Introduction Thyroglossal duct cyst and/or fistula represent the most common congenital anomalies of the neck. Many procedures have been described for excising thyroglossal cysts. These procedures vary from simple cyst excision to anterior block neck dissection. Objective The aim of the paper was to evaluate the concept of posterior hyoid space according to the Maddalozzo modification of the Sistrunk operation. Patients and methods This prospective study was carried out at the general surgery departments of Benha and Zagazig University Hospitals. Twenty-eight patients diagnosed with primary thyroglossal duct cyst were included in this study. The surgical technique used was that described by Maddalozzo et al. Results Twenty (71%) patients had anterior neck cystic swelling and eight (29%) patients had neck fistula. After histopathological examination, the tract passed in front of the hyoid bone in all cases (100 %), whereas ectopic thyroid follicles were detected ventral to the hyoid bone in 11 (39%) cases, behind the hyoid bone in three (11%) cases, and in four (14%) cases, it was found in both the ventral and the dorsal position. Conclusion Our results were promising, and this approach of posterior hyoid space should be studied more extensively for assessment of its efficacy and benefits. This method should also be used to evaluate the possible role of ectopic thyroid tissues in recurrence with the use of the classic Sistrunk procedure.