When the initial presentation is one of infection, management should consist of needle aspiration of the cyst contents and administration of antibiotics selected to control oral flora. If possible, formal incision and drainage should be avoided since this will complicate definitive surgical treatment. It should be noted that thyroglossal ducts initially presenting with an infection are associated with increased incidence of recurrence after surgical resection. Elective removal of an infected lesion should be performed 6 to 8 weeks after resolution of the acute infection.

In the uncomplicated case, elective surgical resection with the Sistrunk procedure has been shown to be effective, with a recurrence risk of about 2% to 5%. The procedure can usually be done on an outpatient basis. The patient should be placed in the supine position, with the neck extended. Preoperative antibiotics to cover skin and oral flora should be administered. A transverse incision is made over the palpable cyst, and the cyst is mobilized from the surrounding structures using electrocautery (Fig. 3). The surgeon should resist the temptation to dissect too closely to the duct, as it progresses posteriorly and superiorly to the hyoid bone. Rather, a generous amount of surrounding tissue should be taken in the dissection up to the hyoid bone, to reduce the likelihood of missed accessory ducts with consequent recurrence. Inability to clearly identify a duct extending to the hyoid bone suggests that the diagnosis is a dermoid cyst rather than a thyroglossal duct cyst; these lesions cannot usually be distinguished on preoperative ultrasound study. Electrocautery can be used to divide the muscle inferior and superior on the hyoid bone, and bone cutter can be used to remove a 1- to 1.5-cm section of the hyoid bone (Fig. 4). In younger patients, when the bone is incompletely ossified, the hyoid can be divided using electrocautery. Then, dissection continues posteriorly and superiorly to the base of the time, again leaving a generous amount of tissue around the duct (Fig. 5). Suture ligation and division of the duct at the base of the tongue is then accomplished, and the specimen removed (Fig. 6). In some cases, a gloved hand can be inserted in the mouth to assess progress of the dissection to the base of the tongue. The wound can be closed in layers of absorbable suture. Routine placement of a drain is unnecessary.

The most serious complication is the exceedingly rare incidence of hemorrhage with airway impingement. This can be avoided by careful hemostatic dissection during the operation. Recurrence of thyroglossal duct cyst occurs in 2% to 5% of cases; this usually becomes evident within 1 year of initial resection. These recurrences typically present
with inflammation and infection in the anterior neck; there may be recurrent drainage from the incision site. The recurrence rate is increased in patients who have had a previous infection prior to surgery, or if an insufficient amount of the hyoid bone has been removed. To manage such recurrences, antibiotics should be administered until significant inflammation resolves, and then reoperation must be performed. To prevent another recurrence, reoperation should be performed with an elliptical incision around the previous incision, and removal of inflamed tissue with a generous hyoid bone resection, and wide excision of the midline and geniohyoid muscle.