Lingual thyroid and its management

Clinical details:

6 years old female patient came with complaints of:

1. Difficulty in swallowing - 6 months

2. Occasional episodes of bleeding from mouth - 2 months

On examination:

Oral cavity: Pinkish globular mass could be seen in the posterior 1/3 of tongue. The mass was firm on palpation. The posterior border of the mass was not visible on oral examination.

Both tonsils were found to be enlarged grade III.

Radiology:

X ray soft tissue neck lateral view:

X ray soft tissue neck lateral view showing mass in the suprahyoid region occupying posterior 1/3 of tongue.

Axial CT scan of neck showing mass involving the posterior 1/3 of tongue.

Contrast CT axial view showing absent thyroid gland in the neck

Ultrasound neck: Absent thyroid gland in the neck

Thyroid profile:

Pt was euthyroid with normal serum T3 T4 and TSH levels

Management:

Patient was taken up for surgery.

supra hyoid midline approach was preferred.

Skin crease incision is made just below the hyoid bone in the neck.

Skin flap elevated in the subplatysmal plane. Hyoid bone was exposed.

Supra hyoid muscles were resected from the superior border of hyoid bone

Mylohyoid muscle fibers are resected and retracted. Lingual thyroid mass removed in toto and the wound closed in layers.

Discussion:

Lingual thyroid is a rare embryonic aberration with an incidence rate of 1 in 100,000 individuals.

This condition is invariably due to failure of descent of thyroid gland. Parathyroid glands in these patients will

be found in the neck in their normal positions because of their separate origin embryologically.

Symptoms are invariably caused due to the mass effect of the lesion. It has also been pointed out that these

ectopic thyroid gland may not be in a position to cater to the increasing demands of thyroxine during menarche / pregnancy and

may undergo enlargement causing increasing symptoms. Incidence of malignancy is also more in ectopic thyroid glands hence

it is always better to resect the gland and place the patient under supplemental thyroid hormones.

Surgical approaches:

1. Removal via the oral cavity: This is the commonly practiced approach. This approach has the advantage of avoiding neck incisions.

The mouth of the patient is kept open by using Boyle's Davis mouth gag. Using either diathermy / laser / cobalator the dissection is

started from the anterior border of the mass and it is removed totally by encircling incision. Bleeders if any can be cauterized using

a bipolar cautery. This approach is advisable if the posterior border of the lesion is visible on opening the mouth.

2. Suprahyoid midline approach: This is another commonly used approach which has been described already. This lesion is useful

in patients with large lingual thyroid mass.

3. Lateral pharyngotomy approach: This approach is useful in removing big mass with a predominant vascular supply from the lingual

artery. This approach will also facilitate repositioning of ectopic thyroid mass in the neck.

4. Midline mandible and tongue splitting approach: Useful in adults with a huge lingual thyroid mass. The mandible is slit in the midline

by performing a midline osteotomy. The tongue is slit right in the middle till the foramen cecum portion is reached. The lingual

thyroid mass is removed in an encircling manner.

Fibrous dysplasia posterior ethmoid with blindness

Complaints:

48 years old male patient came with complaints of loss of vision left eye - 6 months duration.
Persistent left nasal block - 4 years
Discharge from left nose - 4 years
Head ache more on the left side - 5 years (Deep boring in nature)

Past history:

No history of epistaxis
No history of loss of smell

On examination:

Anterior rhinoscopy was unremarkable.
Post nasal examination normal.
Vision was absent in the left eye.

Imaging:

 

 

 

 

 

  

 

CT scan plain axial cut paranasal sinuses show heterodense mass arising from left posterior ethmoid air cells extending up to the anterior face of sphenoid. The mass could be seen compressing the left optic nerve. Diagnosis (Fibrous dysplasia)

 

MRI showing mass arising from posterior ethmoidal air cells on the left side compressing the left optic nerve.

 

Management:

This patient was taken up for endoscopic surgery. The mass from the left side of the nasal cavity was progressively drilled out under endoscopic vision.

Discussion:

The term fibrous dysplasia was first introduced by Litchtenstein in 1938. Usually fibrous dysplasias affect children commonly
in their teens (during the growth phase).
In any fibrous dysplasia involving the nasal cavity and paranasal sinuses the clinical presentation
is initially related to sinus obstruction, visual disturbance, facial asymmetry and nasal blockage.
In fibrous dysplasia the normal woven bone is replaced by isomorphous fibrous tissue and poorly
formed woven bone.

Classification:

Fibrous dysplasias have been classified into:
Monostotic - Involves single bone
Polyostotic - Involves multiple bones
Albright's syndrome - Endocrine hyperfunction, Unilateral Café-au-lait spots, and polyostotic fibrous dysplasia

Among these types the monostotic fibrous dysplasia is more common accounting for 70% of all fibrous dysplasias.

Rarely fibrous dysplasia may become more aggressive and dedifferentiate causing (desmoplastic fibroma). Sometimes the tissue may undergo sarcomatous transformation.

Excision of these mases makes sense because of their propensity to undergo malignant transformation.

Risk factors for malignant transformation include:
1. Polyostotic form
2. Post radiation sequelae
3. Facial bone involvement
4. Albright's syndrome

 

 

Fibrous dysplasia posterior ethmoid with blindness

This is an interesting case report of a patient with fibrous dysplasia of posterior ethmoid with blindness.

Complaints:

48 years old male patient came with complaints of loss of vision left eye - 6 months duration.
Persistent left nasal block - 4 years
Discharge from left nose - 4 years
Head ache more on the left side - 5 years (Deep boring in nature)

Past history:

No history of epistaxis
No history of loss of smell

On examination:

Anterior rhinoscopy was unremarkable.
Post nasal examination normal.
Vision was absent in the left eye.

Imaging:

 

 

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CT scan plain axial cut paranasal sinuses show heterodense mass arising from left posterior ethmoid air cells extending up to the anterior face of sphenoid. The mass could be seen compressing the left optic nerve. Diagnosis (Fibrous dysplasia).

MRI showing mass arising from posterior ethmoidal air cells on the left side compressing the left optic nerve.

Management:
This patient was taken up for endoscopic surgery. The mass from the left side of the nasal cavitywas progressively drilled out under endoscopic vision.

Discussion:

The term fibrous dysplasia was first introduced by Litchtenstein in 1938. Usually fibrous dysplasias affect children commonly
in their teens (during the growth phase).
In any fibrous dysplasia involving the nasal cavity and paranasal sinuses the clinical presentation
is initially related to sinus obstruction, visual disturbance, facial asymmetry and nasal blockage.
In fibrous dysplasia the normal woven bone is replaced by isomorphous fibrous tissue and poorly
formed woven bone.

Classification:

Fibrous dysplasias have been classified into:
Monostotic - Involves single bone
Polyostotic - Involves multiple bones
Albright's syndrome - Endocrine hyperfunction, Unilateral Café-au-lait spots, and polyostotic fibrous dysplasia
Among these types the monostotic fibrous dysplasia is more common accounting for 70% of all fibrous dysplasias.
Rarely fibrous dysplasia may become more aggressive and dedifferentiate causing (desmoplastic fibroma). Sometimes the tissue may undergo sarcomatous transformation.
Excision of these mases makes sense because of their propensity to undergo malignant transformation.
Risk factors for malignant transformation include:
1. Polyostotic form
2. Post radiation sequelae
3. Facial bone involvement
4. Albright's syndrome

The Tamilnadu Dr MGR Medical University MBBS Prefinal Otolaryngology March 2010 question paper with solution

The Tamilnadu Dr MGR Medical University MBBS Prefinal Otolaryngology March 2010 question paper with solution has been uploaded.

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Interesting case report of invasive mucor mycosis causing palatal destruction

Clinical details:
38 years old female
Diabetic on poor glycemic control
Complaints:

Ulcerative lesion of right side of hard palate - 2 years
Devitalization of upper premolars - 6 months
On examination:

Nasal cavity - Whitish mass seen inside the right nasal cavity. The mass was insensitive to touch and cheesy.
Floor of right nasal cavity found to be eroded.

Oral cavity - Slough covered lesion seen in the right side of hard palate. On probing there was no bone palpable
through the slough.

Investigations:
Biopsy from the lesion was reported as mucormycosis.
These fungi can be seen as large number of aseptate ribbon like hyphae with right / obtuse angle branching in necrotic tissue.

Imaging:

Ct scan showing heterodense mass occupying the right maxillary sinus with destruction of its medial wall.
The mass could be seen extending to the right nasal cavity with destruction of the floor of right nasal cavity.

Discussion:

Synonyms include - zygomycosis / phycomycosis
Two main types of mucor mycosis infections occur in humans. They are superficial and visceral.
Superficial mucormycosis involves external ear, fingers and skin commonly.
The visceral form could be Gastrointestinal, rhinocerebral, pulmonary or disseminated.
Visceral forms of mucor infections are common in diabetics and immune compromised individuals.
Among these visceral types the rhinocerebral type is the most common. This is due to the fact that the
nasal mucosa is normally colonized by mucor. Rhinocerebral mucor mycosis can be subclassified into two types.
They include:
Type I - Rhino orbito cerebral. This form is highly fatal
Type II - Rhinomaxillary form. This form is not fatal. This case belongs to type II category.
Mucor infections has a strong prediliction to involve blood vessels, nerves and lymphatics. Invasion of arteries causes
avascular necrosis of the infected area.
Mucor is known to thrive in acidic and glucose rich medium, which is common in a diabetic. Hyperglycemia also impairs
neutrophil chemotaxis thereby reducing immunity.
In addition increased availability of micronutrients like iron in diabetics increase the pathogenecity of the organism.

Management:

Is by wound debridment.
Control of diabetes.
Administration of amphoteracin B.

Tamilnadu Dr MGR Medical Univeristy MBBS Prefinal otolaryngology september 2010 question paper with solution has been upped

The Tamilnadu Dr MGR Medical University Prefinal MBBS otolaryngology September 2010 question paper with solution has been released. Access it from here.

drtbalu's otolaryngology resources: Laryngomalacia

drtbalu's otolaryngology resources: Laryngomalacia: "Introduction: The term Malakia in Greek means softening. The term indicates softening of larynx. This is a disease of infants and children..."

Laryngomalacia

Introduction:

The term Malakia in Greek means softening. The term indicates softening of larynx.
This is a disease of infants and children. This disease is characterised by the presence of stridor which is caused due to excessive redundancy of supraglottic tissues which gets sucked into the glottis due to the negative pressure caused during inspiration. The stridor in these patients are inspiratory in nature.

Age of onset:
This condition gets manifested within first two weeks after birth and usually resolves when the child reaches the age of 2.

Pathophysiology:

1.Excessive redundancy of supraglottic soft tissues
2.Immaturity of neuromuscular system
3.Immaturity of cartilages of larynx
4.GERD
5.Submucosal gland hyperplasia

Possible mechanisms causing stridor in these patients include:

1.Indrawing of cuneiform cartilages on inspiration
2.Omega shaped epiglottis of infants curls upon itself
3.The arytenoids collapse inwards
4.The epiglottis gets displaced against the posterior pharyngeal wall
5.Short aryepiglottic folds
6.Overtly acute angle of epiglottis at the laryngeal inlet

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