Ectopic lingual thyroid with vascular anomalies
A 17-year-old female presented to our outpatient clinic complaining of a sensation of a lump in her throat and moderate dysphagia following an episode of acute rhinopharyngitis. Her height was 158 cm and weight was 63 kg. The patient had no family history of metabolic abnormalities. The ear, nose and throat examination identified a swelling of the base of the tongue. The swelling appeared round with an approximate diameter of 3 cm; it was near the foramen cecum; it had a reddish color; and it had an irregular nonulcerated surface. Fiberoptic endoscopy identified the swelling in the glossoepiglottic area (). It was mobile during deglutition. A thyroid scintigraphy, with technetium-99 pertechnetate, showed a single contrast enhancement in the sublingual region, instead of in the normal anatomical position of the thyroid (). Determination of blood levels of the thyroid hormones showed a free triiodothyronine (FT3) of 3.0 pg/mL (normal range: 2.4–4.2 pg/mL), a free tetraiodothyronine (FT4) of 1.0 ng/dL (normal range: 0.8–1.7 ng/dL), and TSH of 5 IU/mL (normal range 0.3–5.0 IU/mL).\nThe patient started medical suppressive therapy with levothyroxine 25 mcg/day for the first 2 weeks and 50 mcg/day for the next 9 months, but no reduction in either swelling or symptoms was observed, so she was scheduled for surgical treatment.\nA preoperative neck computed tomography (CT) identified an nonhomogeneous, hyperdense soft tissue with distinct margins and round shape at the base of the tongue, with a maximum diameter of 3 cm, and absence of the thyroid gland.\nThe vascularization of the mass was evaluated through carotid arteriography. The mass was vascularized by collateral branches of the lingual arteries in its anterior and posterior regions. The superior and inferior thyroid arteries were bilaterally absent ().\nSurgery was then performed using a transoral approach, under general anesthesia. The mass was removed, with an electrosurgical needle, along a cleavage plane from the foramen cecum backwards to the glossoepiglottic vallecula; hemostasis was adequate. A surgical reconstruction of the base of the tongue was performed by suturing the remaining area of the tongue, and a nasogastric tube was inserted. The nasogastric tube was removed 6 days after surgery, and the patient was discharged a day later with hormone replacement therapy, without deficiency in swallowing or speaking.\nThe hormone replacement therapy was based on thyroxine tablets 50 μg/day.\nHistologically, the mass was found to be “thyroid tissue with alternation of hyperplastic and colloid cystic areas, coated with a layer of squamous epithelium.” The surgical specimen measured 3 × 3 cm ().