746 THE BRITISH JOURNAL O F SURGERY

SHORT NOTES O F RARE O R OBSCURE CASES

A PEDUNCULATED THYROID TUMOUR AT THE BASE OF TEE TONGUE, ARISING FROM TEE REGION OF

TEE FORAMEN CdXUM. BY PRANK HARVEY, LONDOS.

TUIIOURS consisting of thyroid tissue which grow a t the base of the tongue are portions of the thyroglossal mass which develops from the hypoblast in the middle of the furrow that lies between the two elevations on the floor of the primitive pharynx, from which the buccal and pharyngeal parts of the

FIG. $S(i.-Thyroid tuiiiour of the tongue.

tongue are formed.1 These tumours are more often solid than cystic, con-

immature development. When growing in the region of the foramen caecum they are generally sessile, and rarely peduneulated as in the case to be dcscribed.

HISToRY.-on July 2, 1924, I saw with Dr. Harold Greenish, of Fleet, Hants, a girl, age 26 years, who had had a severe haemorrhage from the niouth on the previous day. The patient had complained to her parents for some months oE difficulty in breathing and swallowing ; but little

FIG. 48i.-Appenrance of tuiiiour with sisting of vascular thyroid tissue of tongue held forwards.

RARE OR OBSCURE CASES 747

notice was taken of her complaints, owing to her bcing considered mentally deficient.

For two years thyroid extract had been given with good effect, but had been discontinued, as the patient became very troublesome and refused to take it, and the parents were apathetic. Menstruation commenced a t 14 years, and is, at the present time, regular. The patient’s parents are normal individuals, as are the other members of the family.

ON E x . ~ ~ I ~ N A T I o N . - T ~ ~ girl is cretinoid, stunted in growth, being Only 4 feet 4 inches in height, undeveloped mentally, talks and behaves like a child of eight or nine years of age. No thyroid gland is paIpabIe.

Skin and hair are normal.

FIG. 4BB.--Rlicroscopical appearance of a section of the tumour. ( x 6 5 . )

The patient was anzmic when I first examined her, from the hacmorrhage of the previous day. On looking inside the mouth a tumour could be seen lying a t the back of the tongue nearly filling the space between the anterior pillars of the fauces and pushing the uvula forwards (Fig. 486). The tumour was mobile, about the size of a waInut, pinkish in colour, and with large blood-vessels coursing over it. By using a small laryngeal mirror i t was possible t o see the attachment of the tumour to the base of the tongue, which was by a short, thick pedicle, about a quarter of an inch in thickness. The epiglottis could not be seen. AS the presence of the tumour was causing dyspncea and dysphagia, and also because oi the severe hzemorrhage that had occurred on the previous day, it was decided to remove it.

748 THE BRITISH JOURNAL O F SURGERY

OPERATION, July 4, 1924.-The patient was given a general anxsthetic. A Doyen’s gag was introduced and the tongue held forwards hy a clip (Pig. 487). To avoid hEmorrhage two curved needles threaded with No. 2 catgut were passed undcr the pedicle. An elliptical incision was made with a scalpcl and the tumour with its pediclc was removed. The sutures were tied and effectually controlled the hacmorrhage, which was not severe. Convalescence proved uneventful. The patient has taken thyroid extract since the operation eighteen months ago, with marked improvement in her mental condition.

MICROSCOPICAL EXAMINATION (Fig. 485).-Dr. Cavendish Fletcher and Dr. €1. A. Osborne kindly examined the tumour for me and reported as follo\vs :-

‘& The specimen is a soft rounded mass about the size of a large walnut. It is dull-pink in colour and one section was found to be mainly solid with a small central lumen which on histological examination proved to be a false cyst due to free hacmorrhage and degeneration-a common occurrence in thyroid tumours. The solid portions of the tumour are composed of a cuboidal cpithclium arranged in alveolar and tubular masses-sometimes solid but frequently displaying a central lumen. The stroma is of connective tissue-frequently hyaline-and there is a copious blood-supply. There is no definite colloid. The tumour is encapsuled and obviously an adenoma, resembling a thyroid f e t a l adenoma.”

I have looked through the literature of thyroid tumours in the region of the tongue, but have not found any reference to one with so definite a pediclr, and Sir James Berry, who has taken a kindly interest in the prepara- tion of this paper, tells me he has never seen one.

CONCLUSIONS. 1. Islets of thyroid tissue met with along the course of the thyroglossal

tract are portions of the thyroglossal mass which develops a t the base of the tongue, and are probably left behind as that mass sinks down the neck to occupy the normal position of the thyroid gland.

2. These tumours are generally sessile and rarely pedunculated. 3. In the majority of cases operative procedures are contra-indicated,

owing to the danger of inducing myxaedema. It is only whcn these tumours cause definite symptoms, such as severe dyspncea and dysphagia, that opera- tive treatment is called for.

Finally, I wish to acknowledge my indebtedness to Mr. Ralph Coyte for correcting the proofs of this paper, to Mr. Thornton Shiells for his beautiful drawings of the case, and Mr. Ford for his drawing of the micro- scopical section.

REFERENCE. KEITH. SIR ARTHUR, Human Embryology and Morphology, 1913, 3rd ed., 244, 249,

London, Edward Arnold.