____________________________________________ LINGUAL THYROID: A CASE REPORT

Ramazan Kutlu, Tayyar Kalcioglu, Tamer Baysal, Ahmet Sigirci, Alpay Alkan Department of Radiology, Inonu University, School of Medicine, Malatya, TURKEY (RT, TB, AS, AA) Department of ENT, Inonu University, School of Medicine, Malatya, TURKEY (TK)

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Lingual thyroid is a rare anomaly representing faulty migration of normal thyroid gland. A case of a patient with lingual thyroid presenting with obstructive symptoms and absence of the normal thyroid gland is described. The literature is reviewed and typical ultrasonographic features are represented.

2002 The Journal of Radiology _____________________________________ thyroid (LT) is a rare developmental thyroid anomaly usually affecting females. It is usually located in the midline and in base of the tongue [1]. Although the exact pathogenesis of this ectopic, accessory thyroid tissue is not known, it generally originates from epithelial tissue of non-obliterated thyroglossal ductus [1, 2]. In this report, a case of lingual thyroid in a 40 year old female patient with difficulty in breathing and swallowing complaints for ten years is presented and the role of ultrasound (US) is emphasized.

Lingual

at the base of the tongue extending to the pharynx (Figure 1]. The thyroid gland was not seen on thyroid US examination (Figure 2). Neck US showed a 60x45 mm, smooth contoured, nodular mass containing hypo and anechoic areas (Figure 3). Doppler US revealed low resistance arterial blood flow in the periphery of the mass (Figure 4A, 4B). Direct transoral US over the lesion also showed nodular mass containing cystic and necrotic areas (Figure 5). Technetium 99m thyroid scan revealed isotope uptake in the tongue area and no uptake in the normal thyroid location (Figure 6). Fine needle aspiration biopsy from the mass revealed thyroid tissue with colloidal changes. According to the results of thyroid function tests patient was euthyroid [total T3: 140 ng/dl (82-179); total T4: 5,32 ng/dl (4,5-12,5); free T3: 2,35 pg/dl (1,8-4,2); free T4: 0,75 ng/dl (0,8-1,9); TSH: 1,53 m/u/ml (0,4-4)]. Other laboratory tests were within normal limits. Suppression treatment was given and elective operation planned.

DISCUSSION
The failure of migration of thyroid tissue along the path from ventral floor of the pharynx to its normal location and sequestration within the tongue substance leads to the development of LT [3]. The thyroid gland develops as an endodermal diverticulum between first and second pharyngeal pouches [2]. The tongue and thyroid gland develop at the same time and anatomically the tongue is related with the thyroglossal tract. At the seventh week of gestation the thyroid gland is an endodermal pouch in the foramen cecum, which is the remnant of thyroglossal tract. Normally thyroid gland descends along a path from foramen cecum in the tongue to the final position in front of trachea,

CASE PRESENTATION
A 40 year old female patient was admitted with complaints of difficulty in breathing and swallowing for 10 years that increased progressively. The medical history was insignificant except for a tonsillectomy 12 years previously. P hysical examination revealed a 5 x 5 x 5 cm fixed, hard mass that was covered with normal mucosa in the base of the tongue. The thyroid gland was nonpalpable. A lateral neck roentgenogram showed a smooth contoured, rounded density

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Figure 3. Neck US showing a 60x45 mm mass of regular and smooth contours, containing hypoechoic and anechoic areas.

Figure 1. Lateral neck roentgenogram showing round, smooth countered density increase in the base of the tongue extending into the pharynx.

4A

Figure 2. Thyroid US showing absence of thyroid gland in normal location.

4B Figure 4. Doppler US images showing peripheral blood vessels (A) and low resistance arterial flow (B).

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Figure 5 . Transoral US performed directly over the mass reveals cystic and necrotic areas within the lesion.

Figure 6. Technetium 99m scan showing isotope uptake in the tongue region and absence of isotope uptake in the normal thyroid position. over the thyroid cartilage. This descent may arrest anywhere along this path and this condition may remain unnoticed until puberty [3, 4]. The incidence of LT is reported as 1:100000. It is 7 times higher in females [1]. About 33% of the patients show hypothyroidism findings [5]. Dysphagia, dysphonia, pain, bleeding and fullness in the throat are included among the presenting symptoms. There is no age predisposition and can be seen in every age. The clinical presentation of LT could be classified into two groups according to the appearance of the symptoms. The first group consists of infants and children who had the abnormality found during routine screening. Patients with dysphagia and oropharyngeal obstructive

symptoms during or before the puberty constitute the second group that our patient belonged to this group. As a response to the increased demand for thyroid hormone during puberty, hypertrophy of the gland is seen. A similar response is also encountered during other metabolic stress conditions like pregnancy, infections, trauma, menopause etc [5]. LT usually presents itself as a midline, nodular mass in the base of the tongue. The surface of the lesion is usually smooth and vascularity can be seen [1]. This was the case in our patient and with the help of Doppler US vascularity of the lesion was demonstrated. In about 70% of the patients with LT there is an absence of normal thyroid gland [4]. For that reason if surgical removal of the mass is planned, scintigraphic and radiological examinations together with laboratory tests should be performed to reveal ectopic thyroid tissue. There was no normal thyroid gland on scintigraphic and radiological examinations in our case. Histologically LT resembles normal thyroid tissue [4]. If a goitregenous stimulus is present, colloidal changes are seen like in our case. These changes have a similar US appearance to that seen in normal thyroid glands. If emergency surgery is not necessary, suppression therapy should be tried first in order to decrease the dimensions of the mass. This was the case in our patient and elective surgery following the suppression therapy was planned. Even in the absence of normal thyroid gland, LT is sufficient enough to make the patient euthyroid [4]. The demonstration of the ectopic thyroid tissue is important from the point of thyroid dysgenesis and US plays an important role. Although an uncommon lesion, lingual thyroid should be considered in the differential diagnosis of masses in the oropharynx. US features of LT help in the diagnosis of this lesion.

REFERENCES
1. PS Douglas, AW Baker: Lingual thyroid. Br J Oral Maxillofac Surg 1994, 32: 123-124. 2. JG Batsakis, AK El-Naggar, MA Luna: Thyroid gland ectopias. Ann Otol Rhinol Laryngol 1996, 105: 996-1000. 3. D Ueda, Y Yoto, T Sato: Ultrasonic assessment of the lingual thyroid gland in children. Pediatr Radiol 1998, 28: 126-128. 4. MU Akyol, M Ozcan: Lingual thyroid. Otolaryngol Head Neck Surg 1996, 115: 483-484.

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5. JD Williams, AP Sclafani, O Slupchinskij, C

Douge: Evaluation and management of the lingual

thyroid gland. Ann Otol Rhinol Laryngol 1996, 105: 312-316.

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