Complications and management of thyroglossal duct cyst following Sistrunk procedure in children: a single-center retrospective study in Shanghai, China

Abstract

Background

Thyroglossal duct cysts (TGDCs) are the most common congenital neck masses in children, and the Sistrunk procedure is the established standard surgical treatment; however, large pediatric-specific studies that systematically characterize the full spectrum of postoperative complications using standardized grading systems remain scarce. This study aimed to investigate the incidence, spectrum, and risk factors of complications following the Sistrunk procedure for TGDC excision in a pediatric population, and to summarize effective perioperative management strategies.

Methods

A retrospective analysis was conducted on all pediatric patients with TGDC who underwent Sistrunk surgery at Shanghai Children’s Hospital (Shanghai, China), a tertiary academic pediatric referral center affiliated with Shanghai Jiao Tong University School of Medicine, between January 2019 and December 2023. Surgical complications were graded according to the Clavien-Dindo classification. Risk factors for postoperative recurrence were analyzed using Chi-squared or Fisher’s exact tests as appropriate. Variables included age, sex, prior recurrence status, preoperative infection history, and perioperative antibiotic use. Statistical analyses were performed using SPSS version 22.0, with significance set at P<0.05.

Results

A total of 170 children (89 males, 81 females; mean age 4.72 years; mean follow-up 3.1 years) were included. Twenty-seven patients (15.9%) had undergone prior surgery at other institutions. Overall, 56 patients (32.9%) experienced at least one postoperative complication. By Clavien-Dindo grade, the distribution was as follows: Grade I, 19 patients (11.2%); Grade II, 10 patients (5.9%); Grade III, 11 patients (6.5%). Specific complications included fever (8.8%), salivary amylase-rich seroma (7.1%), wound infection (4.7%), TGDC recurrence (4.7%), pharyngeal leakage (1.2%), and postoperative bleeding requiring reoperation (1.2%). Notably, 12 patients (7.1%) developed seroma with salivary amylase-rich fluid, a previously under-recognized complication. Preoperative TGDC infection was the only significant predictor of recurrence on univariate analysis (13.7% vs. 0.8%, P<0.001). Age, sex, prior recurrence, and perioperative antibiotic use showed no significant association with recurrence.

Conclusions

The Sistrunk procedure is the standard surgical approach for pediatric TGDC; approximately one-third of patients experienced complications, most of which were minor. Preoperative TGDC infection is a strong predictor of recurrence. Recognition of salivary amylase-rich seroma as a distinct complication and implementation of targeted perioperative care—including dietary modification, wound compression, and vigilant monitoring for airway compromise—are essential for optimizing outcomes.

Highlight box.

Key findings

• In this single-center cohort of 170 children undergoing the Sistrunk procedure for thyroglossal duct cyst (TGDC), 56 patients (32.9%) developed at least one postoperative complication, the majority of which were minor (Clavien-Dindo grade I–II) and resolved with conservative management.

• The recurrence rate was 4.7%, and preoperative TGDC infection was the only significant predictor of recurrence (13.7% vs. 0.8%, P<0.001).

• Salivary amylase-rich seroma, occurring in 7.1% of patients, was characterized as a distinct and previously under-recognized complication.

What is known and what is new?

• The Sistrunk procedure is the gold-standard surgical treatment for pediatric TGDC; however, previously reported complication rates vary widely and derive largely from mixed adult-pediatric populations.

• This study provides one of the largest pediatric-specific complication profiles graded by the Clavien-Dindo classification and delineates salivary amylase-rich seroma as a distinct entity arising from disruption of minor salivary glands at the tongue base.

What is the implication, and what should change now?

• Preoperative TGDC infection should prompt heightened perioperative vigilance, and postoperative monitoring should focus on wound infection and recurrence.

• Recognition of salivary amylase-rich seroma enables targeted management—dietary modification and wound compression—and may reduce unnecessary interventions.

Introduction

Thyroglossal duct cysts (TGDCs) are the most common congenital neck masses in children, accounting for approximately 70% of congenital anterior neck lesions (1). They arise from incomplete involution of the thyroglossal duct, an embryonic structure that guides thyroid descent from the foramen cecum at the tongue base to its final pretracheal position. TGDCs typically present as painless, mobile midline neck masses that elevate with swallowing or tongue protrusion (2).

The Sistrunk procedure, first described in 1920, remains the gold-standard surgical treatment. It involves en bloc resection of the cyst, the central portion of the hyoid bone, and a core of tissue extending from the hyoid bone to the foramen cecum. This approach has reduced recurrence rates from approximately 50% with simple cyst excision to less than 5% in most series (3). However, despite the procedure’s efficacy, complications do occur and can range from minor wound issues to life-threatening events such as airway compromise from neck hematoma.

Postoperative complications following Sistrunk surgery have been systematically classified only in a limited number of studies, most notably using the Clavien-Dindo classification (4). Gioacchini et al. (5) conducted a systematic review reporting a 6.2% minor complication rate and a 5.3% recurrence rate. Recent studies have further refined our understanding of risk factors for recurrence, with preoperative infection and cutaneous fistula formation emerging as important predictors (3,6,7).

Notably, certain complications—such as salivary amylase-rich seroma arising from disrupted minor salivary glands at the tongue base during the suprahyoid dissection—have received minimal attention in the literature. Similarly, severe complications including pharyngeal leakage and postoperative hemorrhage requiring emergent reoperation remain under-reported. Large pediatric-specific series with rigorous complication grading are scarce (8-10).

The objectives of this study were therefore threefold: (I) to comprehensively characterize the incidence and spectrum of complications following the Sistrunk procedure in a pediatric cohort using the Clavien-Dindo classification; (II) to identify risk factors for TGDC recurrence; and (III) to describe effective perioperative management strategies based on our institutional experience. The primary novelty of this study lies in its systematic Clavien-Dindo-based complication profiling, with the recurrence analysis presented as a secondary outcome providing context and internal validation for our cohort. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0675/rc).

Methods

Study design and patient population

This retrospective cohort study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Children’s Hospital of Shanghai Jiao Tong University School of Medicine (approval No. 2026R041-F01). The requirement for individual informed consent was waived due to the retrospective nature of the study.

We reviewed the medical records of all consecutive pediatric patients who underwent Sistrunk surgery for TGDC at Shanghai Children’s Hospital between January 2019 and December 2023. Inclusion criteria were: (I) age ≤18 years; (II) confirmed diagnosis of TGDC based on clinical examination, imaging [ultrasound and/or computed tomography (CT)], and histopathological confirmation; and (III) Sistrunk procedure performed at our institution. Exclusion criteria were: (I) incomplete medical records; and (II) follow-up of less than 6 months, applied to the recurrence analysis only. All patients with complete medical records were included in the analysis of immediate postoperative complications.

Surgical technique

All procedures were performed under general anesthesia by experienced pediatric otolaryngologists. The standardized Sistrunk procedure included: (I) a transverse cervical incision over the cyst; (II) dissection and excision of the cyst together with the thyroglossal duct tract; (III) en bloc resection of the central portion of the hyoid bone; and (IV) cone-shaped excision of suprahyoid soft tissue extending toward the foramen cecum. When the cyst was intimately adherent to surrounding structures, meticulous sharp dissection was performed to ensure complete removal. The wound was closed in layers, and a drain was placed at the surgeon’s discretion. Perioperative antibiotic prophylaxis with intravenous cefuroxime (100 mg/kg/day, divided into two doses every 12 hours) was administered in 129 of 170 patients (75.9%) at the discretion of the attending surgeon.

Complication classification

Postoperative complications were categorized according to the Clavien-Dindo Classification of Surgical Complications (4), which grades complications from I (any deviation from the normal postoperative course not requiring pharmacological or surgical intervention) to V (death). When a patient experienced multiple complications, the highest grade was assigned for the per-grade analysis. Complications were identified through chart review of operative notes, nursing records, outpatient follow-up visits, and telephone follow-up.

Data collection and outcome measures

The following variables were collected: demographic data (age, sex), clinical presentation, preoperative infection history (defined as at least one episode of TGDC-related inflammation, abscess, or cutaneous fistula), prior surgical history, intraoperative findings, operative time, perioperative antibiotic use, postoperative complications (type, timing, and management), length of hospital stay, and recurrence (defined as clinical or radiological evidence of a new TGDC following complete surgical excision). Follow-up data were obtained through outpatient clinic visits and telephone interviews.

Seroma fluid was analyzed for salivary amylase content when the clinical picture suggested salivary origin (persistent mucous discharge from the wound). Amylase levels were measured using an automated clinical chemistry analyzer, with values >100 U/L considered positive for salivary origin.

Statistical analysis

Data were analyzed using IBM SPSS Statistics version 22.0 (IBM Corp., Armonk, NY). Continuous variables are expressed as mean ± standard deviation or median (interquartile range), as appropriate. Categorical variables are presented as frequencies and percentages. Univariate analysis of risk factors for TGDC recurrence was performed using the Chi-squared (χ²) test for categorical variables. When expected cell frequencies were less than 5, Fisher’s exact test was applied. Specifically, Fisher’s exact test was used for analysis of age (expected frequency: 2.6), sex (expected frequency: 3.8), prior recurrence (expected frequency: 1.3), and perioperative antibiotic use (expected frequency: 1.9). Variables analyzed included age (≤5 vs. >5 years), sex (male vs. female), prior recurrence status (yes vs. no), history of preoperative TGDC infection (yes vs. no), and perioperative antibiotic use (yes vs. no). A two-tailed P value <0.05 was considered statistically significant. Given the limited number of recurrence events (n=8), multivariable logistic regression was not performed.

Results

Patient demographics

A total of 170 children were included, comprising 89 boys (52.4%) and 81 girls (47.6%). The mean age at surgery was 4.72 years (range, 6 months to 14 years), and 32.9% (56/170) were older than 5 years. The mean follow-up was 3.1 years (range, 6 months to 5.3 years). All patients underwent the Sistrunk procedure as described for their initial surgery. The mean length of hospital stay was 5.6±3.2 days (median, 5 days). The mean operative time was 42.5±13 minutes.

Notably, 27 children (15.9%) had been referred to our institution with postoperative TGDC recurrence after surgery at other hospitals. Of these, 6 had previously undergone a primary Sistrunk procedure, 17 had undergone simple cyst excision without hyoid bone resection, and 4 had incomplete operative records. All 27 patients received a formal Sistrunk procedure at our center.

Complication rates and classification

Postoperative complications occurred in 56 of 170 patients (32.9%) overall (Table 1). Fever was defined as a body temperature of ≥38.0 ℃ occurring more than 24 hours postoperatively that required pharmacological treatment; transient low-grade fever during the immediate postoperative period was not classified as a complication. Classified by the highest Clavien-Dindo grade per patient, the distribution was:

Table 1. Postoperative complications classified by the Clavien-Dindo system.

Grade	Definition	Complications in this series	N (%)
I	Any deviation from normal postoperative course; no pharmacological or surgical intervention needed	Neck swelling [12]; fever [15]	19 (11.2)
II	Requiring pharmacological treatment, blood transfusion, or parenteral nutrition	Salivary seroma [4]; wound infection [8]; pharyngeal leakage [2]	10 (5.9)
III	Requiring surgical, endoscopic, or radiological intervention	TGDC recurrence [8]; postop bleeding [2]; thyroid cartilage injury [1]	11 (6.5)
IV	Life-threatening complication; ICU management required	None	0 (0.0)
V	Death	None	0 (0.0)

Patients are classified by the highest Clavien-Dindo grade. A total of 56 patients (32.9%) experienced at least one complication; per-grade totals (19+10+11=40) are fewer than 56 because patients with complications spanning more than one grade are counted only under their highest grade. Numbers in parentheses indicate specific complication event counts, which may exceed the number of unique patients per grade due to co-occurrence. ICU, intensive care unit; TGDC, thyroglossal duct cyst.

Grade I (19 patients, 11.2%): included postoperative neck swelling in 12 patients (7.1%) and fever in 15 patients (8.8%). Eight patients experienced both swelling and fever. All resolved spontaneously or with antipyretics alone. Eight of the 12 patients who developed postoperative seroma also fell into this grade, as their seroma resolved with wound care alone without pharmacological intervention.

Grade II (10 patients, 5.9%): included salivary amylase-rich seroma requiring pharmacological treatment in 4 patients (2.4%), wound infection requiring intravenous antibiotics in 8 patients (4.7%), and pharyngeal leakage managed conservatively in 2 patients (1.2%). Four patients had more than one Grade II complication. Patients with seroma presented with local neck swelling and thick, sticky mucus expressible from the wound drain. Laboratory analysis confirmed high salivary amylase concentrations in the aspirated fluid. Management included daily wound dressings, local compression, dietary modification (non-acidic, semi-liquid diet), and subcutaneous atropine (0.01 mg/kg per dose) administered before each of the three daily meals for 5 days. Resolution occurred within 1 week in all cases.

Grade III (11 patients, 6.5%): included TGDC recurrence requiring reoperation in 8 patients (4.7%), postoperative bleeding requiring emergent surgical hemostasis in 2 patients (1.2%), and inadvertent thyroid cartilage resection requiring reconstructive surgery in 1 patient (0.6%). The patient with inadvertent thyroid cartilage resection had normal vocal cord mobility confirmed by postoperative laryngoscopy, with no evidence of vocal cord paresis or paralysis.

Age-stratified analysis showed no statistically significant difference in overall complication rates between patients aged ≤5 years and those aged >5 years (Fisher’s exact test, P>0.05). No Grade IV (life-threatening) or Grade V (death) complications occurred. The age-stratified recurrence rates are presented in the “Recurrence and management” section and Table 2.

Table 2. Univariate analysis of preoperative risk factors for TGDC recurrence.

Risk factor	N=170 (%)	Recurrence, n (%)	Chi-squared/Fisher	P value
Age			Fisher	0.71
≤5 years	114 (67.1)	6 (5.3)
>5 years	56 (32.9)	2 (3.6)
Sex			Fisher	0.72
Male	89 (52.4)	5 (5.6)
Female	81 (47.6)	3 (3.7)
Prior recurrence			Fisher	0.36
Yes	27 (15.9)	2 (7.4)
No	143 (84.1)	6 (4.2)
Preoperative infection			Chi-squared =13.22	<0.001*
Yes	51 (30.0)	7 (13.7)
No	119 (70.0)	1 (0.8)
Perioperative antibiotics			Fisher	0.40
Yes	129 (75.9)	5 (3.9)
No	41 (24.1)	3 (7.3)

Fisher: Fisher’s exact test (two-tailed) applied when expected cell frequency <5. Among the 56 patients who experienced postoperative complications, a surgical drain had been placed intraoperatively at the surgeon’s discretion in the majority of cases. Therapeutic antibiotics beyond the standard prophylactic regimen were administered primarily to patients with wound infection, suspected pharyngeal leakage, or persistent postoperative fever. Most patients with Grade I–II complications were managed conservatively without additional surgical drainage or escalation of antibiotic therapy, whereas all patients with Grade III complications who required reoperation had drains placed during the repeat procedure. *, Chi-squared =13.22, P<0.001 (Pearson Chi-squared test). TGDC, thyroglossal duct cyst.

Severe complications

Two patients (1.2%) developed acute postoperative hemorrhage in the recovery ward, presenting with progressive neck swelling, subcutaneous ecchymosis, tachypnea, and signs of airway compromise within hours of surgery. Both underwent emergent re-exploration with successful hemostasis and no long-term sequelae.

Two additional patients (1.2%) developed pharyngeal leakage following inadvertent perforation of the thyrohyoid membrane during hyoid bone resection. The injury occurred due to anatomic distortion where the hyoid bone was fused with the thyroid cartilage, leading to misidentification of the correct dissection plane. Both patients presented with persistent clear-then-turbid wound drainage and were managed with immediate cessation of oral intake, nasogastric tube placement, intravenous broad-spectrum antibiotics, daily wound care, and local compression. The leaks resolved within two weeks without further surgical intervention.

Recurrence and management

Eight patients (4.7%) developed TGDC recurrence after surgery at our institution and required reoperation. Age-stratified analysis showed recurrence rates of 5.3% (6/114) in children aged ≤5 years and 3.6% (2/56) in those aged >5 years (P=0.71, Fisher’s exact test). For the first recurrence, one patient received scar revision combined with a Sistrunk procedure and developed a second recurrence six months later and was ultimately treated successfully with cyst excision and anterior cervical strap muscle flap transposition. The remaining seven patients underwent repeat Sistrunk surgery. Time to recurrence ranged from 4 months to 2 years.

Among the 27 patients referred from other institutions, one who received non-Sistrunk surgery (scar revision and cyst excision) experienced recurrence and subsequently underwent a third operation with cyst excision and muscle flap transposition, with no further recurrence.

Risk factor analysis

Univariate analysis of preoperative risk factors identified preoperative TGDC infection as the sole significant predictor of recurrence (Table 2). Among 51 patients with a preoperative infection history, 7 (13.7%) developed recurrence, compared with 1 of 119 (0.8%) without infection (χ²=13.22, P<0.001). No significant association was found between recurrence and age (≤5 years: 5.3% vs. >5 years: 3.6%, Fisher’s exact P=0.71), sex (male: 5.6% vs. female: 3.7%, Fisher’s exact P=0.72), prior recurrence status (prior: 7.4% vs. primary: 4.2%, Fisher’s exact P=0.36), or perioperative antibiotic use (with: 3.9% vs. without: 7.3%, Fisher’s exact P=0.40).

Postoperative events and recurrence

As a secondary analysis, we examined the association between postoperative wound infection and subsequent recurrence. Among 8 patients who developed postoperative wound infection, 4 (50.0%) experienced recurrence, compared with 4 of 162 (2.5%) without wound infection (Fisher’s exact test, P<0.001). However, this association should be interpreted with caution owing to the bidirectional temporal relationship: wound infection may predispose to recurrence by compromising local tissue healing, or incomplete excision may manifest initially as a wound infection before frank recurrence becomes apparent.

Discussion

This single-center retrospective study of 170 pediatric patients represents one of the largest pediatric-specific analyses of complications following the Sistrunk procedure using the standardized Clavien-Dindo classification. Our findings demonstrate that although 32.9% of patients experienced some form of postoperative complication, the majority were minor (Grade I or II) and managed conservatively. Importantly, we identify salivary amylase-rich seroma as a distinct and previously under-recognized complication, and provide detailed accounts of severe complications including postoperative hemorrhage and pharyngeal leakage.

Complication spectrum and comparison with literature

The overall complication rate of 32.9% in our series is higher than the 6.2% minor complication rate reported by Gioacchini et al. (5), though their analysis included mixed adult-pediatric populations and may have underestimated true rates by relying solely on published complication data. Our rigorous classification using the full Clavien-Dindo system, combined with detailed review of nursing and outpatient records, likely contributed to more complete capture. In particular, complications such as salivary seroma (7.1%) and postoperative fever (8.8%), which are often omitted from surgical series (11), were systematically documented in our study.

Our wound infection rate of 4.7% is comparable to the 3.7% reported by Gioacchini et al. (5) and the 5.5% reported by Lekkerkerker et al. (8) in a series of 91 pediatric patients. The recurrence rate of 4.7% aligns with the 5.3% in Gioacchini et al. (5) and the 2.3–5% range in recent large series (3,12), confirming the long-term efficacy of the Sistrunk procedure. The modified Sistrunk procedure—which incorporates a more extensive suprahyoid dissection—has been proposed as a surgical approach that may further reduce complications and recurrences (3,12,13). Although our study did not directly compare the original and modified techniques, our institutional practice incorporates key elements of the modified approach, including cone-shaped suprahyoid core excision extending toward the foramen cecum, and the low rates of severe complications observed in this series support its continued use.

Salivary amylase-rich seroma: a distinct entity

To our knowledge, this study provides a detailed characterization of salivary amylase-rich seroma as a distinct complication following the Sistrunk procedure. This complication arises from disruption of minor salivary glands at the tongue base during the suprahyoid core-tissue excision—a mandatory component of the Sistrunk technique. Accumulation of salivary secretions in the surgical dead space leads to persistent mucous drainage and local swelling, mimicking wound infection or inflammatory seroma. We carefully considered whether the amylase-rich fluid could instead reflect pharyngeal leakage, which would also produce amylase-positive drainage. Several lines of evidence support a minor salivary gland origin rather than pharyngeal perforation: (I) none of the affected patients exhibited clinical or radiological signs of pharyngeal perforation, such as subcutaneous emphysema, pneumomediastinum, or contrast extravasation; (II) the drained fluid was thick and mucoid rather than thin salivary fluid, and oral intake did not acutely increase drainage; (III) all lesions resolved with local conservative measures (dietary modification, wound compression, and atropine in refractory cases) without requiring nil per os (NPO) status or nasogastric feeding; and (IV) Baig et al. (14) demonstrated that immunoglobulin A specifically defines secretions from salivary tissue in post-Sistrunk drainage, providing a biological basis for a minor salivary gland source in our patients. Biochemical confirmation via amylase assay enables targeted management: dietary modification (avoiding acidic foods that stimulate salivary secretion), local wound compression, daily wound care, and in refractory cases subcutaneous atropine (0.01 mg/kg per dose before meals). All affected patients responded within one week. Recognition of this entity is important to avoid unnecessary antibiotics or surgical re-exploration. None of the 170 surgical specimens in our series showed malignant transformation. Although malignant transformation of TGDC is rare, it can occur in pediatric patients, with papillary thyroid carcinoma being the most commonly reported type (15). The possibility of malignancy should be considered in the presence of suspicious clinical or radiological features, such as rapid growth, a firm or irregular mass, cervical lymphadenopathy, or a dominant solid component on imaging. In selected cases, PET/CT may be useful for both diagnosis and follow-up, particularly for detecting residual, recurrent, or metastatic disease and for guiding the extent of surgery (16). When malignancy is confirmed, management should follow the principles of differentiated thyroid cancer treatment, including total thyroidectomy and radioactive iodine therapy as indicated.

Severe complications

Postoperative hemorrhage requiring emergent reoperation (1.2%) is consistent with the 0.5–2% range in the literature (8,10,17). This emphasizes the importance of vigilant postoperative monitoring—all cases in our series were identified during routine nursing rounds, enabling prompt intervention. Pharyngeal leakage (1.2%) occurred due to inadvertent thyrohyoid membrane perforation during hyoid resection, a rare complication that has been described following the Sistrunk procedure (10,18). In both of our cases, the injury resulted from anatomic distortion caused by hyoid-thyroid cartilage fusion, which can obscure the correct dissection plane and thereby increase the risk of perforation. Conservative management (NPO, nasogastric feeding, antibiotics, compression) achieved resolution within two weeks in both cases.

Risk factors for recurrence

Preoperative TGDC infection emerged as the sole significant predictor of recurrence (13.7% vs. 0.8%, P<0.001), corroborating Gumussoy and Cukurova (3), Bory et al. (6), and Rohof et al. (19). The mechanism likely involves inflammation-induced distortion of tissue planes, making complete excision of microscopic duct remnants more challenging. Perkins et al. (20) demonstrated that hyoid preservation during initial surgery increases recurrence risk after revision, underscoring the importance of adhering to the complete Sistrunk technique, especially in reoperative settings.

Unlike some prior studies (6,7), we did not find age, sex, or prior recurrence to be significant predictors of recurrence. This discrepancy may reflect cohort size differences or population heterogeneity. Importantly, perioperative antibiotic use was not associated with recurrence risk, suggesting that while antibiotics reduce wound infection rates, they do not influence the completeness of TGDC excision.

Concerning the association between postoperative wound infection and recurrence (50.0% vs. 2.5%, P<0.001), the temporal relationship is bidirectional and cannot establish causation in this retrospective design. Wound infection may be a manifestation rather than a cause of incomplete excision, and this finding warrants cautious interpretation. This finding is in line with Campbell et al. (21), who identified postoperative infection (adjusted OR =11.98) and postoperative seroma (adjusted OR =5.03) as the factors associated with recurrence following the Sistrunk procedure.

Perioperative management recommendations

Based on our experience, we recommend: (I) routine postoperative monitoring of vital signs, neck appearance, and respiratory status, with immediate surgical exploration for progressive swelling or airway compromise; (II) intravenous antibiotics (amoxicillin-clavulanate) for wound infection, with abscess drainage reserved for refractory cases; (III) for suspected pharyngeal leakage, immediate NPO status, nasogastric tube placement, enhanced wound care, and local compression; (IV) for salivary seroma, dietary modification, local compression, and subcutaneous atropine therapy rather than antibiotics or surgical drainage; and (V) counseling on appropriate neck positioning and activity restriction to minimize wound tension. These strategies were implemented in our cohort as follows: vital signs and neck inspection were recorded every 4 hours during the first 24 postoperative hours, with immediate re-exploration for progressive swelling, stridor, or respiratory distress; intravenous antibiotics were started at the first sign of wound infection and de-escalated to oral therapy once clinical improvement was noted; patients with suspected pharyngeal leakage were kept strictly NPO with nasogastric feeding for at least 7 days before contrast evaluation and gradual resumption of oral intake; and patients with salivary seroma received a non-acidic semi-liquid diet, daily wound compression, and weekly review until resolution.

Limitations

Several limitations warrant acknowledgment. First, the retrospective design carries inherent selection and data completeness biases. Second, the absolute number of recurrence events (n=8) precluded multivariable logistic regression; only univariate associations could be assessed. Third, inclusion of patients with prior surgery at other institutions introduced baseline heterogeneity. Fourth, the single-center nature may limit generalizability. Fifth, the Clavien-Dindo per-grade totals (n=40) do not sum to the total number of patients with complications (n=56), reflecting overlap across grades; future studies should consider reporting both per-grade and per-patient complication profiles. Sixth, although the clinical features and response to conservative management support a minor salivary gland origin in our seroma cases, amylase positivity alone cannot definitively exclude a small pharyngeal perforation in individual patients. Seventh, because the primary outcome of this study was immediate postoperative complications, the 6-month minimum follow-up criterion was applied only to the recurrence analysis, which may limit the comparability of our recurrence rates with those of other series. Prospective multicenter studies with larger cohorts are needed to validate these findings and develop robust risk stratification tools for TGDC recurrence.

Conclusions

The Sistrunk procedure remains the standard surgical treatment for pediatric TGDC, with a recurrence rate of 4.7% in our series. Although approximately one-third of patients experienced complications, the majority were low-grade and resolved with conservative management. Preoperative TGDC infection is a strong predictor of recurrence, underscoring the importance of timely surgical intervention. We describe salivary amylase-rich seroma as a distinct and previously under-recognized complication, effectively managed with dietary modification and wound care. Awareness of severe complications and implementation of vigilant perioperative monitoring protocols are essential for ensuring optimal surgical outcomes.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This retrospective cohort study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Children’s Hospital of Shanghai Jiao Tong University School of Medicine (approval No. 2026R041-F01). The requirement for individual informed consent was waived due to the retrospective nature of the study.

Data Sharing Statement

Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0675/dss

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DOI: 10.21037/tp-2026-0675