TONGUE

LESIONS

Thilanka Umesh Sugathadasa

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Disorders of the Tongue

Anatomy of the Tongue

Structure of the Tongue

Dorsal surface

Keratinized squamous epithelium present.

Contains filiform, fungiform, vallate & foliate papillae along with taste buds.

Ventral surface

Non- keratinized stratified squamous epithelium with numerous blood vessels.

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Functions of the Tongue

Formation of the food bolus

Taste sensation

General sensation

Speech

Deglutition

Self-cleansing process

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Tongue Lesions

Condition Other factors Clinical features Diagnosis & Mx

Erythema Migrans

Common genetic condition.

Tongue is having red patches(Geographic tongue)

It causes sore tongue.

Affects children’s as well as adults

Erythema migrans typically involve the dorsum of the tongue, sometimes the ventrum, and rarely other sites of the oral mucosa.

They are irregular red, depapillated map like areas. Sometimes surrounded by distinct yellowish or whitish slightly raised margins.

Spread or move to other areas sometimes within hours.

Also those red areas change shape, increase in size & spread or migrate.

Sometimes tongue also fissured.

Increased thickness of the intervening filiform papillae.

Often asymptomatic

Occasionally the similar lesions may be the oral manifestation of systemic conditions such as Psoriasis or Reiter’s syndrome

Diagnosis by history & appearance.

No treatment needed.

Correct any deficiency states.

Median Rhomboid glossitis

Depapilated rhomboidal area in the Centre of the dorsum of the tongue just anterior to the sulcus terminalis.

Can occur at any age.

Predisposing factors are smoking Denture wearing Corticosteroids sprays/ inhalers HIV infections

Rhomboidal shape

Red/ Smooth- depapilated

Nodular lesion just anterior to the circumvallate papillae.

Occasionally white

Occasionally hyperplastic or even lobulated exophytic appearance.

Clinical diagnosis

Tobacco habits should be stopped.

Antifungals

Foliate papillitis

Inflammation of the foliate papillae.

The foliate papilla contains lymphoid tissues & may occasionally become inflamed as it happen with tonsillar tissues which also contains tonsillar aggregates.

Seen on the lateral border of the tongue in the area of the junction between anterior 2/3 & posterior 1/3 of the tongue.

Cause mild soreness.

Patient need reassuarence.

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Also this is not an uncommon site for development of oral malignancies including lymphomas.

Macroglossia

May be congenital or acquired.

Congenital causes of macroglossia are congenital hypothyroidism.(cretinism)

Muscular hypertrophy as may occur in facial hemihypertrophy.

Beckwith’s hypoglycemic syndrome.

Down’s syndrome and in mucopolysachcharidosis(Hurler’s & Hunter’s syndrome)

Secondary macroglossia may occur in Acromegaly, Amyloidosis & due to Haemangioma, Lymphangioma & neurofibromatosis.

Lingual Thyroid

Presence of the nodular swelling on the posterior 1/3 of the dorsum of the tongue in the midline posterior to the foramen caecum.

This is near the apex of the v-shaped arrangement of the circumvallate papillae.

Developmentally it is the site of origin of the thyroid gland.

Oftenly this may be the only thyroid tissue present in the patients.

So should not do the excision of the nodule until confirmed the neck thyroid gland is functioning or not by scintigraphic examination with radioactive iodine.

Sometimes may be fibroepithelial lesion can be diagnosed by the above test.

Fissured Tongue

Hereditary condition

Down’s syndrome

Variant of orofacial granulomatosis reffered to as Melkersson Rosenthal syndrome

Sjogren’s syndrome(Can see lobulations)

Apparently increases with the age.

Vitamin deficiency

Black or brown hairy tongue.

Occur in the posterior dorsum of the tongue.

Can see tuftof black or brown hairy growth arising from that area of the tongue.

This is believed to be the hairy elongation of the filiform papillae.

No define causes, mostly color may be due to the chromogenic bacteria.

But Drugs/ Smoking/ Poor oral hygiene ./ mouth washes

Ankyloglossia

Tongue tie

No significant speech difficulty.

Tongue functions of cleansing, of teeth & vestibules during eating impaired.

Rx- Surgical excision

Atrophy of the lingual mucosa.

Localized Erythema migrans/ Median rhomboid glossitis

Generalized 1. Conditions that leads to reduction of nutrition + oxygen supply - Anaemia(Appear pallor) - OSMF(blood supply impaired so oxygen get deprived) - Radiation induce fibrosis - Epidermolysis bullosa - Cicatricial pemphigoid

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2. Diseases that affects the epithelium - OLP

Luekoplakia Chronic mucocutaneous candidosis Tertiary syphilis

Leukoplakia

Homogeneous Leukoplakia Common type, uniformly White plaque Common in buccal mucosa Low malignant potential.

Non homogeneous Leukoplakia Nodular, Verrucous, speckled types Consist of white patches or nodules in a red, often eroded area of the mucosa Have high risk of malignant transformation rate

Hairy Leukoplakia

Tuft of white hair like projections on the lateral border of the tongue.

No potential for malignant transformation rate so leukoplakia is a misnomer.

Associated with immunodeficient status including AIDS.

Also reported in the immunosuppressed renal transplant patients.

Cleft tongue

Completely cleft tongue is rare.

Partial cleft is relatively more common-manifested as a deep groove.

Also found as one feature of the oro-facial- digital syndrome.

Partial cleft may result in collection of food debris & microorganisms in the base with accompanying irritation.

Sublingual keratosis

Type of the leukoplakia seen on the ventral aspect on the tongue.

Homogeneous but wrinkled surface- often describe as “ebbing tide” appearance.

Rarely seen in the Sri Lankan patients.

More common in western countries.

High malignant transformation rate-35% or more.

Lingual varices

A varix is a dilated tortuous vein, subjected to increased hydrostatic pressure but with poor supporting tissue.

Common after the age of 50 years on the ventral aspect of the tongue-sign of aging

Red or purplish clusters of tortuous dilated veins

Crenation of the tongue

Scalloping seen on the anterior & lateral border of the tongue.

Tip of the scallops fit in to the interproximal spaces between teeth.

Seen in macroglossia & when an inflamed tongue is edematous.

Syphilitic glossitis

Found in the tertiary syphilis

Usually accompanied by syphilitic leukoplakia. Moeller’s glossitis & Hunter’s glossitis

Conditions normally occurs in the Vit B12 deficiency.

In Moeller’s glossitis a sore tongue without depapillation but with red lines on the lateral margins & tip of the tongue is seen.

Sometimes red lines may appear on the dorsum or may be red patches-pinhead size to 1cm diameter area- may mimic erythroplakia.

Hunter’s glossitis is name is given to a beefy red tongue which can be rarely seen.

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The sore tongue without visible lesions (with / without whole mouth involvement)

Deficiency – Iron , folate, Vit B12,B1, B6

Diagnosed or Undiagnosed diabetes.

Dry mouth

Drugs- eg. Captopril

Depressive illness & anxiety(cancerphobia)

Glossodynia/ Glossopyrosis are terms sometimes used.

Strawberry tongue

Deeply red tongue with atrophy of the filiform papillae but prominence of fungiform papillae.

Seen in Scarlet fever & Kawasaki disease(mucocutaneous lymph node syndrome)

Macroglassia

May be congenital or acquired.

Congenital can be seen in Congenital hypothyroidism(cretinism) Muscular hypertrophy- eg: hemihypertrophy. Beckwith’s hypoglycemic syndrome. Down’s syndrome Mucopolysachcharidosis.

Secondary macroglossia may occur in Acromegaly Amyloidosis Haemangioma Lymphangioma Neurofibromatosis

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Erythema migrans

Hereditary hemorrhagic telangiectasia

Fissured tongue

Melkerson Rosenthal syndrome

Hairy Tongue

Hairy Tongue

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Mucopolysaccharidosis

Beckwith’s syndrome

Haemangioma of the tongue

Lingual thyroid

Median Rhomboid glossitis

Median Rhomboid glossitis

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Chronic hyperplastic candidosis on the tongue

Foliate papiliitis

Ankyloglossia

Atrophy of lingual mucosa

Chronic lingual mucosal atrophy may be found in:

•Oral submucous fibrosis

•Haematinic and vitamin deficiencies and anaemia

•Oral lichen planus

•Epidermolysis bullosa due to repeated ulceration and

scarring

•Syphilitic leukoplakia

Atrophy of the lingual mucosa

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