CYST DUCTUARY THYROGLOSSAL
I Made Nudi Arthana
Cyst duct thyroglossal is mass neck congenital Which most often found in children but can also be found in adults. 1,2 Disorders This happen by Because failure obliteration duct thyroglossal during embryonic period. 3,4 Malignant transformation is very rare, which is around 1% and is generally found in old age. 1
LITERATUR REVIEW
Anatomy
Neck in part on restricted by edge inferior mandible, end mastoid and the external occipital prominence. The lateral part of the neck is bounded by the sternocleidomastoideus muscle and the edge of the trapezius muscle. The medial structures consist of the hyoid bone, cartilage cricoid And gland thyroid. Muscles neck, viscera cervical (larynx, trachea, pharynx, esophagus) And structure neurovascular in in neck shrouded by connective tissue called fascia.
This fascia consists of superficial, medial and deep layers. The superficial or superior cervical fascia covers the platysma and subcutaneous fat, enveloping the entire neck including the sternocleidomastoid and trapezius muscles. The middle or pretracheal cervical fascia extends between the hyoid bone, the posterior surface of the manubrium sterni and the clavicle, laterally to the omohyoid and scapula muscles. This fascia envelops the infrahyoid muscles and forms the anterior border of the organ in neck. Fascia cervical deep or prevertebral formed from spinous processes of the vertebrae and form a rigid tube around the deep neck muscles, which is attached to the posterior part of the superficial cervical fascia that covers the trapezius muscle. This prevertebral layer is part from the fascial system that stretches continuously from the base of the skull to the lowest limit of the spinal column. 6
Picture 1. Anatomy neck. 7
Vascularization of the neck bottom supplied by branch thyrocervical trunk originating from the subclavian artery. Branches of the external carotid artery supply the neck and face. Venous drainage from the head-neck area into the superficial cutaneous veins and directly into the subclavian vein. 6
There are approximately 1000 lymph nodes in the human body and 300 of them are in the head-neck area. These glands are located between the medial and deep cervical fascia layers. The lymph flow in the head-neck area goes to to the lymph nodes in the area where the jugular vein and facial vein branch off. 6
The outer neck receives sensory innervation from the cervical plexus (C1-C4). The motor component of the cervical plexus is incorporated into the hypoglossal nerve. The hypoglossal nerve exits the skull through the hypoglossal canal and intersects with branches of the external carotid artery. The glossopharyngeal, vagus, and accessory nerves enter the neck through the jugular foramen. The cervical portion of the sympathetic trunk lies behind the neurovascular sheath between the deep cervical fascial layers of the prevertebral muscles. 6
Embryology
Towards the end of the third week of embryonic life, endoderm thickening appears on the tuberculum impar at the base of the primitive pharynx. This thickening will undergo evagination to form the thyroglossal duct which will descend into the neck area between the first and second branchial arches so that it will be located close to the primitive aorta.
Picture 2. Embryology gland thyroid on sunday third pregnancy. 6
Portions of the fourth and fifth branchial sacs fuse together at the time of descent and will become components of the lateral part of the thyroid gland. to be continued to the side front or penetrate bone hyoid on the line middle and extends into the thyroglossal duct. This duct will solidify and is called the thyroglossal tract. When the thyroglossal tract reaches the front of the trachea, it will divide to form two thyroid lobes connected by the thyroid isthmus. In the fifth to eighth week of pregnancy the thyroglossal duct undergoes obliteration, leaving part proximal that is foramen cecum on base tongue and the distal part is the thyroid pyramidal lobe. 6,8
Epidemiology
Thyroglossal duct cysts are most commonly found in children. 2 Found around 7% from population And only A little Which cause symptoms. 3 Thyroglossal duct cysts are primarily found in children but can also be found in adults. 2 There is no difference in gender predilection between males and females. 6 Swaid AI and Al-Ammar 2 reported that the average age of thyroglossal duct cyst patients appears at 13 years of age. As many as 20% of cases appear above the age of 16 years. 2
Etiopathogenesis
There are two theories regarding the etiopathogenesis of thyroglossal duct cysts. The classical theory assumes that the formation of thyroglossal duct cysts is due to failure. obliteration from duct thyroglossus. Theory Otto state that Thyroid primordial tissue forms near the heart which is then followed by the formation of a connecting channel between the thyroid gland and the epithelial tissue at the base. mouth or duct thyroglossus. Matter This happen consequence increase the rise the head section followed by the thyroid gland. Based on this theory, the thyroglossal duct contains two type epithelium that is epithelium base mouth in superficial part or pars epithelialis and thyroid epithelium in the inferior or pars thyroidea. The border area that is different in differentiation between the two epithelia This will experienced rupture on Sunday 6th. All malformation thyroid can explained based on
This theory is that if the thyroglossal duct is not experienced a rupture at the border area level differentiation, but happen on level lower or pars thyroiditis, then the thyroid tissue will remain in the cranial end of the thyroglossal duct at the time increase the rise part head. Network thyroid ectopic or goiter lingual can arise as a result of this mechanism (figure 3A). 6
Picture 3A And 3B. Malformation from the glands thyroid. 6
If the thyroglossal duct ruptures at a higher level or in the pars epithelialis, non-thyroid epithelial tissue will settle in the area between the base of the tongue and the thyroid gland so that it can be a location for the formation of an epithelial cyst or thyroglossal duct cyst. This epithelial cyst can also contain thyroid tissue (figure 3B). 6
Diagnosis
The diagnosis of thyroglossal duct cyst is based on anamnesis, physical examination and supporting examinations. Preoperative evaluation in Suspected sufferer cyst duct thyroglossal including anamnesis And inspection physique complete, ultrasonography (USG) examination, Fine Needle Aspiration Cytology (FNAC) examination and thyroid function tests. The definitive diagnosis is made by histopathological examination. 1,2,4,8
Complaint sufferer is existence lump on line middle neck, generally in lower bone hyoid. Lump grow bigger slowly However No accompanied by flavor pain. Lump This follow move to on moment swallow And to stick out tongue. When accompanied by infection, lump will colored reddish accompanied by flavor painful And increase grow rapidly. Sometimes sufferers complain of a lump in the neck and difficulty swallowing. 1,2,4-6,8
On physical examination, a painless cystic mass will be found in the midline of the neck below the hyoid bone. Cysts are most often found below the hyoid bone (60.9%), but can also be located intralingually (2.1%), above the hyoid bone (24.1%), or suprasternally (12.9%). If infected, the cyst will colored reddish accompanied by painful press. Cyst follow move to on on when swallowing and protruding the tongue. This is a pathognomonic sign because there is no other midline lump that moves upward when the tongue is protruded. 6
Supporting examination in the form of preoperative radiology in patients with suspected thyroglossal duct cysts is not only to help establish the diagnosis but also to identify normal thyroid glands. 9,10 Each radiological examination technique provides advantages and disadvantages in relation to this. Ultrasonography (USG) examination is accurate enough to provide an image of cystic lesions with a high level of sensitivity. 75%. The advantages that is exposure radiation Which light on patients and also the costs are relatively cheap compared to other radiological examinations such as computer tomography (CT scan ) and Magnetic Resonance Imaging (MRI). 1,2,4-6
Thyroid function tests are important to determine normal thyroid gland function. If abnormalities in thyroid function are found, a thyroid scan needs to be done to rule out the possibility of an ectopic thyroid disorder. 2.10-12
Fine Needle Aspiration Cytology (FNAC) examination to determine the general nature of the disease such as inflammation, benign tumors or malignant tumors. 13,14
On histopathological examination, the cyst appears to be lined by pseudostratified ciliated epithelium or squamous epithelium. Mucous glands and thyroid follicles are usually seen in the adjacent connective tissue. Inflammation due to secondary infection is often found, especially in cases accompanied by sinus in the cyst. Then it will There is a partial loss of the epithelial layer and infiltration of inflammatory cells in the connective tissue. 15
Diagnosis appeal
Differential diagnosis of thyroglossal duct cyst is dermoid cyst, branchial cyst, lymphadenopathy, lipoma and cyst in the thyroid. 1,4,5,9
Management
The management of thyroglossal duct cyst is by surgical excision. all over cyst And channel duct thyroglossal until foramen cecum on base of tongue. The close relationship between the tract and the hyoid bone requires the removal of the middle part of the hyoid to ensure the removal of the tract or commonly called the Sistrunk technique. 1,2,5,16
Technique Sistrunk can lower relapse compared to with simple excision technique. The recurrence rate can reach 85% when simple excision is performed. 5
Picture 4. Decrease ductal cyst thyroglossus. 16
The Sistrunk technique is performed in a supine position, head and neck extension with general anesthesia. A horizontal incision is made on the skin above the cyst, the incision is deepened until the cyst is found, then towards the caudal to identify the presence of a tract to the pyramidal lobe. If found, the tract is excised in its entirety with the cyst. 18,16
Picture 5. Incision skin in a way horizontal on cyst. 16
Dissection is continued cranially towards the hyoid bone and the surrounding connective tissue. The central part of the hyoid bone is cut and continued by performing excision tract from muscle base tongue until foramen cecum. After confirm that adequate proximal dissection has been performed, namely by press part base tongue with finger through mouth, Then ligation and cutting of the tract was performed. 8,16
Picture 6. Cutting bone hyoid. 16
Prognosis
Malignant transformation is very rare, approximately 1%, and is generally found on age continue. 1 Recurrence cyst duct thyroglossal after excision using the Sistrunk technique was reported to be around 0% to 8%. 8,16
REFERENCE
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