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A 26-YEAR-OLD WOMAN was diagnosed with primary hypothyroidism in 1999, and commenced levothyroxine replacement. In 2001 she presented with a 20 lb weight loss due to increasing dysphagia to solid food and throat discomfort. Her thyrotropin (TSH) was 6.0 (normal 0.4-5.0 mIU/mL). Examination of her oropharynx noted a large round mass occupying most of the pharyngeal fossa ( Fig. 1, lower left). This mass was consistent with a lingual thyroid by 99m Tc pertechnetate scanning ( Fig. 1, top). The 123 I radioiodine uptake was 24% with mouth closed and 28% with mouth open. The difference was due to teeth attenuating the photons. 131 I therapy was selected to decrease the size of the lingual thyroid. The thyroid size was reduced by 50% 3 months after the treatment (Fig. 1, lower right) along with marked improvement in swallowing.Hypothyroidism occurs in up to 33% of individuals with a lingual thyroid because of small gland size and limits to hypertrophy. This incidence starts increasing during puberty with rising metabolic needs (1). TSH suppression is the initial therapy for mildly affected and asymptomatic patients. Surgery is invasive and thus reserved for those with severe obstructive complaints (2). 131 I ablation appears to be an effective treatment approach with limited complications and prompt resolution of symptoms (3). References1. Silverman BL 2000 Denouement and discussion: Lingual thyroid. Arch Pediatr Adolesc Med 154:184. 2. Kalan A, Tariq M 1999 Lingual thyroid gland: Clinical evaluation and comprehensive management. Ear Nose Throat J 78:340-349. 3. Danner C, Bodenner D, Breau R 2001 Lingual thyroid: Iodine 131: A viable treatment modality revisited. Am J Otolaryngol 22:276-281.

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