Lymphatic malformation of tongue

Kiran Petkar1,2,*

1Consultant Plastic Surgeon, Kauvery hospital Bangalore, Hosur

2Life Member ISSVA

*Correspondence: drkiranpetkar2009@gmail.com; +91 8769183863

Case Presentation

A 32-year-lady presented with a bulky right side of her tongue since childhood. It has been gradually enlarging and reached a size that interfered with speech and deglutition over the last few years. Besides, she frequently got small vesicles along the right border of the tongue which often got infected before subsiding, only to appear again.

On Examination

It was a firm swelling restricted to anterior tongue on right side. There was bluish hue on the under surface of the tongue. The swelling was non-reducible, non-compressible, non-tender. There were intermittent harder areas. Movement of the tongue was limited both due to the bulk as well as the weakness of the tongue muscles on that side (Fig. 1).

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Clinical diagnosis:

Clinical diagnosis was lymphatic malformation which was hardened at places due to repeated infection and scarring.

Imaging

Imaging Imaging was done to confirm and record the diagnosis, to rule out other components of vascular malformations and to delineate the extent of the lesion. A contrast MRI and colour doppler revealed microcystic lymphatic malformation restricted to the right side of the anterior tongue. (Figs. 2,3) There was no high-flow component. The lesion was found to be interspersed with the intrinsic tongue muscles.

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Management

Debulking of the tongue by excision of the lesion was planned. Routine blood tests including clotting factors were done.

General anaesthesia through nasal intubation and throat packing was used.

Dorsal and ventral myomucosal flaps were elevated and the lesion was excised (Fig. 4).

Lesion was differentiated form the muscle by vision under magnification and the serous oozing on cutting with electrocautery.

Maximum amount of the lesion was excised with minimum amount of interspersed healthy muscle fibres.

Excess of the expanded tongue mucosa was trimmed and closed.

Dead space between the myomucosal flaps was obliterated with sutures.

Post-operatively, the diet was restricted to liquids for two days.

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Recovery

Recovery was uneventful.

Histopathology

Confirmed microcystic lymphatic malformation.

Evolution

Edema subsided in one week. Deglutition and speech improved over the next fortnight. Mild intrinsic muscle weakness on the operated side improved as demonstrated by good tongue thrust (Fig. 5). Tactile and special sensation of taste are intact.

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Discussion

An understanding of vascular anomalies had been hampered in the past decades owing to the unfortunate mix-up in the nomenclature. Every vascular lesion was erroneously labelled as hemangioma or lymphangioma. Fortunately, ISSVA (international society for study of vascular anomalies) classification has ended the confusion mainly by distinguishing vascular tumors (omas) from malformations (Fig. 6).

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Lymphatic malformations are normal lymphatic cell rests that happen to be formed in excess amounts at certain anatomical location during embryonic development. They can be in isolation or in combination with other vascular components. Lymphatic malformation of the tongue is described discretely. As the lesion only grows with the body, radical excision sacrificing healthy tissues is not necessary. Treatment is required when bulk causes mechanical or pressure effects and/or for cosmetic purposes. Treatment is aimed at debulking the organ by maximal excision of the lesion. Serial or repeat excision is also considered in order to preserve the healthy structures in close relation to the lesion.

Dr.-Kiran-Petkar

Dr. Kiran Petkar

Consultant Plastic Surgeon