Analysis of the curative effect and risk factors for recurrence of modified Sistrunk procedure on thyroglossal duct cyst in children

doi:10.21203/rs.3.rs-3133237/v1

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Analysis of the curative effect and risk factors for recurrence of modified Sistrunk procedure on thyroglossal duct cyst in children

https://doi.org/10.21203/rs.3.rs-3133237/v1

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Objectives

The present study aimed to retrospectively summarize the optimization experience of the modified Sistrunk (mSis) procedure, analyze the curative efficacy of this procedure in the treatment of children with thyroglossal duct cyst (TGDC), and investigate the related risk factors for recurrence.

Methods

A retrospective analysis was conducted on children undergoing mSis procedure from March 2012–December 2021. Based on our practical experience, the mSis procedure has been optimized in the following details: the resection at the cartilaginous joint of hyoid bone, core out to the foramen cecum, and the resection and ligation techniques of the fistula near the foramen cecum. Medical history, physical examination characteristics, ultrasound characteristics, and prognosis were evaluated by regression analysis.

Results

Of the 391 children with TGDC, the recurrence rate was 2.30% and the recurrence time ranged from 0.5–34 (average, 7.2) months after the procedure. During the follow-up, 10 children had local wound infection but no recurrence and none had other complications. In the Poisson regression model, the p-values of the three factors of clearness of lesion boundary, surgical history, and lesion diameter were < 0.05 and the relative risk (RR) values corresponding to the above three risk factors, such as Exp (B), were 27.918, 10.054, and 6.606, respectively.

Conclusion

The present study made optimizations based on the previous mSis procedure and integrated the complete resection and less injury. Thus, the procedure was safe and effective with fewer complications and a low recurrence rate. In addition, the indistinct lesion boundary, surgical history, and large lesion diameter were independent risk factors for disease recurrence.

Level of Evidence: IV

thyroglossal duct cyst

congenital neck mass

pediatric

Sistrunk procedure

Thyroglossal duct cyst (TGDC) is the most common congenital cervical malformation, accounting for approximately 70% of midline neck masses in children. It usually occurs in childhood within 10 years of age, albeit the age of onset is < 5 years, and no significant sex-related difference was observed[1]. The lesions of the thyroglossal duct originate from the incomplete degeneration of the channel formed by the decline in thyroid tissues during embryonic development, and the secretions of the residual ductal epithelium are accumulated to form cysts. A fistula is formed when a cyst has secondary infection or ruptures to the surface of the skin. Clinically, it manifests as an asymptomatic enlarged neck mass, which can be located anywhere from the submental area to the suprasternal notch and moves up and down with swallowing or an extended tongue. In case of infection, there are secretions at fistula orificium. Ultrasonic examination, computed tomography (CT), and magnetic resonance imaging (MRI) differentiate TGDC from other neck masses, such as dermoid cysts, lymph nodes, and ectopic thyroid[2]; among these methods, ultrasonography is most valuable in children. Notably, “fistula” formed by infection and rupture is a draining sinus tract. The embryological entity is the same as TGDC, but is often described separately due to varied clinical manifestations[3].

To date, surgical resection remains the most effective treatment option for TGDC. Except for lingual TGDC (the cyst is located at the root of the tongue, accounting for about 0.6–3%[4]) that can be treated with suspension laryngoscopy, the modified Sistrunk (mSis) procedure remains the most effective option for children with neck TGDC[5]. The TGDC removal procedure has undergone development for more than a hundred years. In 1893, Schlange proposed for the first time to remove the middle hyoid bone while removing the cyst or fistula[6]. In 1920, Sistrunk proposed to remove the middle hyoid bone and the foramen cecum, thus formulating the classic Sistrunk procedure[7]. In 1928, Sistrunk modified this classic procedure, without emphasizing the removal of the foramen cecum of the tongue, but separating it to the mucosal layer of the mouth floor, retaining the sublingual root and maintaining a sterile environment for clean incisions in the neck[8]; thus, the mSis procedure was formulated.

In the current study, we modified and optimized the operational details of the previously reported mSis procedure; then, the operative details and key points of practical experience in mSis were summarized and described. Also, the efficacy of the mSis procedure and prognosis were analyzed retrospectively, and the risk factors related to disease recurrence was assessed.

1. Participants

This was a case-control retrospective review of all patients who underwent mSis in Beijing Children’s Hospital, Beijing, China, and Baoding Children’s Hospital, Baoding, China from March 2012 to December 2021. The inclusion criteria: children aged 0-18 who were diagnosed TGDC and underwent mSis under general anesthesia. The exclusion criteria were as follows: 1) preoperatively diagnosed lingual TGDC; 2) children with preoperative clinical diagnosis of TGDC who did not undergo mSis because the correlation between the lesion and hyoid bone was not found during the procedure. A total of 391 cases met the inclusion criteria, including 361 from Beijing Children’s Hospital and 30 from Baoding Hospital of Beijing Children’s Hospital. The cohort comprised 244 males and 147 females, and the age range was 0.76–15.02 (mean, 5.35±2.81) years.

This study was approved by the Medical Ethics Committee of Beijing Children’s Hospital, Capital Medical University [No. (2022)-E-228-R]. The patients and parents were involved in selecting the procedure, and signed the informed consent form for surgery.

2. Clinical data

The data of medical and family history were collected, and all children underwent general physical and special examinations of the pharynx and neck (including thyroid and lymph nodes). Neck ultrasond was a nacessary preoperative examination to evaluate the location and nature of the lesion, the adjacent correlation with vital tissues and organs, as well as the hyoid bone, status of cervical lymph nodes, and confirm that the location and morphology of the thyroid gland. At the same time, fibrolaryngoscopy were used to exclude lingual TGDC.

3. Operative procedure

The operation was performed under general anesthesia. All the included children underwent standard mSis procedure carried out by the team’s deputy senior or senior chief physician. The key steps of the operation were as follows:

Exposure and anatomy of the cyst: The skin, subcutaneous tissues, and platysmas were cut, and the flap was flipped. The suprahyoid and infrahyoid muscles (strap muscles) (Fig. 1a) were cut transversely above and below the cyst and the middle part of the connected hyoid bone. The fully exposed cyst was then dissected using a tungsten alloy needle electrotom to ensure accurate surgical manipulation while avoiding rupture.
Cutting the hyoid bone: Allis forceps were used to lift the middle part of the hyoid bone. After releasing the attachment of the suprahyoid muscles and infrahyoid muscles, the cartilaginous junction between the hyoid body and the greater horn was resected by needle electrotom; the bilateral hyoid bone stumps simultaneously underwent electrocoagulation (Fig. 1b). The remnants of the hyoid body were removed carefully in relapsed patients.
Core out to the foramen cecum: The cyst and the middle hyoid bone were lifted, and dissection continued to the upward wedge separation to lingual foramen cecum and ended at the level of mouth floor mucosa (usually the lingual muscle at the lingual foramen cecum is ring-shaped) (Fig. 1c); entering the pharyngeal cavity was avoided to prevent pharyngeal fistula. In the tongue root mucosa, the fistula was dissected with cold knife to preserve the integrity of the mouth floor mucosa (Fig. 1d). The fistula mucosal epithelium in the dissected tissues was confirmed by naked eyes. The fistula stump was sutured and ligated, and a figure-of-eight suturing was made in the deep area wherein a small potential segment of fistula was connected with the lingual foramen cecum (Fig. 1e). The figure-of-eight suturing was not too high or too deep to suture the epiglottis, and the operated cavity was closed layer-by-layer after hemostasis.

4. Follow-up

The resected specimens of all patients were routinely submitted for pathological examination. All children completed the first re-examination 7–10 days after the procedure and were followed up via outpatient revisits at 1, 3, and 6 months and 1 year subsequently. The follow-up included physical examination and ultrasonography within the first postoperative year, followed by annual telephone follow-up. The possible complications, such as pain, scar, infection, mass recurrence, dysphagia, pharyngeal fistula, tongue deviation, and neck movement limitation were inquired about and focused upon during the follow-up, which ended on March 1, 2023, i.e., 15–156 (mean, 69.62±28.33) months. If cervical infection or mass recurred during the follow-up, ultrasonography was performed at the earliest.

5. Statistical methods

The statistical data were compared between the two groups using SPSS for Windows v12.0 (SPSS, Inc., Chicago, IL, USA), and a p-value <0.05 was considered statistically significant. For the between-group comparison of quantitative data, the independent-sample t-test was conducted in case of normal distribution and homogeneity of variance, and the Wilcoxon rank-sum test was applied in case of non-normal distribution. A chi-square test and the Wilcoxon rank-sum test was used for the between-group comparison of binary and ranked data, respectively. In multivariate analysis, Poisson regression was used instead of multivariate logistic regression due to a large difference in the number of cases between the recurrence and the non-recurrence groups (382/9).

1. Demographic information and clinical characteristics

A total of 391 children were included in the present study with disease course of 0.5–120 (average, 14.32±17.60) months. The clinical information of 391 children with TGDC is summarized in Table 1. The mean age of the TGDC cohort was 5.35±2.81 years, included 244 males and 147 females, and comprised 273 (69.8%) children who sought medical treatment due to neck masses and 118 (30.2%) with neck infections. Moreover, 36/391 (9.2%) had undergone surgery previously at other hospitals with the initial diagnosis of neck cyst (22), thyroglossal duct cyst (12) and branchial fistula (2), and the 36 cases underwent neck cyst and fistula resection surgery before, with only 6 cases underwent partial hyoid bone resection at the same.

2. Safety and effectiveness

During the follow-up, 10 children presented local wound infection but no recurrence and only 1 child was not satisfied with incision scar, but none had other complications, such as bleeding, unplanned reoperation, unplanned intubation, pneumonia, nerve injury, dysphagia, pharyngeal fistula, tongue deviation, and limited neck movement. Regarding effectiveness, 9/391 children experienced recurrence, with an overall recurrence rate of 2.30%. Among those with recurrence, 7 had cervical masses, and 2 had redness, swelling, or pus in the neck wound. The recurrence time ranged from 0.5–34 (median=5) months after the procedure and the recurrence time of 8 children was less than 7 months.

3. Risk factors of recurrence

Based on the presence or absence of recurrence, all 391 children were assigned to the non-recurrence and recurrence groups. The basic information, disease characteristics, treatment, and follow-up information of the two groups are compared in Table 1. The results indicated statistically significant differences between the groups in terms of palpable mass in the neck, the maximum diameter of the lesion, and lesion boundary under ultrasound. However, multivariate analysis was needed to eliminate the mutual interference among the factors.

The LogWorth of each clinical characteristic in the multiple regression model was calculated, and each factor arranged in an ascending order based on the p-value. Based on the clinical value and statistical significance, six variables with LogWorth >1 and p-value <0.1 were included in multivariate analysis (Table 2).

Due to the low incidence of recurrence and the large difference in sample size between the recurrence and non-recurrence groups (9/382), Poisson linear logarithm regression was used to evaluate the related factors of recurrence. The frequency of recurrence, consistent with Poisson distribution (Kolmogorov-Sminov Z value =0.005 and p-value =1.000 in Poisson distribution test), was used as the dependent variable, and the main effect included the top six independent variables in Table 2. The deviation value/degree of freedom in the goodness-of-fit of the model was 0.100, which met the requirement of equal discreteness; the Omnibus value of the global test was significant at 0.002. The statistically significant parameters are shown in Table 3 (independent variables with p<0.05). The results suggested that the p-values of the three factors of clearness of lesion boundary, surgical history, and lesion diameter in the model were <0.05, indicating statistical significance and deeming them independent risk factors for recurrence. Correspondingly, the relative risk (RR) values for the above three risk factors, such as Exp (B), were 27.918, 10.054, and 6.606, respectively, suggesting that TGDC children with indistinct lesion boundary under ultrasound, surgical history, and the maximum lesion diameter >2 cm were 26.918, 9.054, and 5.606 times more likely to have recurrence compared to those without the above characteristics, respectively.

1. Operation procedure

Based on our practical experience, the mSis procedure has been optimized in the following details: the resection at the cartilaginous joint of hyoid bone, core out to the foramen cecum, and the resection and ligation techniques of the fistula near the foramen cecum. These detailed modifications realized the complete resection of the lesions while reducing injuries, further lowering the recurrence rate.

1.1 Operation procedures of hyoid bone. In the traditional modified Sistrunk surgery, the central body or middle third of the hyoid bone was transversely cut with the bone cutting forceps on both sides of the hyoid body. The operation procedure adapted in the present study used the needle electrotom to divide the cartilaginous junction between the hyoid body and the greater horn by combining the advantages of the anatomical characteristics in childhood. An overview of the hyoid bone discovered that until middle age, the connection between the body and the greater cornu is fibrous[9]. Therefore, for pediatric TGDC, the needle electrotom can easily accomplish the division of the cartilaginous junction between the body and the greater horn without unnecessary bleeding. A similar conclusion was reported by Ryu et al. after studying 26 pediatric patients[10].

1.2 The tracking and anatomy of foramen cecum. It should be emphasized the importance of maintaining the en bloc principle without trying to identify a sinus tract in the region superior to the hyoid bone[11], and the cuff column of about 1-cm tissue volume was completely separated to the mucosal of lingual foramen cecum level, encompassing mylohyoid muscles and genioglossus. According to Sistrunk, the cuff diameter of tissues around the lingual duct separated along the suprahyoid bone is about 3 mm[8]. However, Horisawa et al. found extensive branches at suprahyoid and infrahyoid areas in the three-dimensional reconstruction of the thyroglossal duct[12]. In 1950, Boyd proposed that the rupture of the thyroglossal duct shortens and thickens the proximal portion, and its epithelium resembles that of the tongue and frequently re-develops a lumen from which an extensive system of branches is grown[13]. Soucy and Penning reviewed 44 TGDC pathological sections and demonstrated that the thyroglossal duct delivers many dendritic branches to the surrounding tissues[14], such that the resection range covered these hidden branch fistulae. Since the separation is deep to the mucosal layer of the foramen cecum, the cold knife should be used for dissection to avoid the possible risk of pharyngeal fistula caused by electrotom resection, affecting healing and facilitating visual observation to confirm the fistula mucosal epithelium in the resected tissues. This procedure does not enter the pharyngeal cavity, avoiding the purse string suture and adopting figure-of-eight suture to consolidate the stumps. Since fully bending backward position would cause glossocoma and tracheal intubation would be close to epiglottis and the root of the tongue, the suture should not be extremely deep.

2. Recurrence and the risk factor

The sample size of previous case-control studies on the application of mSis in TGDC ranged from 24–251, and the recurrence rate was 1.6–16.1%[15, 16]. The present study has the largest sample size involving retrospective data of mSis in children, and the recurrence rate (2.30%, during 15–156-months follow-up) was lower than the average reported by other studies. Statistical analysis revealed that the distinct lesion boundary, surgical history, and lesion diameter were independent risk factors for disease recurrence.

2.1Leision boundary. In this study, the indistinct lesion boundary suggested that infection can lead to local inflammatory or cicatricial adhesions. Moreover, the duration of surgery was 2 weeks after the infection was controlled. However, the above findings indicated that although the skin surface indicated controlled infection, the internal peripheral lesions might still be in the inflammatory recovery stage of the infection. When TGDC is in the infection stage, the tissue is edematous and congested, and the fistula wall and small branches have poor elasticity and toughness and are easy to rupture when separated. Although several studies suggested an association between infection and recurrence[17-19], some reports do not support this association[20, 21]. The present findings demonstrated that the preoperative occult infection stage might affect the complete resection of the small branches and fistulas during the procedure, leading to recurrence.

3.2 Secondary surgery. For patients with surgical history of neck masses, local inflammatory or cicatricial adhesions, unclear anatomical level, and blind operation poses significant challenges for a complete resection of the cysts and fistulas in secondary surgery, leading to residual and recurrent fistulas and the formation of small branches. Kim found that even if experienced doctors used the classic Sistrunk procedure to resect TGDC, the mean recurrence rate was >4%, and re-surgery failed in 33% of recurrent patients[11]. In the present study, the failure rate of re-surgery in the recurrent patients was 5.6% (2/36), further suggesting that in children undergoing non-standard surgeries, such as simple cyst resection and non-dissection of hyoid bone, intraoperative procedures should be detailed and thorough. Perkins et al. demonstrated that if the hyoid bone was not dissected in the first surgery, re-surgery after recurrence would increase the risk of second recurrence[22]. Some studies reported a successful experience of the central neck dissection in the treatment of recurrent TGDC, expanding the resection range of Sistrunk procedure to include the anterior tracheal soft tissues to realize the en bloc resection; the width of the resected tissue volume of the strap muscles and hyoid bone was 3-4 cm and that of the foramen cecum reached 2-3 cm[23]. Moreover, no recurrence or serious complication was observed after the central neck dissection, but risks, such as damage to the internal carotid artery, vagus nerve, and entry into the pharyngeal cavity could not be ignored. These findings provided a reference to improve the efficacy in the treatment of children with recurrent and refractory TGDC after repeated surgeries.

3.3 Leision size. In addition, some researchers proposed a correlation between the cyst size and recurrence[21]. Clinically, the volume of the cyst does not change or changes slowly. If the cyst is infected, the volume increases in a short time but is reduced rapidly when the infection is controlled. The present study found that lesion diameter (>2 cm) is a major risk factor for recurrence. Thus, it is speculated that large cysts are prone to rupture during surgery and leakage into the surrounding tissues, resulting in indistinct boundaries. On the other hand, some children may still be in the recovery stage post-infection.

4. Limitations.

Nevertheless, the present study has several limitations. First, due to the limited sample size, combined with the lower recurrence rate, the sample size of the recurrence and the non-recurrence groups was significantly different, causing bias in the results. Second, the follow-up time was limited. Although the minimum follow-up time of this study (15 months) was significantly longer than the recurrence time (<7 months) of most recurrent children (8/9), there may be potential relapses that may not have been found. Third, the duration for the case included in the present study was prolonged, while the experience of the mSis procedure was accumulated gradually. During continuous unification of surgical details, the surgery-related habits of different surgeons also have a potential impact on the findings. Fourth, for children with recurrence after undergoing mSis procedure, constant attention and investigation are warranted for developing therapeutic regimens, including re-resection, ultrasound-guided local injection of hardening agents, and endoscopic resection of masses at the tongue root (for those with secondary lingual TGDC), to accumulate experience.

The mSis is currently the a widely used procedure in the clinical treatment of children with TGDC. Combining the anatomical characteristics in childhood, the present study made a detailed optimization based on the previous mSis procedure and integrated the complete resection with less injury. Thus, the procedure was safe and effective with fewer complication and a low recurrence rate. In addition, the indistinct lesion boundaries, surgical history, and large diameter of lesion are independent risk factors for TGDC recurrence. For children with such clinical characteristics, the accurate operative skill of mSis procedures should be detailed and thorough in to reduce the recurrence rate.

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Table 1 Patient characteristics, preoperative investigations and follow-up details
		Non-recurrence group (n=382)	Recurrence group (n=9)	Total (n=391)	𝓧²/Z	p
Basic Information	Age, (y)				1.03	0.3099^a
	Median±SD	5.32±2.82	6.29±2.59	5.35±2.81
	Range	0.76–15.02	3.35–11.6	0.76–15.02
	Gender, n (%)				1.386	0.2391^b
	Male	239 (62.6%)	5 (55.6%)	244 (62.4%)
	Female	143 (37.4%)	4 (44.4%)	147 (37.6%)
Medical History	Disease course/(M)				0.05	0.8195^a
	Mean (SD)	14.35±17.37	13±26.79	14.32±17.60
	Range	0.5–120	1–84	0.5–120
	Chief complaint, n (%)				0.043	0.8348^b
	Neck masses	267 (69.9%)	6 (66.7%)	273 (69.8%)
	Neck infections	115 (30.1%)	3 (33.3%)	118 (30.2%)
	Surgical history				1.867	0.1719
	Yes	348 (91.1%)	7 (77.8%)	355 (90.8%)
	No	34 (8.9%)	2 (22.2%)	36 (9.2%)
Physical examination characteristics	Palpable mass, n (%)				4.443	0.0351^b
	Yes	361 (94.5%)	7 (77.8%)	368 (94.1%)
	No	21 (5.5%)	2 (22.2%)	23 (5.9%)
	Good mobility, n (%)				0.243	0.6223^b
	Yes	225 (62.3%)	5 (71.4%)	230 (62.5%)
	No	136 (37.7%)	2 (28.6%)	138 (37.5%)
	Distinct boundary on palpation, n (%)				0.324	0.5690^b
	Yes	345 (95.6%)	7(100%)	352 (95.7%)
	No	16 (4.4%)	0	16 (4.3%)
	Incision and drainage history (%)				1.050	0.3056^b
	Yes	40 (10.5%)	0	40 (10.2%)
	No	342 (89.5%)	9 (100%)	351 (89.8%)
	Spontaneous rupture history (%)				0.067	0.7964^b
	Yes	54 (14.1%)	1 (11.1%)	55 (85.9%)
	No	328 (85.9%)	8 (88.9%)	336 (14.1%)
Ultrasonographic characteristics	Solitary lesion				0.263	0.8769^b
	Yes	315 (82.4%)	8 (88.9%)	323 (82.6%)
	No	67 (17.6%)	1 (9.1%)	68 (17.4%)
	Maximum diameter <2 cm, n (%)				10.883	0.0043^b
	Yes	276 (72.6%)	2 (22.2%)	278 (71.1%)
	No	104 (27.4%)	7 (77.8%)	112 (28.6%)
	Positional relation with hyoid bone, n (%)				2.277	0.6849^b
	Anterior hyoid bone	213 (55.8%)	4 (44.4%)	217 (55.5%)
	Suprahyoid	51 (13.4%)	2 (22.2%)	53 (13.6%)
	Subhyoid	104 (27.2%)	2 (22.2%)	106 (27.1%)
	Deep hyoid bone	14 (3.6%)	1 (11.1%)	15 (3.8%)
	Middle position of neck, n (%)				0.604	0.4483^b
	Yes	324 (84.8%)	9 (100%)	333 (85.2%)
	No	58 (15.2%)	0 (0)	58 (14.8%)
	Cystic echo, n (%)				0.000	0.9836^b
	Yes	196 (55.2%)	5 (55.6%)	201 (55.2%)
	No	159 (44.8%)	4 (44.4%)	163 (44.8%)
	Distinct boundary, n (%)				5.710	0.0169^b
	Yes	332 (90.7%)	6 (66.7%)	338 (90.1%)
	No	34 (9.3%)	3 (33.3%)	37 (9.9%)
	Surrounding tissues swelling, n (%)				0.033	0.8550^b
	No	331 (90.7%)	8 (88.9%)	339 (90.6%)
	Yes	34 (9.3%)	1 (11.1%)	35 (9.36%)
	Sinus tract and fistula, n (%)				0.086	0.1606^b
	No	264 (71.1%)	6 (66.7%)	270 (71.1%)
	Yes	107 (28.8%)	3 (33.3%)	110 (28.9%)
Therapeutic strategies	Postoperative use of antibiotics, n (%)				1.969	0.4634^b
	No	165 (43.1%)	6 (66.7%)	171 (43.7%)
	Yes	217 (56.8%)	3 (33.3%)	220 (56.3%)
	Postoperative indwelling of wound drainage tube, n (%)				0.071	0.7896^b
	No	379 (99.2%)	9 (100%)	388 (99.2%)
	Yes	3 (0.8%)	0	3 (0.8%)
	Postoperative indwelling of gastric tube n (%)				0.192	0.6609^b
	No	374 (97.9%)	9 (100%)	383 (98.0%)
	Yes	8 (2.1%)	0	8 (2.0%)
	Hospital stay /(D)				-0.708	0.4791^a
	Mean (SD)	5.67±1.68	5.27±1.9	14.32±17.60
	Range	1–13	2–9	0.5–120
Follow-up	Follow-up time/(M)				0.7454	0.4560^a
	Mean (SD)	57.45±28.44	63.20±24.83	57.62±28.33
	Range	3–120	31–94	3–120
	Wound healing n (%)				0.267	0.8752^b
	Unremarkable	371 (97.1%)	9 (100%)	380 (97.2%)
	Local scarring	1 (0.3%)	0	1 (0.3%)
	Infection	10 (2.6%)	0	10 (2.5%)
a. Wilcoxon rank-sum test; b. chi-square test

Table 2. LogWorth sequence of recurrence-related risk factors in the multiple regression model
Clinical characteristic	LogWorth	p
lesion boundary （ultrasound）	3.516	0.0003
Maximum diameter (ultrasound, >2 cm or not)	1.929	0.0117
Surgical history	1.376	0.0420
Incision and drainage history	1.280	0.0524
Spontaneous rupture history	1.239	0.0576
Lesion boundary (on palpation)	1.217	0.0606
Disease course (0–6 m/6–12 m/>12 m)	0.829	0.1481
Chief complaint (mass/infection)	0.709	0.1956
Onset age(≥6 y or not)	0.607	0.2469
Sinus tract and fistula (ultrasound)	0.477	0.3337
Middle position of neck	0.450	0.3546
Gender	0.300	0.5008
Positional correlation with hyoid bone	0.257	0.5528
Surrounding tissues swelling or not	0.210	0.6163
Good mobility or not	0.164	0.6862
Cystic echo or not	0.084	0.8241
Number of lesions (>1 or not)	0.030	0.9322

Table 3. Poisson linear logarithm regression analysis.
Factor	B	Standard error	95% Wald confidence interval		Hypothesis testing			Exp(B)	95% Wald confidence interval for Exp(B)
Factor	B	Standard error	Lower limit	Upper limit	Wald chi-square	Degree of freedom	Significance	Exp(B)	Lower limit	Upper limit
Intercept	-5.781	0.9538	-7.650	-3.911	36.734	1	0.000	0.003	0.000	0.020
Maximum lesion diameter >2 cm (yes/no)*	1.888	0.8844	0.155	3.621	4.558	1	0.033	6.606	1.167	37.388
Surgical history (yes/no)	2.308	1.0153	0.318	4.298	5.167	1	0.023	10.054	1.374	73.549
Indistinct lesion boundary (yes/no) *	3.329	0.9231	1.520	5.138	13.009	1	0.000	27.918	4.573	170.445
Incision and drainage history (yes/no)	-28.108	7.9562E+5	-1.5594E+6	1.559358E+6	0.000	1	1.000	6.208E-13	0.000	a
Spontaneous rupture history (yes/no)	-26.886	6.5818E+5	-1.2900E+6	1.2899E+6	0.000	1	1.000	2.106E-12	0.000	a
Indistinct lesion boundary (yes/no) **	-29.534	-	-	-	-	-	-	1.492E-13	0.000	0.000
* under ultrasound;** on palpation;- Since this parameter is superfluous, it is set to zero; a. It is set to system-missing value due to outflow.

No competing interests reported.

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Analysis of the curative effect and risk factors for recurrence of modified Sistrunk procedure on thyroglossal duct cyst in children

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