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Atrophic Glossitis

Atrophy of the filiform and fungiform papillae of the tongue leads to a bald shiny, erythematous tongue dorsum. Such atrophy is often seen in hematinic deficiencies and in patients with prolonged hyposalivation such as those with Sjögren syndrome or after head and neck radiation therapy.213

Clinical Findings

The tongue presents with a smooth, bald appearance and papillae are atrophic (Fig. 76-18). Patients often complain of a burning sensation and experience sensitivity when eating acidic, salty, or crunchy foods.21 They may have associated angular cheilitis if there is a hematinic deficiency. Patients who develop malabsorption after intestinal surgery are prone to developing atrophic glossitis.226

Laboratory Studies and Differential Diagnosis

Patient should have blood work to rule out hematinic deficiencies, in particular iron and vitamins B6 and B12 deficiency. For the last, assay of methyl malonic acid may be more sensitive than just a B12 level alone.

Management and Prognosis

Treatment is with repletion of deficient elements. Topical anesthetics help to control symptoms.

Hairy Tongue (Black Hairy Tongue, Coated Tongue)

This is an extremely common condition that causes much confusion. There is generally an antecedent history of illness and antibiotic use, leading to a common misdiagnosis of candidiasis. There are usually no other lesions on other oral mucosal sites and no pain, which would be highly unusual for candidiasis. To further add to the confusion, a small number of such patients will grow Candida on culture because they are carriers.

Hairy tongue is caused by retention of keratinaceous debris on the tongue dorsum resulting from two factors acting alone or in combination: (1) dehydration (leading to more sticky and mucous rather than serous saliva) and (2) poor oral intake (eating a soft diet or one low in fresh fruits and vegetables).54 Since most patients have an antecedent history of illness or are hospitalized, they often are dehydrated and have poor appetite. Chromogenic bacteria that reside in the tongue produce metabolic by-products that sometimes stain the tongue, as do food dyes.

Clinical Findings

The tongue presents with a matted or coated appearance that is usually symmetric (Fig. 76-19). If located on the posterior midtongue, patients may experience gagging if the “hairs” are long. The thickened matte of keratin on the tongue leads to increased bacterial colonization and their metabolic products (often sulfides) may lead to a foul or stale breath. Such metabolic products may stain the tongue a variety of colors such as brown or black.

Figure 76-19

A. Hairy tongue. B. Brown hairy tongue.

Differential Diagnosis and Laboratory Studies

Candidiasis involving the dorsum of the tongue is an important differential diagnosis, but has more patchy distribution of the curdy plaques, associated erythema, a less symmetric distribution, and involvement of other parts of the oral cavity by similar candidal papules and plaques. Ingestion of bismuth subsalicylate may transiently lead to a black tongue.182

There is no test that is useful. Rare cases have been biopsied and show only elongated filiform papillae. Cultures for Candida are positive in 20%–30% of patients and likely indicate carrier status.

Management and Prognosis

Vigorous hydration and return to a normal diet with fresh fruits and vegetables generally resolve the lesions. The tongue may be brushed as part of the daily oral hygiene regimen to help to dislodge loose keratin squames and reduce discoloration. Hairy tongue is not harmful to the patient.

Fissured Tongue

This is a common condition that occurs in 1%–2% of the population and is generally believed to be developmental in etiology.211

Clinical Findings

It is fairly uncommon in the first and second decade of life and usually seen in adults. Some believe that Candida reside within the fissures and cause symptoms.

There are two main patterns. The first consists of a central fissure, either alone or with smaller fissures radiating from it at right angles (Fig. 76-20A). The second pattern is one of short fissures distributed evenly throughout the tongue without the central fissure (Fig. 76-20B). Some patients report some sensitivity of the tongue with spicy or acidic foods, although in general, this condition is asymptomatic.21 Approximately one-third of patients with migratory glossitis (see below) have concomitant fissured tongue.

Figure 76-20

A. Fissured tongue. B. Fissured tongue with migratory glossitis on right.

Differential Diagnosis and Laboratory Studies

The clinical presentation is striking and a biopsy is not useful. The presence of sensitivity should prompt a careful examination for the presence of migratory glossitis, atrophic glossitis, or even candidiasis within the fissures.

Management and Prognosis

Most lesions are noted on routine examination, are asymptomatic and do not require therapy. Some patients who are symptomatic show resolution of symptoms with a short course of antifungal therapy, but predisposing factors for candidiasis must be addressed or the lesions will recur.

In general, fissured tongue is a permanent condition. However, some patients report that fissures are evanescent.

Benign Migratory Glossitis/Stomatitis (Geographic Tongue)

Clinical Findings

This occurs in 1%–2% of the population and is associated with a fissured tongue in about 30% of cases.211,227 There is an area of atrophy of the tongue dorsum leading to loss of filiform papillae and a slightly depressed erythematous area that is usually sensitive or painful, especially when acidic foods come in contact with it (Figs. 76-21 and 76-22A and B). Such demarcated areas rimmed by a raised white border that is circinate or serpiginous are diagnostic.228 Waning lesions are often merely well-demarcated erythematous patches. A history of atopy is often elicited from such patients or from immediate family members.227 Approximately 13% of patients with psoriasis develop this tongue condition.229 Flare-ups are associated with both physical and psychological stress.

Figure 76-21

Typical migratory glossitis.

Figure 76-22

A. Migratory glossitis presenting with mostly erythema and atrophy. B. Subtle migratory glossitis.

Infrequently, other mucosal sites such as the palatal mucosa, floor of mouth or buccal mucosa may be involved. In such cases, the term “migratory stomatitis” should be applied.230

Differential Diagnosis and Laboratory Studies

Erythematous candidiasis may cause depapillation of the tongue dorsum and cause some soreness and sensitivity.231 Identification of candidal hyphae via cytology distinguishes the two. LP and MMO on the lateral tongue are white lesions that are sometimes mistaken for this condition, but biopsy showing a psoriasiform pattern with many spongiotic pustules in the absence of candidal hyphae is diagnostic.

Management and Prognosis

Patients should be reassured that this is not infectious in etiology, a common concern. Diphenhydramine used as a swish and spit preparation or 2% viscous lidocaine may reduce symptoms. If severe, topical steroids (especially dexamethasone) are helpful. However, patients need to realize that this is an evanescent lesion that tends to recur.

Macroglossia, hyperplastic lingual tonsil, papillitis of the tongue, and tongue nodules are discussed online.

Clinical Macroglossia

Macroglossia refers to the diffuse enlargement of the tongue that may be symmetric or asymmetric. Patients report that the tongue seem enlarged and is more readily traumatized by biting since it may now overly the mandibular teeth. Mild symmetric enlargement is usually caused by loss of muscle tone such as in aging or with some systemic conditions such as amyloidosis.

Loss of muscle tone (“flabby tongue”) is particularly obvious in older patients who have lost all their teeth so that there is concomitant loss of bone height in the mandible. The tongue appears to “spread” over the edentulous mandibular ridge and this also makes it difficult for the lower denture to stay in place. Patients with trisomy 21 often have such flabby tongues.

Asymmetric enlargement is usually caused by the presence of a tumor, in particular a vascular malformation of either lymphatic (lymphangioma) or blood vascular origin (venous malformation) that tends to insinuate between the muscle fibers rather than produce an encapsulated mass.

Differential Diagnosis and Laboratory Studies

In cases of amyloid deposits or a neoplasm, a biopsy is diagnostic. An MRI study is usually helpful for soft tissue tumors in the tongue that present with asymptomatic enlargement.

Management and Prognosis

The diagnosis relies on a careful clinical history and examination, with biopsy as necessary. For symmetric lesions, there is no treatment unless the patient resorts to a surgical recontouring of the tongue.

For patients with amyloidosis, a work-up for plasma cell dyscrasia is indicated. For patients with other tumors, excision with/out the use of embolization in the case of vascular tumors is the treatment of choice.

Hyperplastic Lingual Tonsil

The lingual tonsil is located on the posterolateral aspects of the tongue bilaterally and is part of Waldeyer ring. In its healthy form, it lies below the foliate papillae (Fig. 76-23). Inflammation of this tissue from trauma or upper respiratory tract infection leads to hyperplasia. Although the term “foliate papillitis” is often used for this condition, the more accurate term is “hyperplastic lingual tonsil.”

Figure 76-23

Hyperplastic lingual tonsil.

Clinical Findings

The hyperplastic lingual tonsil, when inflamed, protrudes as a fleshy, soft area with a slightly irregular surface (because of the crypts in the overlying foliate papillae), which then becomes more readily traumatized that then makes it even more inflamed and protuberant.21

Differential Diagnosis and Laboratory Findings

This posterolateral tongue is a common site for SCC and the fairly rapid appearance of this lesion may mimic cancer. Lymphomas may also develop in this area.

Biopsy shows benign hyperplasia of lymphoid tissue.

Management and Prognosis

Excision is curative. Intralesional steroid injections may reduce the size of the lesion so that it is no longer traumatized.

Papillitis of Tongue

There are several forms of papillitis and they represent irritation of the tongue papillae either from local trauma, dryness, or a hypersensitivity reaction (possibly to a contactant).

Clinical Findings

One form is transient lingual papillitis that presents as multiple enlarged white papillae scattered over the surface of the tongue that tends to be relapsing–recurring.232234 Another form presents as reddened and enlarged fungiform papillae on the dorsum of the tongue (Fig. 76-24). A rare form is eruptive papillitis with intrafamilial transmission.235

Management and Prognosis

Dexamethasone mouth rinse reduces inflammation. However, the inciting factor must be addressed to prevent recurrence.

Tongue Nodules

As with the lip, nodules on the lateral tongue tend to have a traumatic etiology and include fibromas (and its variant giant cell fibroma) and traumatic neuroma. More common tumors of the tongue include benign nerve sheath tumors, granular cell tumors, oral lymphoepithelial cyst, vascular lesions such as pyogenic granulomas or venous malformations, and osseous and cartilaginous hamartomas.

All require excisional biopsy and have diagnostic histopathology.

image Xerostomia and hyposalivation are discussed online and in Chapter 161.

image Saliva is very important in maintaining the health of the oral mucosa. It assists in lubrication of the surfaces, begins the digestion of food, helps to prevent infections when the mucosal integrity is lost, and plays an important role in immune regulation and defense. It is important in preventing caries. Recent studies suggest that oral secretions may help predict the presence of malignancies.236