Thyroglossal duct cysts and fistulae represent the most common congenital midline neck anomalies encountered in otolaryngology, with high recurrence rates historically reported following simple excision. In 1920, Dr Walter Ellis Sistrunk fundamentally transformed their management through an embryologically informed surgical approach that addressed the developmental origin of the thyroglossal duct. By recognising the intimate relationship between the duct tract, the foramen cecum, and the central portion of the hyoid bone, Sistrunk proposed en bloc resection of the cyst or fistula, the entire duct tract, and the mid-portion of the hyoid. His landmark publication demonstrated a dramatic reduction in recurrence compared with prior techniques, establishing a new surgical standard. Over a century later, the Sistrunk procedure remains the definitive treatment for thyroglossal duct anomalies, with only minor technical refinements despite advances in imaging, anaesthesia, and perioperative care. Its enduring success reflects the strength of its embryological foundation and meticulous surgical principles rather than reliance on evolving technology. This historical review highlights Dr Sistrunk’s lasting contribution to otolaryngology and underscores the importance of anatomical and embryological insight in developing durable surgical innovations. The continued relevance of the Sistrunk procedure serves as a rare example of a century-old operation that remains essentially unchanged and universally adopted in current surgical practice.