Abnormalities of Tongue

There are many types of tongue abnormalities. They are fairly common. They can be Tongue tie, Macroglossia, Black Hairy tongue, Median Rhomboid Glossitis, Microglossia, Geographic tongue, Tongue Cancer. The details of these conditons are discussed as under:

What is Tongue-Tie

Tongue -Tie (Ankyloglossia) is a problem caused by abnormal development of the tongue.It is a congenital condition, in which the tongue is tied down to the floor of the mouth.The tongue is normally connected to the floor of the mouth by a thin cord, called a frenum.

With tongue-tie the frenum is too short and thick. It prevents the tongue from moving freely.  

 Effect of Tongue-Tie (Ankyloglossia)

Ankyloglossia in breastfeeding infants can causeineffective latch, inadequate milk transfer, and maternal nipplepain, resulting in ultimately weaning. It also causes the speech problem and there is difficulty in swallowing.

Macroglossia

 It is a tongue enlargement that leads to functional and cosmetic problems. Normal speech and swallowing requires normal tooth anatomy and function. Swallowing begins as a tongue mixes food with saliva to form food bolus which is then propelled into the pharynx. Articulation also depends on the tongue ability to alter the impedance of air and change the resonant characteristics of the upper airway. In macroglossia increase tongue bulk impair these functions.

Classification of Macroglossia

It can be generalized or localized.

What Are the Symptoms of Macroglossia

In macroglossia the tongue is always protruded which makes it prone to trauma and drying due to which the upper respiratory tract infections are common. There is speech impairment along with drooling of saliva. Patient has difficulty in swallowing, chances of air way obstruction are there and the patient fails to thrive.

Treatment – treatment is surgical removal of the part of the tongue also called as partial glossectomy with anterior wedge technique. Resection is indicated when there is airway obstruction, difficulty in speech or swallowing and because of cosmetic reasons.

Black Hairy Tongue

It is a disorder characterized by changes in the appearance of tongue. It results from overgrowth of the papillae that house the taste buds.

Causes – Black Hairy Tongue

1. It is caused when filliform papillae elongate and fail to desquamate or fall off.

2. Antibiotics can also cause it.

3. Heavy smoking is also one of the reasons

4. Antiseptic mouthwashes

5. Majority of cases: no known cause

Signs and Symptoms of Black Hairy Tongue

It produces brownish or black areas of discolouration of the tongue.it appear as if there is hair on the tongue. It is more common in middle of the tongue.

Treatment of Black Hairy Tongue

Treatment consists of good oral hygiene and use of a toothbrush or tongue scraper to aid with the desquamation of the tongue. Use of antifungal drugs may be warranted if there is a suspicion of Candida infection.  

Median Rhomboid Glossitis - Central Papillary Atrophy of Tongue

 It is a congenital abnormality of tongue. Rhomboid shape area of desquamation occurs on dorsal surface of tongue, just anterior to circumvallate papillae.

Causes of Median Rhomboid Glossitis - Central Papillary Atrophy of Tongue

 1. Failure of tuberculum impar to recede during fusion of the two lingual swellings during the development of tongue.

2. Not a developmental anomaly; it is due to localized chronic fungal infection

Clinical Features

1. Ovoid, diamond - shape present just anterior to circumvallate papillae

2. Age - most of cases are not diagnosed until the middle age of the affected patients, but the entity is of course present in childhood

3. Sex - male: female

              3   : 1

4. Infected cases may also demonstrate a midline soft palate erythematic in the area of routine contact with the underlying tongue involvement; this is euphemistically, reffered to as a kissing lesion

5. Lesions are typically less than 2cm in greatest dimension and most demonstrate a smooth, flat surface, although it is not unusual for the surface to be lobulated

Geographic Tongue - Benign Migratory Glossitis - Wandering Rash of Tongue

Migratory glossitis is psoriasis – like or psoriasis related condition of tongue resulting in the production of snaky white lines on the tops and sides, often with small parallel grooves adjacent to them.

Causes – the cause is unknown

 

Clinical Features of Benign Migratory Glossitis

Serpiginous white lines may be quite pronounced and often surrounded by the erythematous areas of papillae loss or edematous papillae. White snaky lines with parallel grooves are characteristic.  Small grooves parallel to some lines are present. Many cases have irregular red macules without obvious white peripheral lines.  Here the patient also has a mild white coated tongue, a common co morbid feature of geographic tongue. The erythematous macules are much more obvious when combined with white coated tongue or, as here, with a mild white hairy tongue.  Occasional macules are outlines with irregular white lines, a pathognomonic feature.Geographic tongue occurs even in children and infants

Treatment of Benign Migratory Glossitis

No treatment is usually necessary for benign migratory glossitis. Symptomatic lesions can be treated with topical prednisolone and topical or systemic antifungal medication can be tried if secondary candidiasis is suspected.  

Microglossia

It is a uncommon condition usually congenital.

It is characterized by small tongue. 

Clinical Features of Microglossia

There is difficulty in speech and swallowing.

In oncology squamous cell cancers of the head and neck are often considered together because they share many similarities - in incidence, cancer type, predisposing factors, pathological features, treatment and prognosis. Up to 30% of patients with one primary head and neck tumor will have a second primary malignancy.

The oral cavity or mouth consists of two parts: the vestibule- which is the space between the lips and cheeks and the teeth and gums; and the mouth proper- which is internal to the teeth. The oral cavity refers to the entire contents of this area - including the cheeks, gums, teeth, tongue and palate. The functions of this region include ingestion and the first phases of digestion of food (mechanical destruction by the teeth through chewing), taste, respiration and the function of speech (the movements of the oral cavity and its components shape the sounds produced by the larynx into words).

The tongue is a very mobile muscular organ that, at rest, fills most of the oral cavity. It has many roles including taste, chewing (mastication), swallowing (deglutition), speech and cleaning the oral cavity. Its major roles are to propel a bolus of food backwards and into the pharynx to initiate swallowing and forming words to enable communication. It arises from the floor of the mouth, partly in the oropharynx, and consists of muscles covered by mucous membranes.

Who gets Tongue Cancer        

It is relatively common, with 3% of all malignancies arising within the oral cavity. Tongue cancer is more common than all forms of oral cavity cancer except those of the lip and occurs with increasing age. It is uncommon before the age of 40 and the highest incidence of the disease is in the 6th and 7th decades with sex incidence being a 3:1 male predominance.

Geographically, the tumour is found worldwide, but there is significant variation in incidence. The disease occurs with highest incidence in Indian populations.

Predisposing Factors for Tongue Cancer

All cancers of the head and neck show a strong association with alcohol consumption and tobacco smoking, particularly of cigarettes - in fact, tobacco is thought to be implicated in well over 80% of cases of squamous cell carcinoma of the head and neck. Chronic exposure of the epithelial surfaces of the head and neck to these irritants are thought to result in a "field cancerisation" sequence of hyperplasia, dysplasia and carcinoma. That is, the development of premalignant lesions may then undergo malignant change to become a cancer. Smoking and alcohol act synergistically in the development of head and neck cancer - the risk when both of these factors is present is more than double the risk of exposure to one factor alone.

There is a dose-response relationship between exposure to tobacco smoking and the development of head and neck cancer - the more you smoke, the greater the risk. Smokers are up to 25 times more likely to develop head and neck cancer than their non-smoking counterparts. Passive smoking, tobacco chewing and cigar smoking are also risk factors for the development of head and neck cancer. Up to the point of development of overt carcinoma, many of the changes associated with cigarette smoking will reverse if the patient quits smoking.

Alcohol consumptions a risk factor for the development of head and neck cancer also shows a dose-response relationship - with heavy drinkers being at greater risk. In addition, drinkers of spirits may be at a greater risk than those who drink wine.

Chronic viral infection is also associated with the development of head and neck carcinoma. The Epstein - Barr virus is strongly associated with the development of nasopharyngeal cancer, whilst Human Papilloma Virus, Herpes Simplex Virus and Human Immunodeficieny Virus have been associated with the development of a number of different cancers of the head and neck. This is thought to be due to their interference with the function of tumors suppressor genes and oncogenes.

Other risk factors include immune deficient states (such as post solid-organ transplant); occupational exposures to agents such as asbestos and perchloroethylene; radiation; dietary factors; a genetic predisposition to the development of the disease; and poor oral hygiene.
Cancers of the oral cavity occur with highest incidence in countries where the betel nut is chewed. With cancers of the lips, sun exposure is an additional risk factor in development.

Progression of Tongue Cancer

This type of tumor spreads by local extension and through the destruction of adjacent tissue. Lymphatic invasion with spread to the cervical lymph nodes is common at diagnosis. Haematogenous spread to distant sites such as the liver, bones and lungs may also have occurred at the time of diagnosis.

How is Tongue Cancer treated

Localized disease (T1-T2) lesions are treated with curative intent by surgery or radiation. Small lesions that are well lateralized should be excised (partial glossectomy). Larger lesions where excision would compromise speech and swallowing ability should be treated with radiotherapy.

Patients treated with local or regionally advanced disease are treated most successful with a combined modality therapy of surgery, radiation therapy and chemotherapy. Concomitant chemotherapy (with 5-Fluorouracil and cisplatin) and radiation therapy appears to be the most effective sequencing of treatment.

Patients with recurrent and/or metastatic disease are, with few intentions treated with palliative intent. Chemotherapy can be used for transient symptomatic benefit. Drugs with single agent activity in this setting include methotrexate, 5FU, cisplatin, paclitaxel, docetaxel. Combinations of cisplatin and 5-FU, carboplatin and 5FU, and cisplatin and paclitaxel are also used.

Improvement in symptoms is an important measurement. Specific monitoring may be by thorough serial inspection of the head and neck region - looking for disease recurrence as well as second primary tumors. Ideally this would include a pan-/triple-endoscopy. There are no specific screening recommendations at the moment but several clinical trials are currently being undertaken into the benefit of different screening techniques.

The symptoms that may require attention are somatic pain from bone metastases, visceral pain from liver or lung metastases and neurogenic pain if nerve tissue is compressed. Coughing and breathlessness from lung involvement may require specific treatment. Infection can also be a serious problem in patients with tongue cancer.
 

 

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