Foramen Cecum Research Articles

Massive bleeding from an ectopic lingual thyroid follicular adenoma during pregnancy

Ectopic thyroid is a rare developmental anomaly. It can be found anywhere between the foramen cecum and the normal position of the thyroid gland. Massive bleeding from an ectopic lingual thyroid is unusual and occasionally fatal. We present a case of a 22-year-old woman who had a large mass at the base of the tongue for over 6 years. In the sixth month of pregnancy, the patient experienced massive bleeding from the tongue base mass. A thyroid scan revealed that this mass was the only functioning thyroid tissue. Because of massive bleeding and her shock status, the patient received an emergent embolization of the bilateral lingual arteries. Then the huge lingual thyroid was subsequently excised via a mandible swing approach to prevent further episodes of bleeding. Pathology analysis indicated ectopic thyroid tissue with follicular adenoma. She delivered without complications in the 36th week and had a normal baby. This case was a very rare one in our review. Although ectopic lingual thyroid usually is not managed surgically, excision of ectopic lingual thyroid can be life-saving when it is causing bleeding or airway obstruction. (Am J Otolaryngol 2002;23:185-188. Copyright 2002, Elsevier Science (USA). All rights reserved.)

A Case of Congenital Vascular Malformation which Near the Foramen Cecum and Midline of Tongue Tip

A Case of Congenital Vascular Malformation which Near the Foramen Cecum and Midline of Tongue Tip

Bilateral choanal atresia associated with nasal dermoid cyst and sinus: a case report and review of the literature

The relationship of choanal atresia to various systemic malformations is well acknowledged by the CHARGE acronym: colobomas, heart defects, atresia choanae, retarded growth and development, genito-urinary defects, and ear defects. In the past, we have reported the finding of an isolated skull base malformation associated with choanal atresia. We report here a unique case of choanal atresia associated with a patent foramen cecum and intracranial extension of a dermoid sinus. The embryogenesis of this condition is accounted for by the mesodermal flow theory of choanal atresia formation, and implies a need for thorough imaging of the anterior skull base in cases of bilateral atresia.

Ectopic thyroid tissue manifesting as a unique cause of an oropharyngeal mass

The thyroid gland descends in its embryologic development from the foramen cecum at the base of the tongue to the front of the pharyngeal gut where it reaches its final position in the seventh week. The trajectory of the migration forms the thyroglossal duct, which obliterates normally and finally disappears. When the process of migration is disturbed, aberrant thyroid tissue may appear in later life along the tract of migration. Thyroid tissue, however, has also been found at sites besides the embryologic tract of migration as in the submandibular region, in the carotid sheath, retropharyngeal, and intracardial. We present a patient in which the clinical presentation, imaging techniques, cytologic and histologic findings made the diagnosis of ectopic thyroid tissue difficult.

THE THYROID AND PARATHYROID GLANDS: CT and MR Imaging and Correlation with Pathology and Clinical Findings

Thyroid imaging approach is based on the preliminary clinical evaluation. Lesions that are smaller than 2 cm should be assessed with US, which is capable of discriminating masses as small as 2 mm and distinguishing solid from cystic nodules. US-guided FNAB provides tissue for cytologic examination of thyroid nodules. CT and MR imaging are indicated for larger tumors (greater than 3 cm diameter) that extend outside the gland to adjoining structures, including the mediastinum, and retropharyngeal region. Metastatic lymph nodes in the neck and invasion of the aerodigestive tract are also in the realm of CT and MR imaging. Thyroid nodules are categorized on scintigraphy as hot or cold nodules. Hot nodules are rarely malignant, whereas cold nodules have an incidence of 10% to 20% of malignancy. Calcifications (amorphous, globular, nodular, and linear) occur in adenomas and carcinomas and have no differential diagnostic features except for psammomatous calcifications, which are a pathognomonic finding in papillary carcinomas and a small percentage of medullary carcinomas. Papillary carcinoma is the most common malignant tumor (80%) followed by follicular (20% to 25%); medullary (5%); undifferentiated; anaplastic carcinomas (< 5%); lymphoma (5%); and metastases. Lymph node metastases are common in papillary carcinoma, 50% at presentation, and less common in follicular carcinomas. The metastatic nodes in papillary carcinoma may enhance markedly (hypervascular); show increased signal intensity on T1-weighted images (increased thyroglobulin content or hemorrhage); and reveal punctate calcifications. Localized invasion of the larynx, trachea, and esophagus occurs predominantly in papillary and follicular carcinomas; the incidence is less than 5%. Ectopic thyroid tissue may be encountered in the tongue (foramen cecum); along the midline between posterior tongue and isthmus of thyroid gland; lateral neck; mediastinum; and oral cavity. Goiter and malignant tumors, notably papillary carcinoma, may develop in ectopic thyroid tissue. Carcinomas may also arise in thyroglossal duct cysts, which develop from duct remnants between the foramen cecum and thyroid isthmus. Infectious disease of the thyroid gland is not common and the CT and MR imaging findings are similar as described under neck infection. Other types of inflammatory disorders including Hashimoto's thyroiditis, granulomatous thyroiditis, and Riedel's struma display no specific imaging features. Imaging studies may, however, be indicated to confirm a suspected clinical diagnosis and assess compromise of the airway (Riedel's struma). HPT is a clinical diagnosis in which hypercalcemia is the most important finding. Parathyroid hyperplasia, adenoma, and carcinoma represent underlying lesions. To relieve the patient's symptoms surgical extirpation is indicated. The surgical success rate without imaging is 95%. The indications for imaging studies vary but it is generally agreed that reoperation after a previous failed surgical attempt and suspicion of an ectopic parathyroid adenoma should be investigated by imaging. These consist of US, nuclear medicine studies, CT and MR imaging. US and technetium sestamibi scanning have the highest accuracy rate for localizing an adenomatous gland at and near the thyroid gland. Ectopic adenomas, particularly if they are located in the mediastinum, are preferrably investigated with CT and MR imaging with gadolinium and fat suppression. Carcinomas and parathyroid cysts are optimally evaluated by CT and MR imaging. On MR imaging adenomas are low in signal intensity on T1-weighted images, high in signal intensity on T2-weighted images, and enhance post introduction of gadolinium.

Thyroid gland and surgery of the thyroglossal duct: exercise in applied embryology.

Thyroglossal duct cysts (TDCs), the most common congenital cervical abnormality, originates from the medial anlage of the thyroid gland and presents as a painless asymptomatic midline suprahyoid mass. It does not represent a diagnostic challenge. The tract may persist as a fibrous cord or leave nests of cells anywhere along its embryonic path, and it gives rise to the development of TDC. The Sistrunk operation described in 1920 consists of en bloc cystectomy and central hyoidectomy, with tract excision up to the foramen cecum. This procedure remains an effective treatment for TDC. Malignant degeneration of TDC is rare (0.7%).

Paraganglioma of the Tongue

Paragangliomas are neuroendocrine tumors arising from extra-adrenal autonomic ganglia. We present what is to our knowledge the first immunohistochemically documented case of a paraganglioma of the tongue, a 2.5-cm benign tumor growing in the position of the foramen cecum. The patient was an elderly woman who presented with throat irritation. The histologic profile and ultrastructural appearance of this lesion were classic for paraganglioma, and cells stained strongly for neurosecretory granules by immunohistochemistry. Carcinoid, ectopic thyroid neoplasm, and other tumors that mimic paraganglioma were ruled out on immunohistochemical grounds. To our knowledge, paraganglia have not been previously documented in the tongue; this tumor may have arisen from a branch of cranial nerve VII or IX, or from an embryologic remnant of the thyroid or thyroid capsule.

Ectopic thyroid gland simulating a submandibular tumor

(Editorial Comment: The reporters call our attention to a rare situation in which a lateral neck mass is a benign ectopic thyroid.) Ectopic thyroid is any thyroid tissue not located anterior to the second, third, and fourth tracheal rings along the midline of the ventral portion of the neck. Submandibular location of the thyroid gland is a very rare congenital anomaly1 that results from the failure of the primitive thyroid premordium to descend from the foramen cecum in the embryo. The ectopic thyroid may be mistaken for a lymphadenopathy or any other mass (depending on the localization, eg, lymphangioma, ranula, salivary gland tumor, dermoid cyst, lipoma, or thyroglossal duct cyst). Surgical removal of an ectopic thyroid may lead to profound hypothyroidism, unless thyroid hormone replacement therapy is initiated, because 70% of patients with displaced thyroids

Lingual Osseous Choristoma: A Study of Eight Cases and Review of the Literature

A choristoma is a tumor-like mass of normal tissue in an "abnormal" location. Lingual osseous choristoma, previously known as osteoma of the tongue, is a rare entity: we found documentation of eight cases at our center during the 10-year period between 1987 and 1996. These cases were analyzed along with 50 others reported in the English language literature between 1913 and 1996. Lingual osseous choristoma frequently occurs during the third and fourth decades of life, and predominantly affects women (81%). Most of the osseous choristomas in our review were located in the posterior third of the tongue, primarily at or close to the foramen cecum or circumvallate papillae (87.9%). While 39.7% of the patients were asymptomatic, the remaining patients complained of symptoms including a lump in the throat (25.8%), dysphagia (6.9%), gagging (5.1%), nausea (3.4%) and irritation (3.4%). Treatment of lingual osseous choristoma consists of simple excision. The tumor's origin has been discussed elsewhere.

Anatomic location of the tongue base neurovascular bundle.

Knowledge of the location of the hypoglossal/lingual artery neurovascular bundle (HLNVB) is essential in performing tongue base resections for neoplasm and for obstructive sleep apnea. Transoral and transcervical resections of the tongue base may be performed with greater exposure and certainty when the relationship of the HLNVB to local landmarks is understood; knowledge of the HLNVB allows resection of a larger amount of contralateral tongue base during partial glossectomy without violating the contralateral remnant tongue's blood supply. Ten cadaver heads were dissected to determine the position of the HLNVB with respect to soft tissue and bony landmarks at the tongue base. Our results indicate the position of the tongue base HLNVB is significantly inferior and lateral, that is, 2.7 cm inferior and 1.6 cm lateral to the foramen cecum, 0.9 cm superior to the hyoid bone, and 2.2 cm medial to the mandible. This inferolateral location allows the potential for aggressive tongue base resection without neurovascular compromise.

Microvascular surgical anatomy of the vertebrobasilar junction.

We examined the pertinent microvascular anatomy of 28 formalin-fixed brains to develop anatomic guidelines for aneurysm surgery in the region of the vertebrobasilar junction. Using a surgical microscope, the outer diameters were observed for the following main arteries: vertebral, basilar, posteroinferior cerebellar, and anteroinferior cerebellar. The number of lower brain stem perforating arteries was examined in relation to their course. The distance between the arteries and their perforators was measured with respect to anatomic landmarks. The anatomy of the main arteries was characteristically variable, whereas the anatomy of the perforators was constant, particularly in terms of their numbers and points of penetration into the brain substance. The four major points of entry were the lateral medullary area just caudal to the posterior olivary sulcus, the posterior olivary sulcus, the small lateral fossa at the superior olivary groove, and the foramen cecum. Each of these areas coincides with the origin of common vertebrobasilar aneurysms. The anatomy of the main arteries was variable. In contrast, the perforators penetrated the adjoining brain stem at specific locations, regardless of the caliber of the main artery. Despite a small vertebral artery or its major branches, perforators penetrating the brain are significant and may effect the outcome of aneurysm surgery or endovascular procedures.

舌内に発生した甲状舌管嚢胞例

A thyroglossal duct cyst may occur anywhere between the foramen cecum area and the suprasternal notch, but only rarely does it occur in the intralingual area. A case of a thyroglossal duct cyst in the intralingual area is reported. The patient was a 19-year-old female who suffered from the sensation of a foreign body in the throat for a period of 1 month. Since a cystic mass was found at her tongue, she was referred to our department for further examination and management. MRI revealed the cystic mass to be in the left intralingual area. Suprahyoid pharyngotomy was performed to remove the cystic mass. The foramen cecum was also removed. However, the hyoid bone to which the cyst was not adherent was preserved. The resected cystic mass measured 57×30×18mm in size. Histopathologically, the cyst wall was comprised of a layer of fibrous connective tissue. No recurrence was noted within the 6 months' follow-up period.

TWO CASES OF RECURRENTED THYROGLOSSAL DUCT CYST IN WHICH PRE AND INTRAOPERATIVE CYSTOGRAPHY WERE USEFUL FOR RADICAL OPERATION

We experienced two patients with recurrent thyroglossal duct cyst (TGDC) whose radical operations were facilitated by pre- and intra-operative cystography with confirmation of residual cysts and/or fistulas. Case 1 involved a 52-year-old man with re-recurrent TGDC. His hyoid bone was not resected at the initial operation. In spite of cystectomy with hyoid bone resection at the second operation, recurrence appeared again. Case 2 involve a 28-year-old man who had been repeatedly treated by incision and drainage whenever abcess formation and high fever developed due to infection of TGDC. At the last operation he underwent a cystectomy without resection of the hyoid bone. Preoperative cysto- and fistelography using 60% Urographin and intraoperative cysto and fistelography using Pioctanin for these two cases greatly contributes to recognize the residual cystic lesions and fistulas. There procedure consequent by facilitated the radical operation for them. In a review of our previous 23 cases of recurrent TGDC at the department, these lesions were predominantly found between hyoid bone and thyroid cartilage, in a frequency of 86.9%. However, in these two cases, their lesions were located in more proximal site to the foramen cecum. Recurrence of the disease often occurs in patients whose hyoid bones are not resected and who are associated with infection at the initial operation, but it can be seen in those whose hyoid bones are resected. The causes may be residual tiny cysts and fistulas. Cystography and fistelography performed in the two cases were useful to determine the residual cysts and fistulas spreading to foramen cecum linguae after resection of the hyoid bone. In conclusion, pre- and intraoperative cystography and fistelography are useful methods not only for radical operation of recurred TGDC but also for the initial operation of TGDC.

Unusual leiomyomatous hamartoma of the hard palate: A case report

Harmartomas of the head and neck are common lesions, often taking the form of melanocytic nevi or vascular malformations such as hemangiomas and lymphangiomas. Hamartomas composed of other tissue types are much rarer and within the oral cavity are usually located on the tongue near the foramen cecum or on the anterior hard palate near the incisive papilla. Although most occur as isolated phenomena, a small number may be associated with other local developmental defects or with a syndrome complex. A normal 5-year-old girl had a 1 cm soft sessile swelling in the vault of the hard palate on the left side. Histopathologic examination showed bundles of smooth muscle embedded in fibrovascular stroma and accompanied by abundant mature fat and a small amount of salivary tissue. The features were regarded as those of a leiomyomatous hamartoma and could be distinguished from a smooth-muscle tumor, teratoma, and benign mesenchymoma by virtue of the clinical and histopathologic features. No recurrence has been seen after excision.

Ectopic thyroid tissue presenting as a midline neck mass

Ectopic thyroid tissue can be found anywhere between the foramen cecum and the normal position of the thyroid gland. Although very uncommon, it is most often found in the region of the foramen cecum, in patients in whom the gland fails to descend. Extralingual thyroid tissue is most commonly located in the anterior cervical area, the region of the thyroglossal duct. It must be differentiated from thyroglossal duct cyst, in that it frequently represents the only source of thyroid tissue. In the majority of patients with lingual thyroid tissue, this is the only functioning thyroid. We present the case of a thirteen year old male child with a midline cervical mass first noted at one year of age. Since its early presentation, this midline mass had increased and decreased in size, and over the last three months had been associated with odynophagia and anterior neck swelling. A presumptive diagnosis of thyroglossal duct cyst was made. A preoperative thyroid scan revealed that this midline mass was in fact the only functioning thyroid tissue; therefore no surgery was performed. This case demonstrates the essential role of a thyroid scan in the preoperative evaluation of a midline neck mass. Recognizing that ectopic thyroid tissue may present as a thyroglossal duct cyst and may be the only functioning thyroid avoids subjecting the child to inappropriate surgery and a life of replacement therapy.

Imaging evaluation of breast-feeding and bottle-feeding systems

To compare infant sucking and swallowing patterns during feeding with a new artificial nipple and during breast-feeding. Fifteen healthy, term infants were fed successfully for 1 week with use of the new tricut nipple; then each infant's oral cavity was examined during feeding by using real-time ultrasonography. Measurements of nipple length and compression were made, together with observations concerning the integrity of the seal formed by the infant's mouth around the nipple. These data were compared with similar data from previous studies of 16 breast-fed infants. Although no artificial feeding system exactly simulates breast-feeding, the new tricut nipple was sucked in a manner similar to the way the human nipple is sucked and delivered milk posteriorly to the foramen cecum region of the tongue, just as the breast does. Although further studies are necessary, to evaluate other characteristics of the new tricut nipple, the measurements from this investigation are useful additions to the ultrasound data these investigators have accumulated on various artificial feeding systems. These data may also prove helpful in determining the most appropriate nipples for infants with various feeding disorders.

The surgical anatomy of the perforating branches of the basilar artery.

The perforating branches of the basilar artery were examined in 14 brain stems injected with india ink or methylmethacrylate. Three groups of the perforators were distinguished: the caudal, the middle, and the rostral. The caudal perforators varied in number from two to five and in diameter from 80 to 600 microns. In addition to their terminal branches, which entered the foramen cecum, the perforators occasionally branched off the pontomedullary artery, the pyramidal vessels, and the hypoglossal branches. The middle perforators arose either separately from the basilar artery or along with the basilar artery collateral branches. They ranged in number from five to nine and in diameter from 210 to 940 microns. The perforators gave rise to the pontomedullary artery (8.3%), the long pontine arteries (25.0%), and the anterolateral vessels (100%). The rostral perforators originated from the terminal part of the basilar artery (91.6%), as well as from the superior cerebellar artery (91.6%) and the posterolateral artery (16.6%). They varied in number from one to five and in diameter from 190 to 800 microns. The anastomoses among various perforating vessels were noted in 41.6 to 66.6% of the cases. The authors discussed the possible clinical significance of the anatomical data observed in this study.

Osteoma of tongue — A short report

Osteoma of the tongue is a rare benign tumur. Not more than 40 case of this lesion have been reported in literature. The patient was a 30 year old male who presented with a pedunculated hard mobile mass protruding from the dorsal surface of the tongue near foramen cecum. Sections showed a homogeneous bony tissue. A total excision was curative.

What is the optimal depth for core-out toward the foramen cecum in a thyroglossal duct cyst operation?

The high recurrence rate of thyroglossal duct cyst operations is well documented. Sistrunk's operation is widely accepted as the best procedure to prevent recurrence. Nonetheless, the optimum depth of core-out is still not well documented. We previously reported a standard running pattern of the thyroglossal duct in an anatomical reconstruction study. In more detailed pathological studies, we have tried to determine the optimal depth for core-out toward foramen cecum and the optimal width of the hyoid bone to be resected. The following items were clarified. (1) Double the horizontal distance from midline to the most distant thyroglossal duct in front of the hyoid bone was 2.4 to 9.6 mm. (2) The length of the single duct above the hyoid bone which spreads into many ductuli as it approaches the foramen cecum was about 3 to 5 mm in 2- to 6-year old children. (3) The diameter of the thyroglossal duct at the level of the cranial top of the hyoid bone was 175 to 1,400 microns. Half of the examined cases were less than 500 microns, which may have rendered direct dissection impossible. Based on these studies, we propose: (1) that a minimum of 10 mm of the hyoid bone should be resected, and for the sake of safety, more than 15 mm is preferable; and (2) that the depth of the core-out should be less than 5 mm in young children to avoid the breakdown of the branched ductuli near the foramen cecum.

Anatomical reconstruction of the thyroglossal duct

The high postoperative recurrence rate of the thyroglossal duct cyst is well known. Since Sistrunk's operation was used, the recurrence rate was remarkably reduced, but the anatomical description of the thyroglossal duct through the entire tract has not been clarified in detail. For a more accurate anatomical understanding of the thyroglossal duct, 10 specimens obtained from Sistrunk's operation were studied using histological reconstruction, and a common running pattern of the thyroglossal duct was found. The cyst is usually located caudal to the hyoid bone mostly at the midline. The duct extends upward from the cyst ventral to the hyoid bone, with many or a few branches and secretory glands. These ducts or branches merge into a single duct at the level of the cranial portion of the hyoid bone. However, as it leaves the hyoid bone and approaches the foramen cecum, a single duct spreads out into many ductuli like the tip of a broom, which communicate with many secretory glands. There were three cases in which the duct was found behind the hyoid bone, but in no case did the thyroglossal duct run through the back of the hyoid bone. The duct behind the hyoid bone was recognized as a branch from the main duct in the dorsal direction. It ascended to the dorsal surface of the hyoid bone and terminated blind. These findings emphasized the importance of Sistrunk's operation to prevent a recurrence.