Purpose or Case Report: The thyroglossal duct cyst (TGDC) is the most common congenital malformation in the neck. The Sistrunk procedure is the standard surgical treatment and includes resection of the central hyoid and a cuff tongue base musculature toward the foramen cecum.

We present a 24yr old F with a TGDC complicated by fistulous drainage and multiple surgeries. Imaging was critical for definitive identification of a sinus tract and treatment. She presented initially with a cystic neck lesion treated as a ranula with sublingual then submandibular gland excision. She subsequently presented with spontaneous drainage of saliva from the neck 2 yrs later and underwent Sistrunk procedure. When she presented with persistent salivary draining within 1 week of Sistrunk, there was concern for a persistent thyroglossal duct tract or alternate connection to the oropharynx not visualized despite direct laryngoscopy.

Obturation of the wound was attempted, without success. This novel concept of balloon occlusion pullback fistulogram in the open surgical wound led to discovering a tract extending superiorly toward the tongue base. A 14 Fr Foley catheter was inserted into the draining neck wound, balloon expansion in the cavity. Gentle traction was used to occlude the wound and fill the cavity. Ten mL of Omnipaque 180 contrast was infused through the catheter, outlining the balloon in the subcutaneous cavity and an opacified fistulous tract extending midline toward the tongue base posteriorly.

The otolaryngologist, present during flouroscopic exam, employed a similar technique in the OR with methylene blue diluted with saline. This created a roadmap resulting in a revised Sistrunk procedure, excising all abnormal appearing tissue and tongue base. The procedure was completed under direct laryngoscopy identifying the tongue base tissue that needed to be cored out. Only a few reported cases in the literature used fistulograms to identify TGDCs and determine the extent including associated sinus tracts, none of which described the same novel technique of balloon occlusion pullback within the open wound.

Radiographic demonstration of the thyroglossal tract is useful to indicate the extent and location. We present this novel balloon occlusion pullback fistulogram to provide crucial information about the fistulous tract regarding extent, direction, and relationship with adjoining structures for complicated or recurrent TGDCs. This information is crucial in definitive surgical planning.
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