A 32-yr-old woman presented to the anesthetic clinic for preoperative evaluation for excision of a lingual thyroid. The pink mass was seen in the midline at the base of tongue and partly covered with yellow slough (Panel A). Contrast computed tomography showed the well-defined homogenously enhancing mass (black arrow) at the base of tongue (Panels B and C). The mass was not encroaching on the epiglottis (white arrow), and there was no evidence of airway obstruction.

Lingual thyroid is a rare developmental anomaly and results from failure in descent of the thyroid gland from the foramen cecum to its normal prelaryngeal site.1  The prevalence is 1:100,000 to 1:300,000 with a female:male ratio of 4:1.1 

There are no predictors of a difficult airway in patients with midline lingual masses, and oral examination may not reveal any abnormality, especially with more posteriorly located masses.2  Asymptomatic patients may present with difficulty in mask ventilation and/or intubation due to pressure effects of the mass on the epiglottis.2  Oral airway insertion to prevent tongue collapse after anesthesia induction or direct laryngoscopy and oral intubation may result in significant bleeding due to trauma to the glandular tissue.1 

In this case, we have planned to secure the airway with awake flexible bronchoscopy.3  In patients presenting with difficult airway due to undiagnosed lingual masses, video-assisted, laryngoscopy-guided intubation is an option and may be better than a laryngeal mask airway or flexible bronchoscopy because it is a visually guided procedure and the vallecula can be mechanically lifted to visualize the glottis.

Competing Interests

The authors declare no competing interests.

References

1.
Buckland
RW
,
Pedley
J
:
Lingual thyroid: A threat to the airway.
Anaesthesia
2000
;
55
:
1103
5
2.
Ovassapian
A
,
Glassenberg
R
,
Randel
GI
,
Klock
A
,
Mesnick
PS
,
Klafta
JM
:
The unexpected difficult airway and lingual tonsil hyperplasia: A case series and a review of the literature.
Anesthesiology
2002
;
97
:
124
32
3.
Apfelbaum
JL
,
Hagberg
CA
,
Caplan
RA
,
Blitt
CD
,
Connis
RT
,
Nickinovich
DG
,
Hagberg
CA
,
Caplan
RA
,
Benumof
JL
,
Berry
FA
,
Blitt
CD
,
Bode
RH
,
Cheney
FW
,
Connis
RT
,
Guidry
OF
,
Nickinovich
DG
,
Ovassapian
A
;
American Society of Anesthesiologists Task Force on Management of the Difficult Airway
:
Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.
Anesthesiology
2013
;
118
:
251
70