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Independents' Day

May 2008: Tongue problems

By Dr Nigel Stollery

By Dr Nigel Stollery

1 Scarlet fever

Scarlet fever is an exotoxin-mediated illness secondary to group A beta-haemolytic streptococcal infection. The peak incidence is between four and eight years of age and it affects both sexes equally. The condition does not usually occur in children older than 10 years, as most will have developed immunity, or in those under two because of the presence of maternal antiexotoxin antibodies.

Scarlet fever usually has a 1-4 day incubation period and causes fever, sore throat, headache, myalgia, vomiting and nausea, with a characteristic rash appearing 12-48 hours after the onset of the fever. In some cases the tongue is affected, usually with a white coating and red, inflamed papillae. The coating will disappear after a few days, leaving a very red tongue with a typical strawberry appearance.

The aim of treatment is to prevent complications and rheumatic fever and shorten the duration of the illness. The treatment of choice is penicillin,1 or a cephalosporin if the patient is allergic to penicillin.

2 Ranula

A ranula is a pseudocyst caused by mucous extravasation into surrounding tissue, usually resulting from trauma to a major salivary gland excretory duct. Ranulae have a prevalence of 2 per 10,000 and account for 6% of all oral sialocysts.

Around 70% occur in patients under the age of 20, with peak prevalence at 10-20 years of age.

Ranulae are relatively painless, and usually asymptomatic until they reach a size where they interfere with movement of the tongue, as in the case shown in the picture.

Treatment, if required, usually consists of excision of the cyst and the damaged salivary gland and duct. Other methods include marsupialisation2 and packing of the pseudocyst with gauze, which conserves more tissue.

3 Geographic tongue

Geographic tongue, or benign migratory glossitis, affects around 3% of the population and has a polygenic mode of inheritance.3

In general the condition is asymptomatic, but some patients report an associated increase in sensitivity to hot and spicy foods. Other mucosal tissue, such as the inside of the cheeks and lips, may also be affected.

The condition is more common in children and twice as common in women than men. It is also seen in around 10% of patients with psoriasis.4

Treatment is not required and patients can be reassured that the condition is not serious.

4 Leukoplakia

Leukoplakia is a white oral plaque that cannot be characterised clinically or pathologically as any other disease. The condition is usually asymptomatic and is more common in men and patients over 40.

In most cases, no aetiological factors can be identified. However, leukoplakia is associated with:
• Smoking
• Chewing tobacco
• Chronic trauma
• Alcohol intake, especially spirits
• Immunosuppression.

In 18% of cases, the lesion will undergo malignant transformation within 20 years of diagnosis,5 and it is good practice to refer the patient for biopsy. If the lesion is normal, no further treatment is required, although possible causative factors should be eliminated. Spontaneous regression occurs in some cases.

If dysplasia is present, the affected area should be excised and the patient should be re-examined every 3-6 months.

5 Angiooedema

Angiooedema results from increased vascular permeability and presents as painless, non-pitting, non-pruritic and well circumscribed swelling. This is usually most apparent around the head and neck. In severe cases, laryngeal oedema may compromise the upper respiratory tract, leading to breathing problems and, in some cases, death.

There are many different causes of angiooedema. These include hereditary angiooedema, which affects one in 150,000 people; acquired angiooedema, of which there are only 50 documented cases; and angiooedema caused by allergic reactions, including reactions to drugs such as ACE inhibitors, aspirin and streptokinase. Angiooedema may also be idiopathic.

Adrenaline, steroids and antihistamines are generally the first-line treatments for allergic angiooedema. However, in hereditary and acquired angiooedema, and reactions caused by ACE inhibitors, these are less effective and iv fresh frozen plasma is the therapy of choice.

6 Recurrent aphthous ulceration

Aphthous ulceration is a common and often painful condition that most people will have experienced at some point in their lives. However, in some patients ulceration is recurrent.

About a third of patients have a family history of the condition, and it is more common in patients with HLA types A2, A11, B12 and DR2.

Predisposing factors include iron or folic acid deficiency (20% of cases); trauma; stress; malabsorption (3% of cases); immunodeficiency and drugs (NSAIDs, alendronate and nicorandil). Recurrent aphthous ulceration is also associated with the luteal phase of the menstrual cycle in some women.

7 Lingual thyroid

Lingual thyroid is an ectopic thyroid gland on the tongue. It is rare, with a reported incidence between 1 in 10 and 1 in 100,000, and four times more common in women than men.6

During embryonic development the thyroid gland starts as a proliferation of endodermal epithelial cells on the median surface of the developing pharyngeal floor. From here it migrates downwards via the thyroglossal duct to its final location in the neck. During this migration thyroid remnants may remain at any level, producing an ectopic gland. In 90% of cases of ectopic thyroid glands this occurs at the highest level, producing a swelling on the tongue that is termed a lingual thyroid.

Lingual thyroid glands are diagnosed by scintigraphy of the thyroid gland with technetium pertechnetate or radioactive iodine and thyroid function tests. This will reveal an underfunctioning thyroid in 70% of cases, and these patients will require replacement therapy with levothyroxine and monitoring.

8 Black tongue

Black tongue is usually a temporary, harmless condition, although it is often alarming to patients. It is caused by an overgrowth of porphyrin-producing bacteria or yeast on the tongue's surface.

Contributing factors include:

• Antibiotics
• Poor oral hygiene
• Medications containing bismuth
• Tobacco
• Tea and coffee.

Brushing the surface of the tongue with a toothbrush or rinsing with hydrogen peroxide 1-2% solution may help.7


Dr Nigel Stollery
GP, Kibworth, Leicestershire and clinical assistant in dermatology, Leicester Royal Infirmary

1 Scarlet fever 2 Ranula 3 Geographic tongue 4 Leukoplakia 5 Angiooedema 6 Recurrent aphthous ulceration 7 Lingual thyroid 8 Black tongue

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