Sistrunk Procedure (Thyroglossal Duct Cyst)
6028060281wRVU: 8.6 — Excision of recurrent thyroglossal duct cyst or sinus (8.60 wRVU; use when prior excision exists)60000wRVU: 1.76 — Incision and drainage of infected thyroglossal duct cyst (1.76 wRVU, 10-day global; for staged I&D before definitive excision)60252wRVU: 21.46 — Total thyroidectomy for malignancy with limited neck dissection (21.46 wRVU; for concurrent thyroidectomy when TDCC with thyroid pathology)60254wRVU: 27.71 — Extensive thyroid surgery with radical neck dissection (27.71 wRVU; for TDCC with extensive nodal disease)
Thyroglossal duct cyst, midline neck [/ left / right of midline]
Same
Sistrunk procedure: excision of thyroglossal duct cyst with central hyoid bone resection and core excision of tongue base musculature to foramen cecum
[Attending name], MD
[Resident name]
General endotracheal. Neck extended over shoulder roll.
Patient presents with a [X]-cm midline neck cyst inferior to the hyoid bone consistent with thyroglossal duct cyst. [Present since infancy / recent enlargement / prior infection / ultrasound confirmed.] [Thyroid gland confirmed in normal location on preoperative ultrasound.] [No prior excision / Prior excision at [date] with recurrent cyst.] Risks including recurrence (higher without hyoid resection), nerve injury (superior laryngeal, lingual, hypoglossal), wound complications, and salivary fistula (if pharynx entered) discussed. Consent obtained.
Thyroglossal duct cyst [X] cm, midline, adherent to hyoid bone. Tract identified coursing superiorly through hyoid bone to base of tongue. Central hyoid segment approximately [1-1.5] cm resected en bloc. Tract followed through tongue base musculature to foramen cecum; core of musculature ([X] mm) excised with the tract. Cyst [intact / inadvertently entered (capsule intact and fully excised)].
The patient was positioned supine with the neck extended over a shoulder roll. The anterior neck was prepped and draped in sterile fashion.
A [transverse / elliptical] incision of [X] cm was made in a natural neck crease overlying the cyst, at or slightly below the hyoid bone level. Subplatysmal flaps were elevated superiorly and inferiorly. The cyst was identified in the midline and dissected free from the surrounding strap muscles and subcutaneous tissue, taking a cuff of tissue with the cyst to ensure complete excision.
The tract was followed superiorly to the hyoid bone. The central portion of the hyoid bone (approximately 1-1.5 cm) was divided on each side with [bone cutters / heavy Mayo scissors]. The central hyoid segment was removed en bloc with the cyst.
The tract was followed through the base of tongue musculature toward the foramen cecum. [Intraoral guidance was used with a finger placed in the floor of the mouth to direct dissection.] A core of tongue base musculature (approximately [5-10] mm) was excised en bloc with the tract. The tract was suture-ligated at the most superior extent with [2-0 Vicryl]. [The pharynx was entered at the foramen cecum; the mucosal opening was closed with [2-3 interrupted 4-0 Vicryl] sutures before closure.]
The specimen (cyst, central hyoid segment, and attached tract with tongue base core) was removed intact and sent to pathology, with the superior (cephalad) end marked with suture for orientation. The wound was irrigated with saline. Strap muscles were reapproximated with [3-0 Vicryl]. Platysma closed with [3-0 Vicryl]. Skin closed with [4-0 Monocryl]. Patient tolerated the procedure well.
None
Thyroglossal duct cyst with central hyoid segment and tongue base tract core. Superior margin marked with suture.
Minimal
None
Patient to PACU. Discharged to home same day.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Thyroglossal duct cyst, midline neck
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Sistrunk procedure: excision of thyroglossal duct cyst with central hyoid resection and core excision of tongue base musculature to foramen cecum
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal, neck extended over shoulder roll
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a *** cm midline neck cyst consistent with thyroglossal duct cyst. [Ultrasound confirmed normal thyroid in expected location.] [No prior excision / Recurrent (prior excision ***, 60281 applies).] Risks including recurrence, nerve injury, and wound complications discussed. Informed consent obtained.
FINDINGS: Thyroglossal duct cyst *** cm, midline, adherent to hyoid. Tract followed to tongue base; central hyoid *** cm resected en bloc. Core of tongue base musculature (*** mm) excised with tract to foramen cecum. Cyst excised intact.
DESCRIPTION OF PROCEDURE:
Patient supine, neck extended. Transverse incision *** cm in neck crease. Subplatysmal flaps elevated. Cyst dissected free from strap muscles with cuff of tissue. Tract followed to hyoid; central portion (~1-1.5 cm) divided bilaterally with bone cutters and removed en bloc with cyst. Tract followed through tongue base musculature with [intraoral finger guidance]. Core of tongue base musculature (~*** mm) excised en bloc with tract. Tract suture-ligated at most superior extent with 2-0 Vicryl. [Pharynx entered at foramen cecum; mucosal opening closed with interrupted 4-0 Vicryl.] Specimen (cyst, hyoid segment, tract) removed intact; superior margin marked with suture and sent to pathology. Wound irrigated. Strap muscles approximated with 3-0 Vicryl, platysma 3-0 Vicryl, skin 4-0 Monocryl. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Thyroglossal duct cyst with hyoid segment and tongue base tract to pathology; superior margin marked
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to PACU. Discharged home same day.
Signed: .ME, .MYDEGREE
.TODAYVariants
Recurrent thyroglossal duct cyst (CPT 60281)
CPT 60281 (8.60 wRVU). Scar tissue from prior dissection increases difficulty and recurrence risk. Document prior surgery, adherence to scar, and need for wider excision of tongue base musculature. Consider intraoperative needle aspiration of the field to identify residual tract.
Infected or previously drained cyst (CPT 60000 then 60280)
Prior drainage or infection creates dense fibrosis. If surgery is staged (I&D first, excision 4-6 weeks later when inflammation resolves): bill 60000 (1.76 wRVU) for I&D and 60280 for definitive excision on separate claims. If infection present at time of definitive excision, document increased complexity and consider modifier -22.
Ectopic thyroid mimicking TGDC
Critical pitfall. Up to 1-2% of midline neck masses in children represent ectopic thyroid — potentially the patient's only functional thyroid tissue. Always confirm normal orthotopic thyroid on preoperative ultrasound before proceeding. If ectopic thyroid is confirmed, do NOT excise — refer for endocrinology evaluation and radionuclide scan. Excising ectopic thyroid without a functioning orthotopic gland causes permanent hypothyroidism.
Thyroglossal duct cyst carcinoma (TDCC)
Rare; almost always papillary thyroid carcinoma. Sistrunk procedure alone is curative for most cases confined to the cyst without gross extrathyroidal extension or lymph node involvement. Thyroid evaluation and ultrasound mandatory. Concurrent thyroidectomy (60252, 21.46 wRVU or 60254, 27.71 wRVU) is considered when thyroid pathology is present or per institutional protocol — not routinely for all TDCC.
Charting Tips
- Confirm normal thyroid gland location on preoperative ultrasound before any surgery — ectopic thyroid mimics TGDC and excision can cause permanent hypothyroidism
- Document central hyoid bone length removed (standard is approximately 1-1.5 cm)
- State that tract was followed through tongue base musculature to foramen cecum with a core of musculature excised — this is the key step distinguishing Sistrunk from simple cyst excision and drives the reduced recurrence rate
- Document whether pharynx was entered and if so, how the opening was closed (2-3 absorbable sutures)
- Note cyst integrity — intact excision is preferred. If entered, confirm all capsule was removed
- Mark the specimen with suture for orientation (superior = cephalad end); assists pathology in evaluating superior margin
- For recurrent cases, document extent of prior excision and current dissection relative to prior scar
Billing Tips
- Bill 60280 for excision of thyroglossal duct cyst or sinus (6.01 wRVU, 90-day global). Bill 60281 for excision of recurrent thyroglossal duct cyst or sinus (8.60 wRVU). Use 60281 any time the patient has had a prior excision, regardless of how long ago or where it was performed. Document prior surgery explicitly.
- The Sistrunk procedure — cyst excision, central hyoid segment, and tract through tongue base to foramen cecum — is all bundled in 60280/60281. Do not separately bill hyoid bone excision or tract dissection.
- CPT 60000 (incision and drainage of infected thyroglossal duct cyst, 1.76 wRVU, 10-day global) applies when I&D is performed for acute infection, typically as a staged procedure before definitive excision 4-6 weeks later. If I&D and excision are performed at separate sessions, bill 60000 for the I&D and 60280 for the definitive excision.
- If infection or abscess is present at the time of excision (not staged I&D), document it — this increases operative complexity and supports modifier -22 if the dissection is substantially more difficult. To justify -22, document total operative time compared to typical, specific reason for increased difficulty, and describe the extra work performed.
- Concurrent thyroidectomy for thyroglossal duct cyst carcinoma (TDCC): use 60252 (total thyroidectomy for malignancy with limited neck dissection, 21.46 wRVU) or 60254 (extensive thyroid surgery, 27.71 wRVU) when thyroidectomy is indicated based on thyroid findings. Do not use 60240 (total thyroidectomy for benign disease, 14.66 wRVU) for malignancy. Sistrunk procedure alone is curative for most TDCC cases (papillary carcinoma confined to the cyst, no extrathyroidal extension, normal thyroid); concurrent thyroidectomy is reserved for cases with thyroid pathology or per institutional protocol.
- 90-day global period: wound checks, suture removal, and routine follow-up are bundled. Recurrence requiring re-excision within 90 days uses modifier -78. Recurrence after 90 days uses 60281.
General coding reference. Verify with your institution’s billing department before submitting claims.