This patient’s presentation is consistent with a lingual thyroid. When obstructive symptoms are present, surgical excision of the ectopic thyroid tissue followed by appropriate thyroid hormone replacement is the best management.
A lingual thyroid results from failure of the normal caudal migration of the thyroid gland from the foramen cecum down to its normal position anterior to the larynx and trachea. Either the entire thyroid or just a portion of the gland may fail to migrate. Hypothyroid symptoms are noted in up to 30% of patients with a lingual thyroid. Caution must be used in surgically excising a lingual thyroid, as this may be the only thyroid tissue in the patient, with removal leading to severe hypothyroidism.
Walling reviews ectopic thyroid tissue. Ectopic thyroid tissue can appear in any position from the base of the tongue to the mediastinum (see Illustration C). Symptoms associated with ectopic thyroid tissue are varied: some are asymptomatic, others may experience symptoms related to local obstruction or hemorrhage. Thyroid supplementation is often required in these patients.
Toso et al. describe the management of ectopic lingual thyroid. The ectopic thyroid tissue may be the only thyroid tissue present in the patient, thus for patients with mild symptoms, the authors recommend conservative substitutive thyroid hormone therapy only. If the ectopic thyroid tissue is causing obstructive symptoms, particularly of the airway, they recommend surgical removal. With surgical removal, thyroid function must be evaluated pre- and post-operatively due to the risk of post-operative hypothyroidism.
Illustration A depicts a lingual thyroid gland manifesting as a red mass located at the base of the tongue.
Illustration B demonstrates how a lingual thyroid might obstruct the esophagus and thus lead to feeding difficulties.
Illustration C depicts possible locations for ectopic thyroid to occur.
Answer 1: This medication regimen would be more appropriate for a case of hyperthyroidism, such as Graves' disease.
Answer 2: Correct treatment for acute thyroiditis; however, antibiotic therapy will not address the hypothyroid symptoms noted in the presentation of this child.
Answer 3: Possible treatment for a lingual thyroid; however, given the patient's obstructive symptoms and resultant feeding difficulties, surgical excision would be preferred.
Answer 5: Both the hypothyroid and obstructive symptoms seen in this patient are indications for pursuing treatment.
Walling AD. Ectopic thyroid tissue. Am Fam Physician. 1987 Sep;36(3):147-50.
PMID:3630879 (Link to Abstract)
Toso A, Colombani F, Averono G, Aluffi P, Pia F. Lingual thyroid causing dysphagia and dyspnoea. Case reports and review of the literature. Acta Otorhinolaryngol Ital. 2009 Aug;29(4):213-7.
PMID:20161880 (Link to Abstract)