Koempel's Suprahyoid Technique |
| The
Sistrunk procedure, first described in 1920, remains the standard of
care for thyroglossal duct remnant (TGDR) excision. It requires removal
of the cyst or sinus tract, the central portion of the hyoid bone, and
a core of tissue extending superiorly to the foramen cecum. Despite
nearly a century of surgical experience, recurrence rates have ranged
from as low as 1.2% to as high as 20% across published series, and
inadequate dissection of the suprahyoid region has consistently been
identified as the primary contributing factor. In response to this
persistent clinical challenge, a systematic, anatomically grounded
approach to the suprahyoid area was developed through sixteen years of
intraoperative observation and formally described in 2014 by Koempel.
Koempel's technique, which transformed the most technically uncertain
component of the Sistrunk procedure into a reproducible,
landmark-guided dissection, achieved a 0% recurrence rate in 74
consecutive cases over nine years and has since been validated in a
major systematic review and cited in leading single-institution series
worldwide. Thyroglossal duct remnants, encompassing both cysts and sinus tracts, represent the most common congenital anomaly of the anterior neck in childhood, affecting approximately 7% of the general population. The fundamental difficulty of the procedure lies not in the infrahyoid dissection — which is generally straightforward — but in the segment above the hyoid bone. A thyroglossal tract in the suprahyoid area is rarely visible or palpable during surgery, is often friable and easily disrupted, and may exist as multiple branching ducts rather than a single identifiable structure. Anatomical reconstruction studies using three-dimensional serial sectioning have demonstrated extensive broom-like branching of the thyroglossal duct both above and below the hyoid, with a single tract at the level of the bone itself. Serial pathological analysis of TGDR specimens further established that microscopic thyroglossal duct tissue was present superior to the hyoid in 74% of primary resections and in 100% of revision cases — making complete suprahyoid clearance not merely desirable but essential to surgical cure. Prior descriptions of the suprahyoid component of the Sistrunk procedure offered little precise guidance. Authors recommended removing a "wide cuff of tissue" or a "generous core of tongue musculature" — language that left the extent of dissection entirely to the surgeon's judgment. Without a reliable anatomical landmark to define the margins of resection, the tissue removed varied substantially from case to case and surgeon to surgeon. Sistrunk himself recognized the difficulty of isolating the tract above the hyoid, cautioning against any attempt to do so, and recommended instead a blind coring technique toward the foramen cecum at a 45-degree angle. While conceptually sound, this guidance proved extremely difficult to reproduce consistently, and two recurrences within a short period prompted a careful re-evaluation of the procedure that ultimately led to the development of the technique described here. Koempel's modified approach proceeds through twelve discrete steps. Soft tissue skin flaps are raised to 1 cm above the hyoid superiorly and 1 cm below the inferior extent of the TGDR. The median raphe of the strap musculature is divided, and the pretracheal fascia is identified and preserved as the posterior border of dissection throughout. As the surgeon proceeds toward the hyoid, several millimeters of the medial aspect of the strap muscles bilaterally are included in the specimen. Using the laryngeal prominence as a midline reference, 1 to 1.5 cm of the central hyoid is measured, and lateral cuts are made through the bone or cartilage before any tissue superior to the hyoid is addressed — a sequence that eliminates the risk of inadvertently transecting a suprahyoid tract during hyoid division. The most distinctive and consequential step involves the identification of a specific tissue plane change in the suprahyoid region. Using monopolar electrocautery with a Colorado tip — chosen to minimize bleeding and prevent blood from obscuring the operative field — along with gentle blunt dissection with a small hemostat, the muscle fibers extending superiorly from the resected hyoid segment are carefully and slowly transected. These fibers run in a superior-to-inferior orientation. Dissection continues until the tissue surface transitions from these vertically oriented muscle fibers to a smooth, glistening appearance underneath. This visual and tactile change — representing the interface between the mylohyoid and geniohyoid muscles and a deeper fibrinous layer or a portion of the genioglossus muscle — constitutes the critical anatomical landmark that defines the anterior and lateral margins of suprahyoid resection. It is objective, reproducible, and present regardless of whether a gross duct tract is visible. Once this plane is reached, a 1 cm diameter area of tongue base is outlined and resected en bloc with the specimen. Careful observation is maintained throughout for the appearance of mucinous material, which would indicate the need for wider excision. The tongue musculature defect is closed with a figure-of-eight suture of absorbable material followed by a second running layer. The hyoid ends are not reapproximated. A rubber band drain is brought out through both ends of the wound. Notably, no attempt is made at any point to isolate or follow a specific duct tract — consistent with the original Sistrunk recommendation — thereby eliminating the risk of tract disruption and incomplete resection that had historically contributed to recurrence. The clinical impact of adopting this approach was immediate and substantial. In a retrospective series of 94 patients treated over a 16-year period, including both primary and revision cases, 92 underwent a Sistrunk procedure and were eligible for recurrence analysis. Mean patient age was 5.2 years, ranging from 9 months to 16 years. Before consistent application of the suprahyoid technique in 2004, the recurrence rate following a Sistrunk procedure was 11.1% (2 of 18 cases). After systematic adoption of the technique, not a single recurrence was observed in 74 consecutive cases over the following nine years — a difference that was statistically significant by Fisher's exact test (p = 0.037). The overall recurrence rate across the entire Sistrunk cohort was 2.2%, and intraoperative visualization of a suprahyoid tract was documented in only 26.6% of cases, confirming that the technique functions effectively precisely because it does not depend on tract identification. External validation arrived the following year through the first systematic review specifically addressing surgical management of recurrent thyroglossal duct cysts in children. Nine studies meeting predefined inclusion criteria were identified, comprising 66 patients who underwent 114 secondary surgeries across four main surgical approaches: repeat Sistrunk procedure, en bloc central neck dissection, suture-guided transhyoid pharyngotomy, and the suprahyoid technique described above. Repeat Sistrunk procedures carried a 30.12% recurrence rate. En bloc central neck dissection achieved a 20% recurrence rate. In contrast, both suture-guided transhyoid pharyngotomy and the suprahyoid technique reported 100% success rates in their respective patient cohorts. The review's authors concluded that these were the only two approaches that clearly delineated the specific amount of suprahyoid tissue to be removed, and that this specificity was the likely driver of their superior outcomes. Additional prospective studies and broader institutional adoption were called for to confirm reproducibility. A 28-year single-surgeon series examining central neck dissection for recurrent and infected thyroglossal duct remnants provided further context. That analysis subdivided the challenges of TGDR surgery into three anatomical compartments — infrahyoid, posterior hyoid, and suprahyoid — and assigned a different surgical strategy to each. Central neck dissection, operating along fascial planes rather than following embryological remnants, reliably controls infrahyoid disease and improves access to the hyoid and posterior hyoid space. However, that same analysis explicitly acknowledged that central neck dissection does nothing to address the difficulties of following the thyroglossal tract into the tongue base — the domain where the suprahyoid technique operates. The two approaches are therefore not competing strategies but complementary ones, with the suprahyoid technique addressing the anatomical frontier that central neck dissection leaves unresolved. The advantages of the suprahyoid technique are multiple and clinically meaningful. It is applicable to both primary and revision cases, with no difference in the identifiability of the key anatomical landmarks even in previously operated fields — a finding attributed to the fact that in most revision procedures, the hyoid and suprahyoid structures are found largely undisturbed. It requires no specialized equipment, no intraoperative imaging, and no entry into the pharynx. Its defining landmark — the transition from vertically oriented muscle fibers to a smooth, glistening deep plane — provides an objective, reproducible criterion for determining the extent of resection that replaces the subjective estimation inherent in previous descriptions. And its step-by-step structure makes it teachable and applicable by surgeons-in-training and low-volume TGDR surgeons who would otherwise have the highest rates of recurrence. The technique does not replace the Sistrunk procedure. It refines it at its most vulnerable point, converting the least reproducible component of an otherwise well-defined operation into a systematic, anatomically grounded dissection. The evidence base, while primarily derived from single-institution retrospective series and one systematic review, is internally consistent and directionally unambiguous: where the technique has been applied systematically, recurrence rates fall to zero. Its inclusion in the routine management of both primary and revision thyroglossal duct remnants is supported by the available literature and should be considered by any surgeon seeking to reduce recurrence in this most common of pediatric congenital cervical anomalies. References: 1- Koempel JA. Thyroglossal duct remnant surgery: a reliable, reproducible approach to the suprahyoid region. Int J Pediatr Otorhinolaryngol. 78(11):1877-1882, 2014 2- Ibrahim FF, Alnoury MK, Varma N, Daniel SJ. Surgical management outcomes of recurrent thyroglossal duct cyst in children--A systematic review. Int J Pediatr Otorhinolaryngol. 79(6):863-867, 2015 3- Isaacson G, Kaplon A, Tint D. Why Central Neck Dissection Works (and Fails) for Recurrent Thyroglossal Duct Remnants. Ann Otol Rhinol Laryngol. 128(11):1041-1047, 2019 4- Jiménez Gómez J, Gaspar Pérez M, Jiménez Arribas P, San Vicente Vela B, Santiago Martínez S, Betancourth Alvarenga J, Güizzo Tobares JR, Sánchez Vázquez B, Esteva Miro C, Álvarez García N, Núñez García B. Treatment of thyroglossal cyst using Koempel's technique: initial experience. Cir Pediatr. 37(1):1-4, 2024 |
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