Thyroglossal Duct Cyst in a Tertiary Hospital in Kaduna: A Retrospective Review

Abstract

Background:

Thyroglossal duct cyst (TGDC) is the most common congenital midline abnormality in the Head and Neck region, commonly presents as, a painless slowly progressive midline swelling, which moves with deglutition, and tongue protrusion. The aim of the study is to assess the clinical presentation and treatment of TGDC at a tertiary hospital in Kaduna, North-Western Nigeria.

Methodology:

It was a retrospective descriptive study; medical records of patients diagnosed with TGDC from January 2013 to September 2025 were reviewed. Data were collected from medical records, with variables including demographics, clinical presentation, investigations, and treatment outcomes. Categorical variables were presented in frequency tables and percentages, continuous variables were presented in mean and standard deviation, the relationship of variables was analysed using Chi-square and Fisher's exact test, level of significance was set at p value <0.05.

Results:

Forty-six patients (74.2%) had complete records and were reviewed. Their ages ranged from 1–54 years (mean 15.0 ± 14.5 years), with males accounting for 54.3%. Most patients (80.4%) presented within five years of symptom onset, predominantly with neck masses (97.8%), while 8.7% had discharging sinuses. Central (69.6%) and infrahyoid (63.0%) lesions were most common. Twelve patients had infected cysts, with three requiring incision and drainage. Half underwent Sistrunk's procedure, while the remainder defaulted. Five patients developed complications, but no recurrence occurred. FNAC was significantly associated with undergoing Sistrunk's procedure (p = 0.008), unlike age or gender.

Conclusion:

The Sistrunk procedure provided a good outcome with minimal complications among those treated. However, there is significant patient default that needs further investigation in order to gain insight into the reasons.

Introduction

Thyroglossal duct cysts (TGDC) are the most common cyst as well as the most common congenital midline abnormality in the Head and Neck region.[1,2,3,4] It usually presents within the first decade of life, with reported cases of presentation in young adults.[1,4,5,6] It may also occur much later in life, with reported cases of an increase in the chances of malignant transformation to a papillary thyroid carcinoma.[6,7,8,9,10,11,12]

The prevalence is reported to be about 7% in the population, with equal distribution amongst males and females.[1,2,5,13,14]

The thyroid gland begins to develop at the 3^rd week of gestation from a median downgrowth of a column of cells from the primitive pharynx.[5] This canalized column forms the thyroglossal duct tract, passing in front, behind, or through the developing hyoid bone and reaching its final position inferior to the thyroid cartilage at the 7^th week.[5,15,16] It usually disappears by the 10^th week of gestation, and failure of obliteration of this tract gives rise to TGDC.[2,3,5,6,15]

The cyst typically presents as a slowly progressive, painless, fluctuant midline mass, which characteristically moves with tongue protrusion and swallowing due to its attachment to the hyoid bone.[1,2,5] The mass on some occasions is associated with pain, fever, intermittent discharging sinus(es) or fistula, and dysphagia when infected. [1,2,5]

TGDC is found in the midline between the tongue and the mediastinum in about 70- 75% of cases, with a few documented cases of paramedian presentation, often to the left. [1,2,5,17] Most of the cysts are found in the infrahyoid region (25-65%), 20-25% at the suprahyoid level, 15-20% at the hyoid level, with rare findings in the thyroid gland as well as the larynx.[1,2,3,5,18]

Histopathologically, the cyst is found to be filled with fluid, lined with respiratory, squamous, or a combination of both epithelia.[2,19] Granulation tissues or giant cells are sometimes found due to the high level of susceptibility to inflammation by these cysts.[2]

The confirmation of TGDC relies primarily on ultrasonographic imaging, which is noninvasive, widely available, cost-effective, and well tolerated in pediatric age groups.[2,17] It is the most preferred initial imaging method.[1,15] It also aids in establishing the presence of a normal-functioning thyroid gland with or without the presence of an ectopic gland, found in 10% of cases, which may be the only functioning thyroid tissue in 75% of patients.[1,2,15]

Surgical removal of the cyst is the definitive management, with the Sistrunk procedure widely accepted as the gold standard, which entails excision of the cyst along with a cuff of tissue, including the central portion of the hyoid bone and a core of tongue muscle up to the foramen cecum.[1,2,5,6] The recurrence rate following this procedure has been reported to be as low as 3-5% with a few cases of complications.[3,15,16,20,21]

Preoperative infection and prior drainage are among the few reported factors responsible for the recurrence rate.[10] Notably, an infected cyst should be treated with antibiotics before surgery.[2]

The aim of the study was to review the clinical presentation and treatment outcome of TGDC from 2013 to 2025 of patients seen at a tertiary hospital in Kaduna.

Materials and Methods

It was a retrospective descriptive study at a tertiary referral Centre serving North-Western Nigeria with specialized otolaryngology, head and neck surgery services. The study reviewed the records of patients who were diagnosed with TGDC from 2013 to 2025.

All patients clinically diagnosed with a thyroglossal duct cyst from January 2013 to September 2025 were considered for selection. Patients with inadequate records were excluded from the study.

Medical records were systematically reviewed using the hospital's manual and electronic database. The records were then screened against inclusion/exclusion criteria.

The primary outcome was the presence of TGDC diagnosed by clinical criteria of the presence of an anterior neck cyst that moves with swallowing and protrusion of the tongue, while the secondary outcome was the treatment outcome; successful treatment outcome was complete resolution of the cyst post-surgery.

Variable classifications were demographics: age and gender. Presentation: duration of symptoms, presence of mass, location, centrality, presence of infection. Treatment: Sistrunk procedure, incision and drainage, and antibiotics. Treatment outcome: successful removal of TGDC, postoperative complications, and presence or absence of recurrence, duration of hospital stay, and duration of follow-up post-surgery.

Data were extracted from the database. All data collected were entered into Statistical Product and Service Solution (SPSS) version 27.0. Frequency and percentage tables were generated for categorical variables, and the mean and standard deviation were calculated for continuous variables. Relationships between variables were calculated using chi-square and Fisher's exact test; the level of significance was set at p value <0.05.

Ethical clearance was obtained from the Hospital Research and Ethics Committee, NECC/ADM/214/VI/279, issued on 15^th October 2025. Patient confidentiality was maintained throughout the study period.

Results

A total of 62 patients with TGDC were identified; however, only 46(74.2%) had complete data, hereby reviewed. The patients' age ranged from 1 to 54 years, with a mean age of 15.0±14.5 years. Males constituted 25 (54.3%), while females were 21 (45.7%).

Most patients (80.4%) presented within five years of symptom onset, predominantly as painless neck masses (97.8%). Additional symptoms included discharging sinus (8.7%), foreign body (FB) sensation (2.2%), dysphagia (2.2%), and odynophagia (4.3%). Twelve cases (26.1%) were infected at presentation; 3 required incision and drainage (I & D), and all responded well to antibiotics.

Table 1.

Characteristics of presenting symptoms

Variable	Frequency N=46 (%)
Primary presentation
Painless neck mass	45(97.8)
Sinus	1(2.2)
Additional symptoms
Discharging sinus	4(8.7)
Foreign body sensation	1(2.2)
Dysphagia	1(2.2)
Odynophagia	2(4.3)
Infection at presentation
Yes	12(26.1)
No	34(73.9)
Incision and drainage required	3(6.5%)

The central location (69.6%) was most common, followed by the right paramedian (17.4%). Infrahyoid localization (63.0%) predominated, followed by suprahyoid (15.2%), and a few at the level of the hyoid bone (10.9%).

Table 2.

Centrality and Location of Mass

Variable	Frequency N=46(%)
Centrality
Central	32 (69.6)
Left	5 (10.9)
Right	8 (17.4)
Location
Infrahyoid	29 (63.0)
Suprahyoid	7 (15.2)
Hyoid	5 (10.9)

Initial clinical diagnosis at first presentation was accurate in 93.5%. Misdiagnosis included thyroid cyst, lipoma, and multiple cysts. (see table 3)

Table 3.

Diagnosis at first presentation

Diagnosis	Frequency	Percentage N=46(%)
TGDC	43	93.5
Thyroid cyst	1	2.2
Lipoma	1	2.2
Multiple cyst	1	2.2
Total	46	100

Ultrasound scan (USS) was the most commonly requested investigation (87.0%), revealing cystic lesions. Out of the 40 requests recorded, the cyst was seen to range from 0.1 to 4.6cm (mean of 2.7cm). Most of the patients (95%) had a normally positioned thyroid gland, while one each had ectopic or absent (post thyroidectomy) glands. The cyst was distinct from the thyroid in 87.5% of cases. (see table 4)

Table 4.

State of the Thyroid Gland and Relation to Cyst on USS

Variable	Frequency N=40(%)
Thyroid gland
Normal	38 (95.0)
Ectopic	1 (2.5)
Absent	1 (2.5)
Relation of cyst & Thyroid Gland
Distinct	35 (87.5)
Attached	5 (12.5)

Fine needle aspiration cytology (FNAC) was performed in 26.1% of the patients, all showing Benign features.

Thyroid function test (TFT) was done in 13(28.3%) of patients, of whom 53.8% of these had normal function. While some have elevated thyroid-stimulating hormone (TSH), a single test shows elevated Thyroxine (T4) despite elevated TSH. (see Table 5).

Table 5.

Thyroid function test

Thyroid Function Test	Frequency	Percentage N=13 (%)
Normal	7	53.8
Elevated TSH	3	23.1
Elevated TSH and depressed T4	1	7.7
Elevated triiodothyronine (T3)	1	7.7
Elevated TSH and T4	1	7.7
Total	13	100

Only twenty-three (50.0%) of the patients underwent Sistrunk’s procedure; others defaulted from surgical care. Six cases had intraoperative cyst rupture. Drains were placed in 65.2% post op and a mean hospital stay of 4.4±0.9 days. The mean follow-up time was 11.9±14.0 weeks. Complications were seen in 5 patients (2 hematomas, 1 granuloma, 1 keloid, and 1 hypertrophic scar), but no recurrence was recorded.

Table 6.

Comparison between age group and rate of having Sistrunk’s procedure

Age group (years)	Yes	No	Total
0-10	10	14	24
11-20	6	5	11
21-30	3	1	4
31-40	0	2	2
Greater than 40	4	1	5
Total	23	23	100

There was no statistically significant difference between the age group and the rate of undergoing Sistrunk’s operation. (Fisher's exact test=4.995, p=0.288).

There was no statistical difference between gender and the rate of undergoing Sistrunk’s procedure (Chi-square = 0.088, p= 0.50).

Comparison between the rate of patients who had FNAC versus the rate of Sistrunk’s procedure revealed that 12 patients had Fine needle aspiration cytology (FNAC), of which 10(83.3%) eventually underwent Sistrunk’s procedure; this was found to be statistically significant (chi-square = 7.216, p=0.008).

Discussion

The predominance of cases in children and young adults with a mean age of 15.0 ± 14.5 years aligns with studies by Sholadoye et al in Northwest Nigeria and Ogunkeyede et al in Southwest Nigeria, as well as other African and international studies.[1,3,4,5,10,13,14] TGDC is classically a congenital midline neck anomaly that often presents in the first two decades of life.[13,15] The slight male preponderance (54.3%) observed mirrors the gender distribution reported in many studies.[1,4,5,6,13,14] Although some found a female preponderance, others reported no significant gender difference.[3,7,10,17]

In this study, most patients (80.4%) presented within five years of symptom onset, similar to findings of Sholadoye et al and Ogunkeyede et al. Afolabi et al., in their study, found late presentation to be the most common.[1,5,6] The predominant presentation as a painless midline neck mass (97.8%) agrees with the classical presentation pattern described worldwide, including works by Amos et al, Muhialdeen et al, Ndegbu et al, and other studies.[2,3,4,5,10,13,14,19,20] A smaller proportion presented with discharging sinus (8.7%) or infected (26.1%), consistent with reports that infection complicates TGDC.[3,5] The few cases requiring incision and drainage and antibiotics further emphasise the importance of infection control before definitive surgery.[5,6,14]

The central and infrahyoid locations are the most common (69.6% & 63.0%, respectively), corroborating previous reports that the infrahyoid region is the most frequent site of TGDC due to embryological descent of the thyroglossal tract.[1,4,5,7,13,14,19] Accurate clinical diagnosis in 93.5% of cases reflects good clinical awareness among clinicians, in keeping with findings from other studies.[1,4] Misdiagnosis as thyroid cysts or lipomas, however, underlines the need for routine imaging, as ultrasound (USS) is safe, accessible, and confirms the cystic nature and thyroid position.[4,5,6,7,10,13,17]

In this study, 95% of patients had a normally positioned thyroid gland, with only one ectopic thyroid, comparable to rates in other studies. The mean size of 2.7cm reported in this study is lower than that reported in studies by Ndegbu et al and Taha et al.[4,13]

Fine needle aspiration cytology (FNAC) and thyroid function testing (TFT) were underutilised. The FNAC revealed benign cytology in all tested patients, supporting the generally non-cancerous nature of TGDC.[13] Nonetheless, malignancy arising within TGDC, though rare, has been reported, predominantly papillary carcinoma by Muhialdeen et al Mochida et al and Thiansen et al. Hence, histopathological evaluation remains mandatory following excision.[3,11,12]

Only half of the patients underwent the Sistrunk procedure, reflecting a high default rate possibly due to financial or accessibility barriers. This low surgical uptake contrasts with 80-90% completion rates in some studies.[1,4,5,6,7,10,13] The Sistrunk operation remains the gold standard, with a reported recurrence rate < 5% when performed properly.[10,14,13,19] The absence of recurrence in our study reflects its effectiveness.

A drain was placed in 65.2% of the patients who underwent the Sistrunk operation. This high rate was comparable to the study of Brook's et al in America, where drains were utilised in 79.3% of their patients; in their study, the use of drains had a similar complication rate to that of patients without drain use.[22] The mean hospital stay of 4.4 ± 0.9 days was higher than the findings of Ndegbu et al which was 2 days. It should be noted that the study by Ndegbu et al was on adults exclusively, in contrast to this study, which included all age groups.[4]

Postoperative complications occurred in 5 patients (10.9%), mainly minor complications: hematoma, granuloma, keloid, and hypertrophic scar, slightly higher than in other studies.[1,3,14] No recurrence was documented in this study, as opposed to reports by Muhialdeen et al further supporting favorable outcomes with the Sistrunk technique when correctly executed; however, other possible explanations for the absence of recurrence may be short follow-up time and possible loss to follow-up.[3]

The study was a retrospective study with 25.8% missing data despite all efforts to retrieve patient information. The missing data is an inherent limitation of a retrospective study, generally similar to findings. Review by Tolani et al reported that up to 74% of published studies have reported missing data with different ways of handling it.[23] The effective sample in this study is 46 there by any generalization of the findings will have to consider the relatively small sample size reviewed in this study.

In this study, there was a high default rate of 50%. This is concerning and requires a thorough investigation; the possibility of this default may be financial constraints, poor health-seeking behavior, societal myths, and fear of surgeries. Jasuyajolu et al reported in a review that only about 36% of households in Nigeria can afford to pay for essential surgical care without devastating consequences to their finances. This was further compounded by the fact that less than 5% of Nigerians are covered under the National Health Insurance Scheme (NHIS).[24] Assessment of the rate of undergoing surgery revealed no difference between the age group and the rate of undergoing Sistrunk's operation; there was also no difference between gender and the rate of undergoing Sistrunk's procedure. However, patient that underwent FNAC had a higher rate of having the surgery. This difference may be due to the health-seeking nature of the individuals; however, the exact reasons for the high default rate need further investigation.

Overall, the findings reaffirm TGDC as a benign, correctable congenital anomaly with a good prognosis. The major challenges remain late presentation, infection, and loss to follow-up, which are common barriers in resource-limited environments. Strengthening patient education, early referral systems, and subsidized surgical access could substantially improve outcomes.

Conclusion

Sistrunk procedure provided a good outcome with minimal complications among those treated. However, there is significant patient default that needs further investigation in order to gain insight into the reasons.

Financial Support

There was no external financial support for this study.

Conflict of interest

There was no conflict of interest to be declared for this study