Lingual thyroid is a rare congenital condition where thyroid tissue is found at the base of the tongue due to improper descent during embryonic development. This blog explores a complex case involving a 60-year-old male patient presenting with a lingual thyroid, highlighting the diagnostic process, surgical approach, and outcomes.
A 60-year-old gentleman arrived with complaints of difficulty in swallowing, a problem he had endured for several years. Initial clinical examinations and diagnostic tests were initiated to understand the nature of the issue and determine an effective treatment path.
A flexible laryngopharyngoscopy revealed a smooth swelling at the base of the tongue. However, this test could not determine the consistency of the swelling.
A contrast-enhanced MRI provided crucial insights, confirming that the swelling was solid. Differential diagnoses at this stage included:
The midline positioning and slow growth of the lesion were characteristic of a lingual thyroid.
Given the location of the swelling and its proximity to critical structures, airway management was of utmost importance. The medical team decided against a tracheostomy. Instead, they performed an intubation guided by a flexible scope, ensuring safe airway control during the surgery.
The patient was placed in Rose’s position, and a Boyle-Davis mouth gag was used. Adjustments were made to account for the patient’s limited mouth opening and buck teeth. A smaller blade size ensured better control during the procedure.
The team employed coblation, using an Evac 70 wand initially, later switching to a Procise Max wand. Coblation was chosen for its ability to minimize collateral damage through its 4-in-1 functionality:
The surgery focused on creating a plane between the lingual thyroid and intrinsic tongue muscles. The dissection involved:
The lesion was successfully excised in two segments to ensure complete removal. Coblation significantly minimized tissue damage and postoperative complications, such as charring or collateral damage to surrounding structures. The patient was kept intubated overnight to monitor airway safety and prevent any complications during extubation.
Coblation provided precise tissue removal with minimal thermal damage, proving especially effective in the confined, vascular environment of the tongue base.
Handling such tools requires significant expertise. The surgeon’s ability to adapt to challenges—like switching between wands and ensuring continuous traction—was critical to the procedure’s success.
Advanced equipment like the Da Vinci robotic system offers an alternative approach for similar cases. Transoral robotic surgery can provide enhanced precision and reduced surgeon fatigue.
