection.
follows an upper respiratory infection. An infected cyst is
result in a thyroglossal stula.
A relative contraindication for thyroglossal duct cyst
removal is the presence of active infection. In this situation,
treatment with antibiotics is recommended, allowing sufcient time for the inammatory process to settle prior to excision (normally about 6weeks). If necessary, needle aspiration
of the cyst contents can be done to help resolution.
9.4 Preoperative Planning
History and physical examination are the mainstay for diagnosis and therapeutic decision making with regard to thyroglossal duct cysts [4]. The single most useful investigation is
ultrasonography. Not only does it aid in the diagnosis and
treatment planning, but also conrms an anatomically normally thyroid gland. If an entirely ectopic thyroid gland is
mistakenly diagnosed as a thyroglossal duct cyst and
removed, the patient will require lifelong thyroid replacement to prevent hypothyroidism.
Other investigations can be performed if clinically relevant, but they are not routinely required. These may include
high-resolution CT scans, MRI, or ne-needle aspiration
biopsy (if there is suspicion of malignancy).
Patients with entirely ectopic thyroid tissue often have
reduced thyroid function and may present with symptoms of
hypothyroidism; they consequently have elevated thyroidstimulating hormone (TSH). If hypothyroidism is suggested
by the history, then thyroid function tests are indicated.
9.5 Evolution ofSurgery forThyroglossal
Duct Cyst Removal
9.3 Indications forSurgery
Surgical excision of a mass in the midline of the neck is performed for both diagnostic and therapeutic purposes. There
are several indications [4] for excision of a thyroglossal cyst
[4]:
• The presence of an undiagnosed mass (diagnostic
procedure)
• Cosmetic appearance
• Infection
• Cancer originating in a thyroglossal duct cyst
Because of the potential elevated risk of recurrent infec-
tion, a thyroglossal cyst over 1cm in size may be excised if
it persists, but most can be safely left. The wall contains nodules of lymphatic tissue, and the initial presentation often
Prior to 1893, simple incision and drainage or excision was
the procedure of choice to treat thyroglossal cysts. The recurrence rate was high (>50%), however, owing to incomplete
removal of the thyroglossal duct [5]. Recurrence has also
been attributed to the thyroglossal duct having microscopic
feather-like projections beyond the clinically obvious duct,
which can be attached to the base of the tongue [6].
In 1893, Schlange [7] proposed the excision of the cyst
along with the central portion of the hyoid bone. This technique reduced the recurrence rate to about 20%.
The procedure of choice now is generally the Sistrunk
procedure, described in 1920 by Walter Sistrunk [8]. In this
procedure, the body of the hyoid bone and a core of tissue
one-eighth of an inch in radius from the hyoid bone to the
foramen cecum is resected en bloc with the cyst and duct,
after its superior and inferior muscle attachments are released
(Fig.9.2). This technique reduced the recurrence rate to 5%
Thyroglossal
Thyroid gland
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Foramen
cecum
Hyoid bone
103
9.7.1.2 Incision
A transverse incision is placed straddling the midline along a
major skin crease in the upper part of the neck (in the region
of the upper border of the thyroid cartilage). If a draining
sinus is present, or if the skin is scarred from previous incision and drainage, an elliptical incision is made so that the
sinus tract or involved skin is removed with the specimen [4].
The incision is carried down into fat and subcutaneous
tissue. Depending on the size and extent of the cyst, the incision may be extended on either side of the midline and may
encounter the platysma along the lateral extent on either side
(Fig.9.3).
duct tract
Fig. 9.2 The extent and anatomic relations of a thyroglossal duct cyst
Thyroglossal
duct cyst
or less. An extension of the Sistrunk procedure involves
removing the epimysium of the suprahyoid muscles, along
with the resection of prelaryngeal adipose connective tissue,
producing recurrence rates reported to be even lower [6].
9.6 Anaesthesia
General anaesthesia is the preferred choice. One dose of
antibiotic prophylaxis may be given at the time of induction,
in cases of current infection or previous recurrent episodes of
infection.
9.7 Surgical Technique
9.7.1 Sistrunk Procedure
9.7.1.1 Positioning thePatient
The patient is placed in a supine position with neck extension. Silicone gel pads or blankets are placed under the
shoulders to achieve extension. Routine antiseptic preparation of the surgical site is performed, followed by inltration
of local anaesthetic with adrenaline or diluted adrenaline
(1:200,000) along the incision site in the neck.
9.7.1.3 Flaps
A ap is raised superior to the hyoid bone to allow adequate
exposure (Fig.9.4).
9.7.1.4 Identication ofStrap Muscles
The strap muscles are identied and careful dissection is carried out, separating the strap muscles from the cyst. Blunt
retractors are used to lateralize the strap muscles (Fig.9.5).
Sharp and blunt dissection is performed to free the cyst from
the thyroid cartilage and thyrohyoid membrane with the cyst
pedicled on the hyoid bone superiorly. Keeping dissection
close to the midline will avoid injury to vital structures that
are more laterally situated. To reduce the risk of recurrence,
it is important to ensure that the entire cyst and tract are
removed; to facilitate this removal, the dissection is continued caudally down to the pyramidal process of the thyroid
gland.
9.7.1.5 Removal ofHyoid Bone
The hyoid bone is then grasped with a tenaculum or boneholding forceps. Using a periosteal elevator or needle-point
monopolar diathermy, the muscles and soft tissues are freed
from the body of the hyoid bone. Avoid aggressive sharp dissection superior or inferior to the hyoid bone, to avoid transecting the thyroglossal duct. After skeletonizing the body of
the hyoid, a bone cutter is used to transect the hyoid bone
(Fig.9.6). Forceps are placed on the hyoid bone and the bone
elevated anteriorly and superiorly. At this point, digital pressure may be applied over the base of the tongue (Fig.9.7).
This displaces the tongue base into the wound, thus facilitating dissection of the suprahyoid musculature.
9.7.1.6 Excision oftheBase ofTongue andCyst
Removal
The retrohyoid portion of the duct can be excised together
with an ellipse of tissue up to the base of the tongue, preferably including the foramen cecum (Figs.9.8 and 9.9).
Copious irrigation with normal saline is carried out. If the
vallecula is inadvertently entered during the operation, the
defect should be closed with interrupted or purse-string
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K. Rajaram et al.
Fig. 9.3 (a) Skin incision is made midline overlying cyst and thyroid cartilage. (b) Incision incorporated to excise a pre-existing sinus
suture. A suction drain is normally placed postoperatively
and the wound closed in layers.
of the thyroid isthmus, a section of tissue that includes both
the thyroglossal duct and part of the bordering strap muscles
is dissected. The resection continues superiorly towards the
hyoid bone, removing the thyroglossal duct and cyst. As with
9.7.2 Extended Sistrunk Procedure
the original Sistrunk procedure, a section of the hyoid bone
is removed in the extended procedure. Above the level of the
Because the procedure originally described by Sistrunk may
not result in complete resection of the entire thyroglossal
duct, an extended Sistrunk procedure has been described,
which aims to surgically remove the entire thyroglossal duct
[6]. For the extended Sistrunk procedure, the site of the incision may vary if there are any neck swellings or stulae that
will also need to be resected. Starting at the superior aspect
hyoid, the thyroglossal duct and cyst are resected along with
the epimysium of the suprahyoid muscles, to ensure that any
branches of the thyroglossal duct are also removed. This
resection continues to the level of the tongue base, but the
tongue base ideally is not breached by the surgeon. A drain is
placed in the neck at the end of the procedure, and the wound
is closed with resorbable sutures (in layers).
ab
Hyoid bone
Th
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Fig. 9.4 Raising of aps to allow adequate exposure. (a) Raising of subplatysmal aps. (b) Raising of subplatysmal aps when excision of a sinus
is involved
Fig. 9.5 Freeing the cyst.
After splitting strap muscles
down the middle, the
thyroglossal duct cyst
(TGDC) is identied and
dissected free from the
surrounding tissues
yrohyoid m.
Sternothyroid m.
TGDC
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K. Rajaram et al.
ab
Fig. 9.6 Removal of the hyoid bone. (a) Once freed up inferiorly, the cyst can be seen pedicled to the hyoid bone superiorly. Also notice the close
relationship between the cyst and the underlying airway. (b) The hyoid bone is then cut on each side of the midline
Fig. 9.7 Digital pressure is applied over the base of the tongue, displacing the tongue base into the wound and facilitating dissection of the
suprahyoid musculature
Fig. 9.8 Cyst removal. The tract can be followed to the foramen cecum
and excised
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Fig. 9.9 Closure of the opening at the foramen cecum
107
divide the hyoid bone medial to the lesser cornu and make
sure that the soft tissue dissection is medial to the anterior
belly of the digastric muscle.
By identifying the thyroid notch and thyrohyoid membrane, one can avoid entering the airway. Accidental entry
into the airway warrants a meticulous closure. Failure to
identify a breach in the thyrohyoid membrane could result in
signicant surgical emphysema. An airtight closure should
be performed in layers: rst involuting the mucosa, followed
by repair of the brous membrane. Strap muscles can be
mobilized to support the repair. The authors recommend
careful placement of Penrose drains and the use of postoperative antibiotics.
In the immediate postoperative period, a haematoma may
develop and threaten the airway. This will usually require
surgical drainage, although the need for tracheotomy, nerve
paralysis, hypothyroidism, or death from airway compromise is extremely rare.
By identifying the thyroid notch and thyrohyoid membrane, one can avoid entering the airway.
Intermediate postoperative complications include abscess
or infection, and late complications include recurrence, scarring, and poor wound cosmesis.
9.8 Postoperative Care
An inpatient overnight stay is recommended. The drain can
be removed once the collection is less than 20mL over 24h.
Routine wound care is followed.
9.9 Complications
Perioperative complications include bleeding, cyst rupture,
and inadvertently entering the airway at the thyrohyoid
membrane. In case of cyst rupture, it is important to suction
the contents before spillage into the operating site, followed
by placement of suture along the cyst wall to prevent further
extrusion of cystic contents. Maintaining the structure of the
cyst in this way facilitates onwards dissection. If spillage
into the operating site has occurred, copious wound irrigation is required.
Dividing the hyoid bone too laterally can damage the
hypoglossal nerve. To avoid nerve injury, it is paramount to
References
1. Gupta P, Maddalozzo J. Preoperative sonography in presumed
thyroglossal duct cysts. Arch Otolaryngol Head Neck Surg.
2001;127:200–2.
2. Thompson LD, Herrera HB, Lau SK. A clinicopathologic series
of 685 thyroglossal duct remnant cysts. Head Neck Pathol.
2016;10:465–74.
3. Williams N, O’Connell R.Bailey & Love’s short practice of sur-
gery. 27th ed. Boca Raton: CRC Press; 2018.
4. Myers EN. Operative otolaryngology. 2nd ed. Philadelphia:
Saunders Elsevier; 2008.
5. Wagner G, Medina JE. Excision of thyroglossal duct cyst: the
Sistrunk procedure. Oper Tech Otolaryngol Head Neck Surg.
2004;15:220–3.
6. Ahmed J, Leong A, Jonas N, Grainger J, Hartley B.The extended
Sistrunk procedure for the management of thyroglossal duct cysts in
children: how we do it. Clin Otolaryngol. 2011;36:271–5.
7. Schlange H. Uber die stual colli congenita. Arch Klin Chir.
1893;46:390–2.
8. Sistrunk WE. The surgical treatment of cysts of the thyroglossal
tract. Ann Surg. 1920;71:121–6.
Part IV
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Pharyngeal Pouch Surgery
Endoscopic Approaches
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tothePharyngeal Pouch: Stapling
Technique
SandroJ.Stoeckli, GerhardF.Huber, andNeilSharma
10.1 Introduction
The rst case of a posterior pharyngoesophageal diverticulum was described in 1764 by Abraham Ludlow [1]. Since
the publication of a case series in 1878 by Zenker and von
Ziemssen [2], the name of the German pathologist Zenker
has been ascribed to the diverticulum. The site of protrusion
of the pouch is the Killian’s triangle [3], the area of least
resistance, with only scanty muscle bres, which lies
between the oblique bres of the inferior constrictor muscle
superiorly and the horizontal bres of the cricopharyngeus
muscle inferiorly. A variety of theories relating to the pathogenesis of Zenker’s diverticulum (ZD) have been investigated so far, but to date, none have been proven correct or
generally accepted [4–8].
In the Western world, Zenker’s diverticulum (ZD) typically affects people in the seventh and eighth decade of life,
with a male predominance of 2–3:1. ZD is extremely rare in
Africa and Asia. Patients usually present with a long history
of slowly increasing dysphagia for solid consistencies, originating from the hypertrophic and hypertonic cricopharyngeus muscle. As the size of the pouch increases, additional
symptoms appear, such as regurgitation of undigested food,
postprandial or nocturnal cough attacks, globus sensation,
and halitosis. Impaired swallowing may lead to signicant
weight loss over years. The most severe complication of a
ZD is aspiration pneumonia. The development of a squamous cell carcinoma within the diverticular sac is exceedingly rare (0.3–0.5%) [9]. A clinical suspicion of a ZD is
10
Fig. 10.1 Lateral view of a barium swallow showing the typical posi-
tion of a Zenker’s diverticulum (ZD)
S. J. Stoeckli (*) · G. F. Huber
Department of Otorhinolaryngology, Head and Neck Surgery,
Kantonsspital St. Gallen, St. Gallen, Switzerland
e-mail: Sandro.stoeckli@kssg.ch; huber@orl-zentrum.com
N. Sharma
Department of Otorhinolaryngology, Head and Neck Surgery,
University Hospital Birmingham, Birmingham, UK
e-mail: n.sharma@bham.ac.uk
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_10
usually conrmed by a barium swallow examination
(Fig.10.1).
Mosher [10] in 1917 and Dohlman and Mattsson [11] in
1960 were the rst to approach ZD endoscopically, although
the widespread dissemination of endoscopic techniques was
delayed as a result of severe complications that included lifethreatening mediastinitis, uncontrollable bleeding from large
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vessels, and pneumothorax. Modern techniques allowed van
Overbeek and Hoeksema [12], Knegt etal. [13], and Collard
etal. [14] to re-evaluate the endoscopic approach and safely
perform the cricopharyngeal myotomy by means of a CO2
laser or stapler technique. In recent studies, the endoscopic
approach with the stapling technique has proven to be minimally invasive, effective, safe, and fast, and has been associated with very low rates of complications and recurrence
[15–22]. In contrast to the open technique, the pharyngeal
pouch is not removed during the endoscopic surgery.
Transection of the common wall between the diverticulum
and the oesophagus, with myotomy of the cricopharyngeus
muscle, eliminates the obstruction and fully incorporates the
diverticular lumen into the oesophageal lumen.
10.2 Preoperative Checklist,
Considerations, andAnaesthesia
As in any other operation, the surgeon must ensure that adequate informed consent is taken in advance, covering the
indication, surgical procedure, alternative options available
to the patient, and potential complications. Associated
comorbidities and medications must be carefully assessed
and taken into consideration by both the surgeon and the
anaesthesiologist in this usually elderly population.
Successful endoscopic treatment of a ZD depends on a
correct diagnosis, good exposure of the diverticulum and the
diverticular bar, and a complete transection of the cricopharyngeus muscle. The size of the pouch should be anticipated
by the surgeon from the barium swallow, and the diagnosis
of ZD conrmed.
The exposure of the diverticular bar may be hampered by
a limited mouth opening, prominent front teeth, retrognathia,
or stiffness of the cervical spine. These factors should be
assessed preoperatively by the surgeon in order to get consent from the patient for conversion to an open procedure
should the endoscopic approach fail.
As in the open procedure, a complete myotomy of the
cricopharyngeus muscle is essential. This can be achieved by
the means of a stapler or a CO2 laser. The stapler is the preferred method, as the staples close the mucosal edges of the
incision, minimizing the risk for a descending infection. In
the study by Murer etal. [21], long-term success was signicantly dependent on the intraoperative ability to expose the
diverticular bar. In cases with narrow anatomy or a small
diverticulum (<3cm), this exposure can only be achieved
with a thin diverticuloscope allowing only the application of
the CO2 laser and not the stapler. The surgeon should always
be prepared during surgery to offer different diverticuloscopes (Fig.10.2) and both the stapler and the CO2 laser.
An alternative technique in very experienced hands is the
transoral exible endoscopic approach, as performed by gas-
S. J. Stoeckli et al.
Fig. 10.2 Large, spreadable Weerda diverticuloscope (Karl Storz,
Tuttlingen, Germany), compared with a thinner, non-spreadable
diverticuloscope
troenterologists. As reviewed by Ishaq et al. [23], exible
techniques for minimally invasive endoscopic treatment of
ZD with different devices have been successfully applied.
This approach has not achieved widespread dissemination,
but is an option in patients who are not candidates for general
anaesthesia. Another alternative, botulinum toxin injection
into the cricopharyngeus muscle in select cases, can produce
good results [24].
The rigid endoscopic approach with either the stapler or
the CO2 laser remains the treatment of choice in the vast
majority of patients. Because of its widespread use, its efcacy, and its safety prole, it has almost completely replaced
the transcervical open approach [25]. The rigid endoscopic
treatment of a ZD is performed under general anaesthesia
with the patient in supine position and an endotracheal tube
in place for ventilation and protection of the airway. Routine
prophylactic broad-spectrum antibiotics are given
perioperatively.
10.3 Indications
Surgery is the only curative treatment for ZD. The indication
for surgery is therefore any symptomatic patient t for general anaesthesia. The nal decision for surgery is the product
of a shared decision-making process among the patient, their
relatives, and the surgeon. The decision is based on the severity of symptoms and the burden of suffering.
10.4 Surgical Technique withTips
The surgical procedure is performed with the patient under
general anaesthesia and according to the technique described
by Collard etal. [14]. The diverticular sac is inspected with a
10 Endoscopic Approaches tothePharyngeal Pouch: Stapling Technique
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Fig. 10.3 Schematic lateral
view of the diverticuloscope
in position with the anterior
blade in the oesophagus and
the posterior blade in the
diverticulum
113
rigid endoscope. Remnants of food or medication are carefully removed. The diverticular bar is exposed by the means
of a double-lipped, spreadable Weerda diverticuloscope
(Karl Storz, Tuttlingen, Germany) with one lip in the diverticular pouch and the other in the oesophagus (Fig. 10.3).
This manoeuvre is performed slowly and gently to avoid
mucosal lacerations or perforation of the diverticulum. The
diverticular bar (the common wall formed by the posterior
wall of the pouch and the anterior wall of the oesophagus,
with the cricopharyngeus muscle in between) is exposed
(Fig.10.4). The bottom of the pouch is inspected with a rigid
endoscope to rule out an occult squamous cell carcinoma.
Depending on local safety regulations, the tip of a Multire
Endo GIA 30 stapler may be modied and shortened in order
to introduce it to the bottom of the pouch, as described by
Collard etal. [14] (Fig.10.5). The Endo GIA 30 stapler is
introduced with the modied tip in the diverticulum and the
staple cartridge blade in the oesophagus (Fig. 10.6). The
position of the stapler may be checked with 0° or 30° endoscopes. The stapler is closed and launched (Fig.10.7). In a
single step, the common wall is transected and the mucosal
edges are closed with a triple staggered row of staples
(3.5mm) on each side. The stapler is retracted, and the myotomy is inspected. A potential small residual septum at the
bottom can be easily divided with microscissors or the CO2
laser (Fig. 10.8). In very large ZD, the procedure can be
Fig. 10.4 Endoscopic view of the exposed diverticular bar through the
Weerda diverticuloscope
repeated with a newly charged stapler in order to fully transect the bar.
In case the large Weerda diverticuloscope cannot be introduced into the pouch because of narrow anatomy or a pouch
of less than 3cm, the diverticular bar can be exposed by the
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