Difficulty in swallowing is called dysphagia. The causes of dysphagia can be divided into pre-esophageal and esophageal causes. While evaluating a case of dysphagia, it is important to consider whether it occurs in young age or old age, and the onset and subsequent progression of dysphagia. A sudden onset usually indicates an inflammatory process or foreign body impaction while a more gradual onset points towards a benign or malignant growth. Intermittent episodes of dysphagia may indicate spasmodic episodes.
Dysphagia and its relation to food is also important. Dysphagia to liquids usually indicates a motor impairment while dysphagia to solids indicates an obstructive lesion. Progressive dysphagia to both solids and liquids indicates malignancy.
While examining a patient of dysphagia, it is important to perform a thorough examination of the oral cavity, the oropharynx, hypopharynx, larynx, esophagus and the neck. The thyroid gland should also be examined along with neurological examination.
A case report published in the Indian Journal of Pediatrics reports a case of dysphagia due to lingual thyroid along with hypothyroidism. Lingual thyroid is developmental anomaly in which the thyroid analage arising from the ventral pharynx between the first and second pharyngeal pouch fails to descend in its normal position. The thyroid tissue is seen between the circumvallate papillae and the epiglottis at the base of the tongue. This may be the only functioning thyroid tissue in the body in 70% cases. It can present either in the young age or in adults. Symptomatic lingual thyroid is more common in adults. It can present with dysphagia, dysphonia, bleeding, difficulty in breathing. It can also present with hyperthyroidism or hypothyroidism.
MRI is the investigation of choice. It can also be visualized by CT scan. Radionuclide scanning using radioactive iodine or 99m Tc pertechnetate is also done to locate the thyroid glandular tissue. Thyroid function tests should also be done to evaluate the thyroid function. The differential diagnosis of midline mass at the base of the tongue is teratoma, carcinoma and soft tissue sarcoma.
In symptomatic patients the lingual thyroid can be surgically removed. In patients who are unfit for surgery or unwilling to undergo surgery it can also be treated with radioactive abalation of the thyroid.
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