Oral and perioral lesions
By Dr Nigel Stollery
By Dr Nigel Stollery
Unilateral tonsillar enlargement
Unilateral tonsillar enlargement can occur as a result of infection, chronic inflammatory response or, more rarely, underlying malignant changes. In the majority of cases a malignancy will not be the cause but this always needs to be considered, especially where there is no response to antibiotics or where there is persistent lymphadenopathy.
If in doubt refer to secondary care for biopsy. Many different types of malignancy can arise from tonsillar tissue, but most are very rare. The two most significant types are squamous cell carcinoma and lymphoma which account for almost 70% and 30% of cases respectively.
Tonsillar crypts are small pockets on the surface of the tonsils that form a reservoir into which debris from ingested food collects. This accumulated debris can then develop into tonsilloliths (tonsil stones) which may cause the adjacent tissue to become inflamed and uncomfortable, mimicking tonsillitis. The action of normal oral flora on this decaying food can also cause halitosis. Tonsillar crypts are quite common and collected debris can easily be ejected by gently running a finger over the surface of the tonsil forcing the food out. Regular gargling with a mouthwash may also help. In chronic and symptomatic cases tonsillectomy may be carried out, although generally this is not required.
Venous varix, also known as venous lakes, presents as dark blue/violet compressible papules caused by dilatation of venules. The lesions are more common on sun-exposed areas such as the ears. Incidence increases with age, the average age of presentation is 65. Treatment options include excision, cryotherapy, cautery and laser therapy although, as the condition is benign, it can be left untreated. Lesions may sometimes be excised to confirm the diagnosis histologically and exclude a melanoma or pigmented basal cell carcinoma which can have a morphologically similar appearance.
When grooves develop in the tongue the resultant appearance is known as scrotal tongue, lingua fissurata, lingua scrotalis or plicated tongue. This condition affects approximately 1-5% of the general population. It is usually present from birth, although it may not be noticed until later in life. Most cases are asymptomatic and treatment is not generally required.
The herpes simplex viruses can be divided into two antigenic types. Type 1 is associated with common cold sore infections of the lips and face and type 2 with genital herpes. The two are by no means exclusive to these areas and lesions of either type may occur anywhere on the body. In severe cases oral aciclovir can be given, this needs to be started as soon as possible after symptoms develop. Where the tip of the nose or periocular areas are affected the cornea should be monitored closely for dendritic ulcers as these can lead to permanent scarring and affect visual acuity.
Gingivitis and gingival hyperplasia may occur as a side-effect of various drugs such as phenytoin, cyclosporin and calcium channel blockers. In other cases, such as the one shown in the photograph, it can result from poor oral hygiene. It is seen more commonly by dentists. Education regarding good oral hygiene is essential. Oral metronidazole can be given for severe cases. Where there is significant hyperplasia from chronic drug use, which fails to respond to oral hygiene measures and antibiotics, resection of the excess tissue may be useful. This can be carried out by conventional surgery or by using a YAG or carbon dioxide laser.Scrotal tongue Herpes simplex Unilateral tonsillar enlargement Tonsillar crypts Gingivitis Venous varix Author
Dr Nigel Stollery
MB BS DPD
GP, Kibworth, Leicestershire and clinical assistant in dermatology, Leicester Royal Infirmary