Modified approach for lingual thyroid transposition: report of two cases

Transposition of the lingual thyroid gland to the submandibular region through a submandibular approach: A case report

BACKGROUND

Ectopic thyroid at the base of the tongue is a rare congenital condition, and it is even rarer to have clinical symptoms and require surgical intervention. This disease is easily misdiagnosed preoperatively. This article reports the diagnosis, surgical treatment, and follow-up of a case of lingual thyroid.

CASE SUMMARY

The patient was a 54-year-old woman who presented with laryngeal foreign body sensation and dysphagia for 20 d. The lingual thyroid was considered for general examination, and surgery was performed to transpose the lingual thyroid to the right submaxillary region. Pathological analysis confirmed thyroid tissue. The patient experienced complete remission after surgery, but developed hypothyroidism and required thyroid hormone replacement therapy, and her thyroid function gradually recovered over time.

CONCLUSION

We report a rare case of lingual thyroid with marked laryngeal foreign body sensation and dysphagia. Symptoms were completely relieved by transposition surgery but postoperative hypothyroidism developed.

Tongue Base Ectopic Thyroid Tissue-Is It a Rare Encounter?

Failure in the embryological development of the thyroid in adults is rarely seen. We present the case of a 79-year-old female patient who complained of dysphagia and progressive upper respiratory obstruction, which started 12 months prior to her admission. An ENT clinical exam revealed a tongue base, spherical, well-defined tumour covered by normal mucosa. Further assessments established the diagnosis of the tongue base ectopic thyroid tissue. Due to the patient's symptoms, a transhyoid tongue base tumour removal was performed. The selected patient gave consent for participation and inclusion in this paper, in compliance with the 1964 Helsinki declaration.

ECTOPIC LINGUAL THYROID PRESENTING WITH MASSIVE HEMATEMESIS

Ectopic lingual thyroid is a rare developmental abnormality caused by aberrant embryogenesis during thyroid migration. Even though, most patients are asymptomatic, uncommonly the mass can be enlarged and cause dysphagia, dyspnea, upper airway obstruction, dysphonia, hypothyroidism. We report a very rare case of ectopic lingual thyroid presenting with massive hematemesis.

Laryngo fiberscopy-guided suspension procedure for an ectopic lingual thyroid obstructing airway

BACKGROUND

Currently, there is no consensus regarding the optimal therapeutic strategy for the management of an ectopic lingual thyroid. A surgical approach is suggested when airway obstructive symptoms cannot be tolerated at all, or when bleeding or malignancy occurs. However, for patients in whom ectopic thyroid is the only functioning thyroid tissue, complete surgical excision needs to be followed by lifelong hormone replacement therapy. We report the case of an infant with ectopic lingual thyroid obstructing the airway that was treated using our novel surgical procedure.

CASE PRESENTATION

A 10-day-old male infant presented with symptoms of airway obstruction and subclinical hypothyroidism. Imaging tests revealed an ectopic lingual thyroid and the absence of a normal pretracheal thyroid gland. We administered oral levothyroxine to lower his thyroid stimulating hormone (TSH) level and reduce the volume of the lingual mass; however, his airway symptoms did not improve. Subsequently, we performed a surgical intervention when he was 2 months old. We split the hyoid bone, and then suspended the lingual thyroid by suturing it to the hyoid bone to elevate the epiglottis. We confirmed the degree of suspension using intraoperative laryngo fiberscopy. After the surgery, the symptoms of airway obstruction were resolved and the patient was clinically euthyroid on low-dose oral levothyroxine.

CONCLUSIONS

Our laryngo fiberscopy-guided suspension procedure can be an effective surgical procedure for the treatment of ectopic thyroid. This relatively simple surgical procedure could completely preserve the patient's thyroid tissue and resolve airway obstruction.

Clinical characteristics and molecular pathology of skull ectopic thyroid cancer

Thyroid cancer is very common, but skull ectopic thyroid cancer has not been reported in 50 years of literatures in foreign countries. There are only four cases of the skull ectopic thyroid cancer reported in more than 30 years of domestic literature including the cases in this report. This paper aims to investigate the clinical characteristics and possible molecular mechanisms of this rare disease. Five keywords of "thyroid gland", "ectopic thyroid", "thyroid cancer", "ectopic thyroid cancer" and "metastatic thyroid cancer" were included and 50 years of literatures in the PubMed-MEDLINE and Wanfang database were reviewed. By combining the test data of 2 cases of surgical patient tissue microarray specimens-molecular immunology pathology, the possible molecular mechanisms were analyzed and molecular regulation network diagram was drawn. The skull ectopic thyroid cancer has not been reported in 50 years of literatures in foreign countries and there are only four cases of the skull ectopic thyroid cancer reported in more than 30 years of domestic literature including the cases in this report. The molecular expressions of skull ectopic thyroid cancer, orthotopic thyroid cancer, and metastatic thyroid cancer were not the same: (I) AKT (P=0.012, 0.002) and mTOR (P=0.002, 0.004) were highly expressed in the skull ectopic thyroid cancer; (II) BRAF (P=0.029, 0.014) and ERK (P=0.002, 0.001) were highly expressed in orthotopic thyroid cancer; (III) MMP-9 (P=0.023, 0.016) was highly expressed in metastatic thyroid cancer. According to the molecular information base, the PI3K is predicted to be a key crossing gene of the above three signaling pathways, which showed no significant differences in these three thyroid cancers (P=0.692, 0.388, 0.227), but PI3K has regulation roles in the three signaling pathways of Akt/mTOR, MAPK, and NF-κB. PI3K gene is an important starting gene of thyroid cancers. After the canceration starts, due to the fact that the local microenvironments of thyroid cancers in different parts are different, the thyroid cancers are regulated by different signaling pathways. The ectopic thyroid cancer was correlated with Akt/mTOR pathway high expression; orthotopic thyroid was related with MAPK/BRAF/ERK signaling pathway high expression; and the metastatic thyroid cancer was related with NFkB/MMP9 high expression.

Transposition of lingual thyroid gland to the submandibular region by transoral approach

The purpose of this case report is to demonstrate surgical technique of only functional but symptomatic lingual thyroid gland transposition to submandibular region by transoral approach without mandibulotomy and tongue-splitting. A 37-year-old female patient was admitted to our hospital with dysphagia and apnea symptoms. Physical examination revealed 3cm×3cm lingual thyroid gland was detected at the tongue base. The patient was euthyroid and thyroid gland was not detected in the neck. Under general anesthesia, right submandibular gland excision and transposition of lingual thyroid tissue to submandibular region with dorsal lingual artery axis flap were performed by transoral approach. Thyroid hormones remained normal in the postoperative period. In conclusion transoral transposition of lingual thyroid to submandibular region as a flap without mandibulotomy is a minimally invasive and function preserving alternative approach. Besides preserving thyroid functions, this transoral surgical technique can be preferred by patients who avoid skin incision for esthetic concerns.

Lingual Thyroid Ectopia: Diagnostic SPECT/CT Imaging and Radioactive Iodine Treatment

BACKGROUND

Lingual thyroid is a rare abnormality of thyroid development that is usually treated conservatively with levothyroxine replacement. Rarely, it becomes large enough to cause obstructive symptoms in the oral cavity, requiring definitive treatment.

PATIENT FINDINGS

This study reports on three patients with lingual thyroid treated with radioactive iodine-131 ((131)I) with successful radioablation of their ectopic thyroid tissues. Measurement of 24-hour radioactive iodine uptake within thyroidal tissues and hybrid single-photon emission computed tomography/computed tomography imaging using either iodine-123 or technetium-99m pertechnetate scans were performed in all patients demonstrating the location and size of lingual thyroid and absence of an orthotopic thyroid gland.

SUMMARY

The aim of this study was to describe nonsurgical management of obstructive lingual thyroid tissue with (131)I therapy for lingual thyroid radioablation. Patients were prepared with a low-iodine diet and levothyroxine withdrawal prior to radioablation for optimizing (131)I uptake in ectopic thyroid tissues. Hybrid single-photon emission computed tomography/computed tomography measurement of anatomic size of lingual thyroid tissue and radioactive iodine uptake guided the selection of therapeutic doses, resulting in administration of 10.7, 17.5, and 15.4 mCi of (131)I, respectively. There were no post-therapy complications, and clinical follow-up demonstrated resolution of obstructive oropharyngeal symptoms.

CONCLUSIONS

Ectopic lingual thyroid tissue is rarely associated with obstructive oropharyngeal symptoms due to progressive enlargement. Radioiodine therapy with (131)I is an effective treatment modality for ablation of ectopic thyroid tissue as an alternative to surgery.

LINGUAL THYROID: 35-YEAR EXPERIENCE AT A TERTIARY CARE REFERRAL CENTER

OBJECTIVE

Lingual thyroid (LT) results from a developmental abnormality due to failure of the thyroid gland to descend to its pretracheal position. Given the low incidence of this disease, standardized management recommendations are lacking. We aimed to describe our institution's experience in LT management and to suggest a practice algorithm.

METHODS

We conducted a retrospective review of LT diagnosed at Mayo Clinic, Rochester, Minnesota, between 1976 and 2010. Demographics, clinical presentation, laboratory data, treatment received, and outcomes were collected.

RESULTS

We identified 29 patients with LT. Eighty-three percent were female; age at diagnosis ranged from 2 weeks to 68 years. Almost one-third of patients were symptomatic, with the most common symptoms being cough and hoarseness. The diagnosis of LT was incidental in 9 patients (31%). Seventy-two percent of patients developed hypothyroidism. Levothyroxine was the treatment of choice, followed by thyroidectomy. Two asymptomatic euthyroid patients were followed without any intervention.

CONCLUSION

Management of patients with LT should be individualized and guided by the patient's symptoms and thyroid hormone status.

Morphological, diagnostic and surgical features of ectopic thyroid gland: a review of literature

Ectopic thyroid tissue remains a rare developmental abnormality involving defective or aberrant embryogenesis of the thyroid gland during its passage from the floor of the primitive foregut to its usual final position in pre-tracheal region of the neck. Its specific prevalence accounts about 1 case per 100.000-300.000 persons and one in 4.000-8.000 patients with thyroid disease show this condition. The cause of this defect is not fully known. Despite genetic factors have been associated with thyroid gland morphogenesis and differentiation, just recently some mutation has been associated with human thyroid ectopy. Lingual region in the most common site of thyroid ectopy but ectopic thyroid tissue were found in other head and neck locations. Nevertheless, aberrant ectopic thyroid tissue has been found in other places distant from the neck region. Ectopic tissue is affected by different pathological changes that occur in the normal eutopic thyroid. Patients may present insidiously or as an emergency. Diagnostic management of thyroid ectopy is performed by radionuclide thyroid imaging, ultrasonography, CT scan, MRI, biopsy and thyroid function tests. Asymptomatic euthyroid patients with ectopic thyroid do not usually require therapy but are kept under observation. For those with symptoms, treatment depends on size of the gland, nature of symptoms, thyroid function status and histological findings. Surgical excision is often required as treatment for this condition.

Transposition of a lingual thyroid to the submandibular space using a modified technique

OBJECTIVE

We report a modified surgical technique for transplanting an ectopic, lingual thyroid to the submandibular space, in order to maintain thyroid function while relieving obstructive symptoms.

CASE REPORT

A 52-year-old woman complained of progressive dysphagia and dyspnoea. Ectopic lingual thyroid tissue was diagnosed. The ectopic thyroid gland was transplanted into the submandibular region via a lateral pharyngeal approach. A random muscle pedicle was prepared to provide a vascular supply to the transposed gland.

RESULTS

Twelve-month follow up confirmed the survival of the transplanted thyroid gland, with preserved thyroid function.

CONCLUSION

Surgical transplantation of a lingual thyroid to the submandibular region offers an alternative treatment method for this anomaly, which avoids the need for resection and lifelong thyroxine replacement.

A new minimally invasive lingual thyroidectomy technique

BACKGROUND

The lingual thyroid is uncommon, and the need for resection of this condition is even more rare. Techniques for removal have historically included wide access with associated disfiguring incisions. We sought to describe a minimally invasive and safe technique for the management of the obstructive lingual thyroid gland that achieves optimal hemostasis with the use of technology.

METHODS

Institutional Review Board approval was obtained to evaluate the safety and efficacy of a minimally invasive technique to remove the obstructive lingual thyroid gland. The procedure is performed in ∼1 hour; requires no splitting of the lip, tongue, or mandible, is associated with negligible blood loss, and is accomplished on an outpatient basis.

RESULTS

The procedure was undertaken in a 34-year-old woman with a longstanding lingual thyroid that began to cause dysphagia. She was found to be clinically and biochemically euthyroid, and was referred for surgical intervention. The procedural time was 90 minutes, and the estimated blood loss was 15 mL. She was discharged shortly after recovery, on an outpatient basis.

CONCLUSIONS

A number of surgical approaches to the obstructive lingual thyroid have been described, including the use of a lip-split, tongue-split, mandibulotomy, and cervical pharyngotomy approach. We describe a minimally invasive transoral procedure that incorporates Harmonic technology and high-resolution endoscopy and is accomplished with no external incisions on an outpatient basis.

Concurrent lingual thyroid and undescended thyroglossal duct thyroid without orthotopic thyroid gland

Thyroglossal duct cyst and lingual thyroid are two common anomalies of thyroid gland development. Each may occur without the thyroid gland in the normal anatomic position, although the association of these three anomalies together is rare. Ectopic thyroid may function abnormally, and this determination can help guide surgical management. Therefore, early evaluation by an endocrinologist is an important part of the therapeutic approach. We report on the presentation and management of a 14-year-old girl with multiple foci of thyroid ectopia, absent orthotopic thyroid gland, and hypothyroidism.

Multinodular goitre in lingual thyroid: case report

Objective:

We report a case of a multinodular goitre developing in a lingual thyroid.

Method:

Case report, and discussion of the embryology and treatment of lingual thyroids.

Case report:

A 66-year-old woman presented with dysphagia secondary to a multinodular lingual goitre. A previously silent lingual thyroid had undergone multinodular change to cause dysphagia and eventually airway compromise. The goitre was excised via a midline, mandible-splitting approach.

Conclusion:

Lingual thyroids have an incidence of one in 3000 to 10 000. There has not previously been a reported case of such an ectopic gland undergoing multinodular changes and presenting in later life.