Sir,
In one of the rarest presentations, a thyroglossal duct cyst (TDC) may have an aberrant intralaryngeal extension causing dysphonia. A 39-year-old male presented with a gradually enlarging left-sided anterior neck swelling with a change of voice for three months. During the examination, a 3 × 2.5 cm firm neck mass that moved with swallowing and tongue protrusion was palpable in the left anterior neck. An ultrasound of the neck revealed a well-defined, thick-walled infrahyoid cystic mass with intralesional diffusely homogenously hypoechoic on the left side of the anterior neck. Indirect laryngoscopy revealed a 2 × 2 cm cyst at the level of aryepiglottic folds, ipsilaterally positioned in the left pyriform fossa, which was restricting airflow and partially obstructing the glottis. As both cysts were on the same side, a contrast-enhanced computed tomography (CT) of the neck was planned to rule out any communication between them and presence of any other laryngeal cysts such as saccular cysts and laryngoceles. In it, a left paramedian peripherally enhancing thick-walled hypodense cystic mass was seen in the visceral space showing an intralaryngeal component with extension into the pre-epiglottic space and glottis causing partial obstruction of the laryngeal airway and compression of false vocal cords [Fig. 1]. No erosion of thyroid cartilage or any ectopic thyroid tissue was seen. Thus, based on the CT scan and fiber optic laryngoscopy findings, the diagnosis was revised to TDC with Endolaryngeal extension. Considering the difficulty in intubation during general anaesthesia with chances of rupture of the Aryepiglottic fold component during intubation, a decision to operate via an Endolaryngeal approach was taken, followed by Sistrunk's operation for TGC. The Cyst was separated from the thyroid cartilage by careful dissection. It was found to extend into the larynx on both sides from the upper border of the thyroid cartilage. There was no thyroid cartilage erosion. A One cm wide tract was also identified and traced superiorly going deep to the hyoid bone. The Cyst was carefully dissected away by sharp dissection from the larynx without causing any laryngeal mucosal disruption or rupture of the Cyst itself. The medial portion of hyoid bone is removed by meticulous excision of persistent duct up to foramen caecum to reduce chances of recurrence [Fig. 2]. The patient had an uneventful recovery. A Laryngoscopic examination on the 3rd postoperative day showed normal laryngeal anatomy with no signs of laryngeal trauma or inflammation. Bilaterally vocal cords were mobile. The patient was discharged on the 7th postoperative day in a comfortable state. A review after a month revealed a complete resolution of dysphonia and hoarseness of voice.
Fig. 1.
Axial sections of contrast-enhanced computerized tomography of the neck show an infrahyoid peripherally enhancing hypodense cystic mass in the pre-epiglottic space on the left side image, extending to the glottis and abutting the thyroid cartilage on the right-side image with no invasion
Fig. 2.
The perioperative image of the Cyst during surgery is on the left image, and the resected image of the Cyst is on the right side
TDC can be found near the hyoid bone and anywhere along the tract that runs from the base of the tongue to the thyroid gland. Only a few cases of TDC with intralaryngeal extension have been reported in the literature [1]. In such cases, patients may present with unusual complaints such as difficulty speaking, hoarseness of voice, and dysphagia which can be confused with laryngeal conditions [2]. The Sistrunk procedure is used for treatment with a recurrence rate of less than 5% [3]. A thorough history and physical examination, followed by preoperative imaging, are essential in making an accurate preoperative diagnosis to plan the best surgical strategy and avoid perioperative complications.
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All authors do not have any actual or potential conflict of interest.
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References
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