Lingual Thyroid Unmasked by Acute Stroke: A Hidden Airway Emergency

Ectopic thyroid tissue, most commonly presenting as a lingual thyroid, is a rare congenital anomaly that is typically asymptomatic. However, when symptomatic, it can cause local symptoms, such as dysphagia, or, rarely, acute airway compromise. We report a unique case where a previously compensated lingual thyroid became immediately life-threatening due to acute stroke-related bulbar motor dysfunction. A 63-year-old man presented with an acute unilateral stroke (left corona radiata infarct). Emergency noncontrast head CT, performed according to the stroke protocol, incidentally revealed a large, 4.0 cm, calcified mass at the tongue base, severely narrowing the oropharyngeal airway. Acute stroke-related bulbar motor dysfunction (manifested as dysarthria and impaired pharyngeal control) compromised the patient's airway protective reflexes, creating a high risk of obstruction and aspiration. Iodine-123 scintigraphy confirmed that the mass was the patient's sole functioning thyroid tissue (absent orthotopic gland). An airway-first multidisciplinary strategy was immediately initiated: tracheostomy under local anesthesia, followed by definitive en bloc resection via midline mandibulotomy/glossotomy with vascular control. The patient was successfully transitioned to lifelong thyroid hormone replacement and achieved a good functional recovery. This case demonstrates that even mild, unilateral stroke-related bulbar motor dysfunction can be sufficient to unmask a previously compensated anatomical obstruction (lingual thyroid), resulting in an acute airway emergency. Effective management requires an immediate, multidisciplinary approach centered on securing the airway safely before tumor resection.