131
Sonography and magnetic resonance tomography of neck cysts
Ann. Cancer Res. Ther. Vol. 29, No. 2, pp. 131-134, 2021
Introduction
Neck cystic masses are fairly frequent developmental
defects, and surgery is the only method of treatment, with
early intervention usually recommended to avoid com-
plications
1)
. As a rule, in surgical practice, there are three
surgical approaches to excising cysts: surgical excision of
the thyroglossal duct, simple excision of the cyst alone, or
excision in accordance with the Sistrunk procedure. The
Sistrunk procedure was introduced by W. E. Sistrunk
in 1920 and involves resection of the cyst, tract, median
part of the hyoid bone, and cuff surrounding the base of
the tongue musculature.
Magnetic resonance imaging (MRI) is an estab-
lished method of monitoring and evaluating the treat-
ment of cystic neck formations in everyday practice.
Postoperative scars can also become inflamed, repre-
senting one cause of recurrent neck cysts
2-5)
. The most
frequent complication of such cysts is an infection, which
in most cases leads to complete and incomplete fistulas,
abscesses neck, abscesses, and low-current pyoinflam-
matory processes, such as local infiltration and lymph-
adenitis
3)
. There are typically anatomical variants of
thyroglossal cysts (TGCs), which necessarily have their
own internal fistula, and are the main cause of recurrence
of TGCs of the neck. However, while such a definition is
easy for operating surgeons to comprehend, it is not quite
accurate with regard to the topographic anatomy
2)
.
Monitoring neck cysts is important for predicting the
appropriateness of a given treatment and determining the
likelihood of recurrence. Ultrasound provides a simple
and cost-effective solution to this problem, but it is im-
portant to take into account the presence of the distal
parts of the internal ducts of the neck cyst. As ultrasound
lacks the ability to obtain a three-dimensional image, it
is in many ways inferior to MRI.
In this study, the utility of sonography and MRI for
monitoring recurrence of cystic formations of the neck
was evaluated.
Material and methods
Ultrasound and MRI were used to monitor for recur-
rence of cystic formations of the neck in 19 patients at 3,
6, 12 and 18 months after an operation. TGCs were veri-
fied in 15 (78.9%) patients, and branchiolic cysts of the
neck were noted in 4 patients (21.1%).
Relapse in 7 (36.8%) patients occurred after non-radi-
cal surgery in the volume of only the removal of the cys-
tic cavity itself, without resection of the hyoid bone div,
confirmed earlier by morphological examination-TGCs.
Sonography and magnetic resonance tomography
in monitoring of recurrent cysts lesions of the neck
Lalita Yunusova
1)
, Toru Aoyama
2)
, Rustam Amanullayev
1)
, Jasur Rizaev
1)
, Gayrat Ikramov
1)
,
Junichi Sakamoto
3)
, Bakhodir Halmanov
1)
4)
1)
Tashkent State Dental Institute, Uzbekistan
2)
Department of Surgery, Yokohama City University, Japan
3)
Tokai Central Hospital, Japan
4)
Samarkand State Medical Institute, Uzbekistan
Abstract
Сysts of the neck are congenital cystic lesions of the neck, often presenting in childhood. Complete surgical excision is
the treatment of choice for these lesions. Recurrence of cystic lesions of the neck after incomplete excision is fraught with
complications due to the need for a second surgery and complications of the recurrent cyst itself. We herein report the de-
tails of recurrent cysts of the neck presenting at 3, 6, 12 and 18 months postoperatively.
Keywords: Сysts of the neck, ultrasound, MRI, recurrence, complications
(Received April 7, 2021; Accepted September 8, 2021)
Corresponding Author
: Toru Aoyama, Department of Surgery, Yokohama City
University, 3-9 Fukuura Kanazawa-ku, Yokohama, Japan. E-Mail: t-aoyama@lilac.
plala.or.jp
132
Annals of Cancer Research and Therapy Vol. 29 No. 2, 2021
The period until recurrence ranged from several months
to 18 months, and in 3 (15.7%) patients, the process could
be regarded as after an operation of inadequate volume,
since the infiltrate under the scar was determined already
in the postoperative period. Two (10.5%) patients were
admitted to the clinic after a second recurrence of a TGC
of the neck.
Sonography was used to diagnose cystic neoplasms
in the pre-operative period (56 patients) and to monitor
for recurrent cystic neoplasms (6 patients). The studies
were carried out using SLE-501 and Affiniti-70 (Philips,
Amsterdam, Holland) devices with linear sensors of 7.5
and 12 MHz, respectively. MRI was performed at 0.2
Tesla (Magnetom OPEN VIVA; Siemens Healthineers,
Erlangen, Germany) using a parallel imaging technique
at a 4-mm slice thickness with a 1-mm gap and an axial
field of view (FOV) of 20 cm and a coronal field of view
of 26 cm. Axial with fat suppression T2-weighted fast
spin echoes (TR/TE, 4102-4269/90; 7150/134), axial with
fat suppression T1-weighted spin echoes (TR/TE, 679-
827/9-15), T2-weighted coronal with fat suppression spin
echo (TR/TE, 3983-5283/80-90), and coronal uncom-
pressed T1-weighted spin echo (TR/TE, 400-713/10-14;
432/27) images were obtained in all patients.
Results
Table 1 showed the background of 19 patients.
Ultrasound in 7 patients revealed cavity formation above
the area of the postoperative scar, with clear, uneven
contours; dimensions of 1.5±07 cm and homogeneous
anechoic content. We observed 13 incomplete median
fistulas; 1 was iatrogenic in origin, and 7 after non-
radical removal of the median cyst of the neck-operations
were performed without resection of the hyoid bone div
(Table 2). The frequency of relapse of cystic neck forma-
tions within six months after surgery is shown in the
Table. In two patients, recurrence of cystic formation was
observed twice. Six patients had a complete external fis-
tula of cystic formation, and in 13 patients, there was an
internal duct of cystic formation of the neck.
TGCs are often prone to relapse, and such relapse
was noted in 15 of our 19 patients. In four cases, relapse
occurred in patients with Type II branchial cysts. The
localization of TGC relapse differed, but for branchial
cysts, the relapse localization was similar. In 8 of the
19 patients, drainage of the cystic cavity was observed
in the anamnesis due to infection of the postoperative
scar (Table 3). In 7 of the 19 patients with recurrent neck
cysts, sonography showed unsatisfactory postoperative
removal of cysts, i.e. the formation of a recurrent cyst. In
other cases, results that were suggestive of infiltration of
the postoperative scar were seen.
On ultrasound, the presence of a small subcutaneous
emphysema, soft tissue edema made it difficult to fully
visualize the postoperative period of the wound, and this
cause of the fracture area during ultrasound examination.
This prevented control from being achieved in 3 (15.7%)
patients, the process could be regarded as after an opera-
tion of inadequate volume, since the infiltrate under the
scar was determined already in the postoperative period.
The vast majority of cases of recurrent neck cysts in
our study were TGCs, which show hypointensive signal-
ing on T1-weighted imaging (T1WI) and hyperintensive
signaling on T2WI. In the 12 (63.2%) patients with slight
infiltration and heterogeneity of the cyst, the intensity of
T1 and T2 signals was determined. Using MRI, recurrent
cystic formation of the neck was determined to be due
Table 1 Background of 19 patients
Patient
Number
Age
Sizes
Contours
Shape
Cyst walls
Internal
structure
Regional
LAP
Type of resection
1
12 y/o
1.5×1.2×1.8 Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
2
36 y/o
2.3×1.5×1.2 Smooth, clear Awry
Thickened
Homogeneous
/−
Conventional cystic cavity resection
3
52 y/o
2.1×0.8×1.5 Smooth, clear Awry
Thickened
Homogeneous
/−
Conventional cystic cavity resection
4
12 y/o
0.8×0.5×1.0 Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
5
10 y/o
0.5×0.7×0.9 Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
6
12 y/o
1.2×1.5×0.8 Smooth, clear Awry
Thickened
Homogeneous
/−
Conventional cystic cavity resection
7
26 y/o
0.5×0.6×1.2 Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
8
10 y/o
0.3×1.2×0.8 Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
9
18 y/o
2.8×1.4×1.5 Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
10
25 y/o
2.0×1.8×1.3 Smooth, clear Awry
Thickened
Homogeneous
/−
Conventional cystic cavity resection
11
20 y/o
1.3×0.8×1.6 Smooth, clear Awry
Thickened
Homogeneous
/−
Conventional cystic cavity resection
12
29 y/o
0.8×1.4×1.2 Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
13
13 y/o
0.6×0.9×1.1 Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
14
14 y/o
0.5×.08×.1.0 Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
15
12 y/o
1.8×1.6×0.9 Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
16
12 y/o
1.4×1.3×1.1 Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
17
11 y/o
1.0×1.1×1.0 Smooth, clear Awry
Thickened
Homogeneous
/−
Conventional cystic cavity resection
18
14 y/o
1.8×1.5×1.1 Smooth, clear Awry
Thickened
Homogeneous
/−
Conventional cystic cavity resection
19
12 y/o
0.6×.0.9×1.1 Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
133
Sonography and magnetic resonance tomography of neck cysts
Table 2 Demographic and clinical factors preceding the recurrence of cystic neck lesions
Relapse
3 month
6 month
12 month
18 month
Age (average value)
6 ± 0.2
12 ± 0.5
16 ± 0.6
21 ± 1.2
Sex:
• F
• М
3
1
6
3
2
1
2
1
Preoperative diagnosis:
• Median cysts
• Lateral cysts
3 (15.7%)
1 (5.2%)
2 (10.5%)
1 (5.2%)
5 (26.3%)
1 (5.2%)
5 (26.3%)
1 (5.2%)
Localization:
• Intralingual
• Supra-lingual
• Sublingual
• On the side of the neck
1 (5.2%)
2 (10.5%)
1 (5.2%)
2 (10.5%)
2 (10.5%)
2 (10.5%)
2 (10.5%)
-
1 (5.2%)
1 (5.2%)
1 (5.2%)
2 (10.5%)
2 (10.5%)
Drainage of the cystic cavity:
• Yes
• No
2 (10.5%)
-
-
-
2 (10.5%)
1 (5.2%)
2 (10.5%)
1 (5.2%)
Type of resection:
• Conventional cystic cavity resection
• Resection by Sistrunk
7 (36.8%)
12 (63.2%)
Postoperative infection
7 (36.8%)
to incomplete radical removal of the cystic cavity in pre-
ceding lateral cysts of the neck in 4 (21%) cases, simple
resection of the cystic cavity itself in 7 (36.8%) cases and
incomplete identification and elimination of the internal
ducts of the neck cysts with Sistrunk surgery in 8 (42.1%)
cases (Table 4).
Table 3 Ultrasound and MRI are signs of recurrent cystic formations of the neck
Features
US
MRI
Localization
Median cysts 5 (26.3%)
Lateral cysts 2 (10.5%)
Median cysts 15 (78.9%)
Lateral cysts 4 (21.1%)
Sizes (max. diameter)
1.5 ± 0.7 cm
3.8 ± 2.0
Contours:
• Smooth, clear
• Rough, fuzzy
2 (10.5%)
5 (26.3%)
7 (36.8%)
12 (63.2%)
Shape:
• Awry
• Rounded
7 (36.8%)
7 (36.8%)
12 (63.2%)
Cyst walls
• Normal (1–2mm)
• Thickened
5 (71.5%)
2 (28.5%)
100%
Internal structure:
• Homogeneous
• heterogeneous
5 (26.3%)
2 (10.5%)
7 (36.8%)
12 (63.2%)
The presence of internal septae
-
-
Invasion of surrounding structures
-
-
Cause of relapse
not detected
detected in 100%
Regional LAP
3 (15.7%)
12 (63.2%)
Type of resection:
• Conventional cystic cavity resection
• Resection by Sistrunk
5 (26.3%)
2 (10.5%)
7 (36.8%)
12 (63.2%)
Table 4 Background of 8 patients
Age
Sizes
Contours
Shape
Cyst walls
Internal
structure
Regional
LAP
Type of resection
1
36 y/o
0.7×1.2
Rough, fuzzy Rounded
2 mm
Homogeneous
/−
Conventional cystic cavity resection
2
52 y/o
0.8×1.5
Rough, fuzzy Rounded
2 mm
Homogeneous
/−
Conventional cystic cavity resection
3
18 y/o
1.4×1.5
Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
4
25 y/o
2.0×1.8
Smooth, clear Rounded
2 mm
Homogeneous
/−
Conventional cystic cavity resection
5
12 y/o
1.2×1.8
Rough, fuzzy Rounded
Thickened
heterogeneous
/+
Resection by Sistrunk
6
12 y/o
1.3×1.1
Rough, fuzzy Rounded
2 mm
Homogeneous
/+
Conventional cystic cavity resection
7
14 y/o
1.8×1.5
Smooth, clear Rounded
2 mm
Homogeneous
/−
Conventional cystic cavity resection
134
Annals of Cancer Research and Therapy Vol. 29 No. 2, 2021
Discussion
The recurrence rate of TGCs after complete excision
using the Sistrunk procedure is reported to be 2.6%–5%,
whereas simple excision of the cyst can result in recur-
rence rates as high as 38%–70%. Previous authors
6-11)
have reported just 2 cases of recurrence in a series of 62
patients. Swaid et al.
11)
reported a recurrence rate of 10%
in a series of 270 patients, with most recurrences occur-
ring when the middle third of the hyoid was left intact. A
recurrence rate of 3.4% was reported in a series of 29 pa-
tients who underwent the Sistrunk procedure
12, 13)
, while
recurrence rates ranging from 1% to 30% have been re-
ported in a few other series
1, 2)
.
The most common cause of recurrence is rupture of
the cyst intraoperatively or leaving a part of the wall be-
hind. Various methods have been used to treat branchial
cleft cysts. Complete surgical excision of the cyst is the
treatment of choice for these cysts. Incision and drainage
are most commonly used to treat infected branchial cleft
cysts, but the associated recurrence rate is high
6)
. Open
complete surgical removal of fistulous tract in case of
branchial fistula is therefore preferred due to the low as-
sociated recurrence rate (5% at 2 years’ follow-up)
2)
.
In the series conducted by Hazenberg et al., the post-
operative recurrence rate was 3%
4)
. In another retrospec-
tive series by Prasad et al., among 34 cases, the incidence
of branchial fistula was 20 (58.82%), while branchial cyst
was found in 14 (41.17%) cases
7, 8)
. The low recurrence
rate of 1.2% was believed to be due to the good identifi-
cation of the fistulous tract with the aid of methylene blue
dye, good magnification with magnification loops and a
microscope and wide excision of the tract along with the
surrounding tissue.
Generally, the etiology for the increased recur-
rence might be postulated to be an extension of the cyst
through the carotid bifurcation, as might be expected
due to suggested origin from second branchial arch rem-
nants
1, 2)
.
Conclusion
As our studies have shown, on sonograms, cystic
formation manifests in the form of an anechoic, weakly
hypoechoic structure formed in the scar area, leaving the
cause somewhat unclear. MRI allows for the identifica-
tion of even the smallest cystic areas, which contributes
to its utility in monitoring for the recurrence of neck
cysts.
Acknowledgments:
This study is supported, in part, by the nonprofit organization
Epidemiological and Clinical Research Information Network
(ECRIN).
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