TONGUE DISORDERS

Types according to ethiology

Infective: herpes, AIDS, TB, Candida, HPV Auto-immune: lichen planus, geographical tongue, Sjogrens syndrome, apthous ulcers, erythema multiforme, bullous lesions dietary: glossitis, burning tongue Idiopathic or multi-ethiological; hairy tongue, varicosities, black tongue, furred tongue, median rhomboid glossitis amyloidosis Tumors (benign and malignant)

Herpes lesions
The tongue may be involved in herpes stomatitis Small vesicles form that rupture to leave small painful ulcers

HPV (papilloma) tongue lesions

Raised nodules with projections seen on skin and mucosae and caused by HPV type 2

condyloma
A STD occurring as a raised pale paillated (warty) lesion in genital/oral mucosae caused by HPV (types 6 and 11) and seen in many AIDS-cases

AIDS tongue lesion

Also called oral hairy leukoplakia (OHL) Seen as white raised lesions on lateral border of tongue, +/- vertical white lines

 This lesion develops on the lateral borders of the tongue, usually bilaterally. Its clinical appearance is characterized by multiple, vertical, white to white-yellowish, hyperkeratinized lines which tend to follow the direction of the foliaceous papillae. These lesions can not be detached

 OHL is caused by Epstein-Barr virus and occurs in 20 to 30% of patients with ARC (AIDS related complex), which precedes the development of AIDS and also in patients with full blown AIDS. OHL also has been reported on the floor of the mouth or the buccal mucosa in AIDS patients. Sometimes Candida infection is superimposed on OHL, which will complicate the diagnosis. OHL may occur in HIV-negative patients in people who are immuno-compromised due to organ transplant, autoimmune disorder or cancer.

 OHL tends to manifest in patients who's CD4+ cell count falls below 300 cells per cc. Patients with OHL have a shorter life span than those that do not present this lesion: 30% of those developing OHL will progress within 1 year to AIDS. This shows that the status of the immune system in patients with OHL is lower than those who do not have OHL. OHL resolve in patients which undergo treatment with ARVs.

TB tongue lesion
Patients with TB may develop a lesion on the tongue as an ulcer with punched out appearance. Histology shows the typical TB granuloma (tuberculoma) with stainable organisms

Histology of TB-granuloma:

candida infection of tongue

Various types of candida is seen: (a) thrush: reddish area with white specks that can be wiped off

(b) Chronic hyperplastic candidiasis (white flecks cannot be rubbed off)

(c ) Acute antibiotic cadidiasis Long-term antibiotic treatment kills all oral flora so that the Candida multiplies to cause acute red burning tongue (glossitis) and mucosae (antibiotic stomatitis)

Auto-immune : Lichen planus (LP)

Erosive LP, atrophic LP (smooth flat appearance) and placque-like LP-lesions may be seen on the tongue. Late changes: tongue with blue-white sheen

Geographical tongue (erythema migrans)

Recurring appearance and disappearance of smooth red atrophic areas with smaller papillae and with defined edges, and scalloped margins that seem to enlarge and fade and reappear elsewhere on the tongue

 In many cases this condition is associated with psoriasis skin disease

histology: a dense layer of neutrophils infiltrate the area next to the epithelium (E)

Sjogrens syndrome (auto-immune)

Primarily affects major and minor salivary glands, but the tongue may become dry, depapillated and grooved (cobblestone appearance)

Apthous ulcers (minor and major)

Small or larger ulcers with red border and pale centre, painfull. Found anywhere in oral cavity. Smaller lesions last about 1 week and larger lesions about 1 month

Erythema multiforme (autoimmune)

Skin, mucosas and tongue mucosa with targetlike lesions or flat ulcerated with red borders

Bullous lesions (autoimmune)

Mucosa and skin with large vesicles and bullae that rupture, leaving ulcerated areas

Dietary changes and the tongue

Fe-, Vit B2 and B6 and Vit. B-12 deficiency leads to glossitis= smooth red, burning sensation (glossitis). Blood tests are indicated for diagnosis of Fe- and B12-deficiency anemia

Idiopathic: hairy tongue

Filiform papillae become long, brown, hair-like and form a mat on the tongue dorsum.

In some cases the papillae become black (so-called black tongue) due to Fe-containing drugs given for anemia

furred tongue
Tongue may become coated with a layer of desquamated cells that forms a pale yellowwhite layer on the dorsum in those who smoke heavy, gastro-intest. disorders and also seen during childhood fevers

Varicose tongue
An age-related condition where the ventral tongue veins become prominent

Median rhomboid glossitis

An asymptomatic atrophic depapillated diamond-shaped depressed area on the dorsum of unknown ethiology, seen in adults

Amyloidosis of tongue
Amyloid forms as a result of: -Chronic systemic infections (eg TB) -plasma cell malignancies large amounts of immunoglobulins are formed which may be deposited (as amikloid) in soft tissues such as the tongue, which then becomes enlarged (macroglossia)

 How to diagnose amiloid: slides are stained with Congo red which will show up the deposits in the tongue and around bloodvessels (red stained) and which will fluoresce green in polarized light

Bening tumors of tongue

Angiomas (hemangioma- and lymphangioma-types) are vascular tumors encountered in children

Malignancy of tongue
Squamous carcinomas starts as (i) red, or (ii) red-and-white or (iii) white lesions on the lateral or ventral sides of the tongue

 that progresses to squamous carcinoma, an ulcer 2 or more cm in diameter, with a rolled indurated (firm) border. The cancer spreads to the neck nodes and is caused by tobacco and sometimes by tobacco in combination with HPV and/or alcohol.