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Differential Diagnosis of Tongue Lesions
Differential Diagnosis of Tongue Lesions
This article reviews the clinical characteristics ot the numerous iocai and systemic conditions that fre-
quently involve ttie tongue and presents ciassitications based on their appearance and common iocations
ttiat can aid dentists in their eariy recognition and clinicai diagnosis. (Quintessence int 2003;34-331-342)
Key words: congenital tongue lesions, lingual cysts, systemic linguai conditions, tongue infections, tongue
lesions, traumatic tongue lesions, tumors of ttie tongue
he tongue is not only the site of a variety of iocai Though there have been various classifications of
T lesions, but it also refieets tbe presence of a num-
ber of systemie diseases. Because tbe dentist will most
tongue lesions proposed,'"' tbe fact that the etiology of
certain conditions remains a mystery makes it impos-
often be tbe first to observe tbese conditions, it is es- sible to deveiop a uniform system. From a clinicai
sential tbat he or she be familiar with their diagnosis. standpoint, it Is best to begin the differential diagnosis
This is particuiariy important because some of these by determining whether the condition is localized or
conditions can have serious consequences, and the part of a generalized systemic disease. Most local le-
prognosis is greatly improved by early recognition and sions can then be categorized as congenital or devel-
treatment. This article is designed to belp the clinician opmentai, traumatic, infectious, neoplastie, or idio-
make a correct and early diagnosis of the more com- pathie, and oral lesions of systemic origin can be
mon forms of lingual pathology and to distinguish divided into tbose that are related to infections, biood
these iesions from some of the congenital and devei- dyscrasias, metabolic diseases, and immunologie dis-
opmental disorders that can also involve this organ. orders. Use of sucb a classification is helpful because it
aids the clinician in ordering the diagnostic process,
Although it is recognized that there may be cbanges in forming an initial impression based on the clinical
the tongue associated witb a number of conditions not findings, and determining what additional tests may be
included in the present article, this discussion focuses necessary before deciding on the definitive therapy.^
mainly on those tongue lesions that are either the oniy
site of the pathology or in which they piay an impor-
tant diagnostic role.
LOCALIZED LINGUAL CONDITIONS
Fig 1 Patient with a deeply tisaured Fig 2 Lingual thyrmd This is sometimes Fig 3 Large lymphangioma of the tongue
tongye. The gtooves can trap lood particles the oniy thyroid tissue present. with a pap i i Ic m ato us appearance.
and become secondariiy inlected.
toothbrush and commercially available effervescent mal cysts originate in the anterior floor of the mouth,
mouthwashes or diluted hydrogen peroxide rinses^ will but their proximity to the tongue may make it difficult
improve oral hygiene and minimize the inflammation. to distinguish the exaet location.
Lingual thyroid. The thyroid gland originates as a Lymphangioma. Lymphangiomas commonly arise
midline endothelial outgrowth at the junction of the from a proliferation of lymphatic vessels and appear at
dorsal anterior two thirds and the base of the tongue birth. They are therefore actually a hamartoma or vas-
in the region of the future foramen caecum. From cular malformation rather than a neoplasm. The su-
there, the thyroid tissue normally descends through perficial lesions are papillomatous in nature and may
the tongue and cervical tissues to reach its final posi- have a relatively normal mucosal covering or a red-
tion in the region of the larynx. However, when this dish to purpie hue (Fig 3}, The deeper iesions are dif-
migration fails, persistent thyroid tissue may he found fuse and appear as grapelike structures covered by
in the tongue (Fig 2), It generally appears as a firm, normal colored mucosa," Unless the lesion is causing
midline mass in the region of the foramen caecum. functional problems, no treatment is necessary.
Symptoms, when present, include dysphagia, difficulty Hemangioma. The hemangioma can be classified
with speech, and a feehng of fullness in the throat. into two types: the congenital hemangioma, which is a
Because this may be the only thyroid tissue present, common vascular tumor of infancy that gradually invo-
biopsy is not recommended. Instead, a radioactive io- lutes during adolescence, and the vascular malforma-
dine uptake scan can be used to establish the diagno- tion, which also is present at birth but never regresses,'
sis and to determine if additional thyroid tissue is The latter is the type that occurs in the tongue.
present.' Unless there are symptoms, no treatment is The lingual vascular malformation appears as a dis-
necessary. However, if the mass is causing functional tinctly reddish, purplish, or bluish lesion that blanches
impairment, partial or total excision and thyroid hor- when compressed. The iatter characteristic is useful in
mone supplementation may be necessary, distinguishing it from pigmented nonvascular lesions.
Thyroglossal duct cyst. Embryologically, as the It has an elevated, sessile appearance, and the overly-
thyroid gland decends from the base of the tongue to ing mucosa is smooth and hypervascular in some
its cervical location, it brings with it a tract of epithe- areas and pebbly in others,^'
lial tissue (thyroglossal duct) that normally involutes Small lesions may require no treatment, but those
by the 10th week of gestation. However, remnants may causing functional problems, or that are at risk of in-
remain, giving rise to cyst formation in the base of the jury and causing profuse bleeding, require surgical
tongue. The lesions are generally asymptomatic unless management.
they become very large or are secondarily infected, Median rhomboid glossitis. This lesion, located in
Dermoid cyst. Entrapment of epithelium during de- the midline of the posterior dorsum, was originally
velopment of the tongue can give rise to subsequent considered to be a developmental condition resulting
cyst formation. The lesion is usually located in the from the tuberculum impar failing to retract and then
body of the tongue more anterior than the thyroglossal becoming trapped by fusion of the two lateral halves of
duct cyst, but it may otherwise be indistinguishable ex- the developing tongue. Currently, however, it is consid-
cept on histologie examination. More commonly, der- ered by many authors to be either a primary, localized
form of cartdidiasis, or that Candida albicans is a sec- raised, often pedunculated, smooth, nonpainful, and
ondary invader'" {see page 334), Ciinicaiiy, the lesion is usually has an apparent etiology. Patients should be
characterized as a smooth or granular, red, flat, slightly questioned concerning habits such as rubbing the
elevated or lobulated area located just anterior to the tongue against sharp or irregular surfaces on the den-
foramen caecutn (Fig 4), When candidiasis is sus- tition,^ The lesion often appears similar to other more
pected, it should be treated with one of the antifungal serious iesions, so biopsy is indicated to confirm the
agents. clinical diagnosis.
Neuroma (traumatic neuroma). This lesion repre-
Traumatic iesions sents a reactive hyperpiasia caused by injury to a
nerve rather than a true neoplasm, it is most often lo-
Traumatic ulcer. Because of its iocation, the tongue is cated on the dorsal surface, where it appears as a cir-
a frequent site of acute trauma. The diagnosis of such cumscribed, sessile nodule covered by a smooth, pink
an injury can usually be made on the basis of patient mucosa. Usually, the patient will relate a history of in-
history. However, there are often instances of irrita- jury to the area. In contrast to the true neurogenic tu-
tion of the lateral borders of the tongue from sharp mors (neurilemmoma, neurofibroma), manipulation of
areas on teeth or restorations that can cause chronic a traumatic neuroma will often result in pain at the
ulcers, hut the patient is unaware of these causes. In site or in the region innervated by the involved nerve,-
such cases, the lesion may resemble a neoplasm, and Treatment consists of surgical excision,
an early differential diagnosis is essential (Fig 5), If a Muccus extravasation cyst. These pseudocysts re-
local source of irritation can be identified and re- sult from injury to an excretory duct of a minor salivary
moved, the lesion can be observed for a week to see if gland leading to the accumulation of mucous in the ad-
healing occurs. If healing does not take place follow- jacent connective tissue. In the tongue, they are usually
ing removal of any irritation, a biopsy is indicated to associated witb the glands of Blandin and Nuhn and
establish the diagnosis, are located on the ventral surface near the tip,"
Pyogenic granuloma. Although traumatic uicers
can occur on the dorsum of the tongue as well as the
margins, in some cases of dorsal trauma there appears INFECTIONS
to be a hyper-response, and a pyogenic granuloma
forms. The lesion may be sessile or pedunculated, and Herpes simplex infection. Primary herpetic gingivo-
the surface characteristics can vary from smooth to ir- stomatitis is typically a childhood disease character-
regular and lobulated. Often there is central ulcéra- ized by the formation of vesicles that rupture and form
tion. The lesion is usually painless, but it tends to generalized, small, shallow, punctate, yellowish ulcers
bleed easily. Treatment consists of surgical excision. with an erythematous halo located on the oral mucosa
Focal fibrous hyperpiasia (fibroma, irritation fi- and tongue. However, adults can also be affected. In
broma, traumatic fibroma). This lesion frequently de- more severe forms of the disease, the lesions coalesce
velops in regions of tbe tongue susceptible to trauma, to form ulcers that may appear similar to major aph-
such as the anterior and lateral dorsal surfaces. It is thous ulcers. However, in contrast to aphthous ulcers.
333
Laskin et ai
a primary herpetic outbreak is usually accompanied by minorlike lesions, form a triad of clinical signs that are
fever, malaise, and lymphadenopathy. When the dis- usually diagnostic of Behcet's syndrome. Other cotn-
ease deveiops in immunocompromised patients, the ponents of this syndrome are arthralgia, phlebitis, skin
lesions are deeper and are present longer than in lesions, and central nervous system involvetnent.'''*'^
heaithy patients.' Aphthous minor ulcers usually respond to palliative
Recurrent (secondary) herpes develops in adults treatment in the form of topical anesthetics, topicai
with a history of primary herpes simplex infection due steroids, cautery, or tetracyeline or chiorhexidine
to reactivation of the virus. It often occurs after dental rinses. Aphthous major ulcers or patients with Behcet's
treatment or injeetion of a locai anesthetic. Aithough syndrome usually require systemic steroids in additioti
these lesions are most often found on the lip, palate, lo the palliative measures,
and attached gingiva, the lateral border of the tongue Folliate papillitis. Folliate papulae are a series of
can also be affeeted.' ridges or lobular, rounded projections located on the
Treatment of herpes simplex infections involves a posterolateral aspect of the tongue. The core of these
soft, bland diet, adequate fluid intake, an antipyretic papillae consists of lymphoid tissue that has been re-
analgésie for pain, and chiorhexidine mouthrinses. ferred to as the lingual tonsil. This tissue, plus the
Antiviral agents, such as acyclovir, vidarabine, or idox- paired palatine tonsils and the pharyngeal tonsil (ade-
uridine ean he used in severe eases to speed up the noids), form the triad of oropharyngeal lymphoid tis-
healing, but they are not curative. sue known as Waldeyer's ring. Because of their appear-
Aphthous ulcers (recurrent aphthous stomatitis, ance and location, the folliate papillae are sotrtetimes
canker sores). Although the etioiogy of the aphthous mistaken for a malignancy by the patient. The fact that
ulcer is unknown, it is important to consider it along they are biiateral and have a similar appearance on
with the inflammatory lesions of the tongue heeause of both sides helps to rule out this possihihty.
its resemblance to the lesions caused by the herpes The folliate papillae may sometimes become enlarged
simplex infection. The aphthous ulcer can be divided as part of a regionai lymphoid tissue reaction to an upper
into minor and major forms. Minor aphthous ulcers respiratory infection, or due to mechanical irritation, and
most commonly develop on unattached mucosal sur- hccome slightly painful and tender. This has been termed
faces. Those that form on the tongue often appear on faliiate papillitis (Fig 7). The condition requires no treat-
the ventral and lateral surfaces. They ehnically present ment other than use of a chiorhexidine mouthrinse, re-
as shaliow, whitish-yeiiow-based craters surrounded moval of any irritating factors, and reassurance to the
by an erythematous border. The lesions are dispropor- patient that the lesion is not a malignancy,
tionately painful to their size. They appear as multiple Candidiasis (moniliasis, thrush). Candida alU-
or single lesions usually iess than 10 mm in diameter. cans is a normal component of the oral flora.
Each lesion lasts approximately 10 to 14 days and However, it is an opportunistic organism that can in-
heals without scar formation. Major aphthous ulcers vade the oral tissues when there is a change in the en-
range from 5 to 20 mm or more in size, occur in fewer vironment brought about by uncontrolled diabetes,
numbers than aphthous minor ulcers, and are most poor orai hygietie, chronic irritation, or the prolonged
often located on the labial/bueeai tnucosa and soft use of broad spectrurn antibiotics: immunosuppression
palate/anterior tonsillar pillars, but also may develop resuiting from chemotherapy, long-term use of
on the dorsum of the tongue (Fig 6). Aphthous ulcers, steroids, or infection with the autoimmune deficiency
along with oeular ulcérations and anogenital aphthous syndrome (AIDS) virus^^
• Irffirnatianal 335
• Laskin et ai
Fig 9 Lriigr; i,lci";ínlr;r: r,r|L..n,TiDi.í; er Fig 10 Meiastatic bronctiogenic carci- Fig 11 Benign migratory glossitis. The
cinomn of the tongue noma of the tip oí tiie tongue. Ttiis is an un- condition is often referred to as geographic
usuai location, witii most metastatic lesions tongue because the pattern resembies a
being located in the base of the tongue. map The pattern changes as areas of
desquamation heal and new areas deveiop.
Squamous cell carcinotna. Oral carcinomas com- tics that have been described, and the definitive diag-
prise approximately 5% of ali malignaneies and 80% nosis is made from the biopsy.
to QO^/n of ali malignant oral tumors.'* The tongue is a A previously rare oral sarcoma that is now being
common site for such lesions. Heavy use of alcohol seen more frequently is Kaposi's sarcoma, a malignant
and tobacco are recognized as major comorbidity fac- neoplasm of the retieulocndothelial system. Occurring
tors for this disease. mainiy in immunocompromised patients, it is now as-
Squamous cell carcinoma presents as a surface le- sociated mainly witb patients baving AIDS.'^' The le-
sion on the tongue with a predilection for the lateral sions begin as painless reddish or bluisb macules tbat
borders, particularly on tbe middle and posterior seg- then coalesce to form purplish nodules, which ulti-
ments (Fig 9). Tbe lesion is often initially painless and mately become ulcerated. Altbougb most commonly
usually has an ulcerated appearance with rolled bor- seen on tbe palate, lesions may also occur on tbe
ders around a neerotie center. It frequently resembles tongue. A biopsy is indicated when tbe diagnosis is
a traumatic ulcer. If a possible traumatic etiology is not obvious and a human immunodeficiency virus
suspected, ie, sbarp cusp or fractured restoration, tbis (HIV) test is confirmatory.
sbouid be treated first. If tbe lesion does not show Metastatic tumors. Metastatic lesions to tbe tongue
signs of bealing within 1 week, a biopsy sbouid be per- bave been reported from primary malignancies in the
formed. kidney, stomach, breast, thyroid, and lungs.^^ However,
Malignant salivary gland tumors. Tbe location of the oral lesions are rarely the first evidence of
tbese tumors is determined by tbe anatomic location metastatic disease.
of salivary gland tissue in the tongue. Tbus, tbe most Most lingual métastases are located in the base of
common sites are in tbe glands of Biandin and Nubn the tongue, altbough a few eases involving tbe tip bave
in tbe ventral tip of tbe tongue and in the posterior also been reported {Fig 10).=^ Lesions in tbe base of
part of the dorsum and base of the tongue. The lesions the tongue may produce pain and, when large, can
begin as slow-growing, asymptomatie, submueosal cause dysphagia. Because of their location and late
masses, but may ulcerate in tbe later stages. Although onset, most lingual métastases are treated palliatively.
the lesions can be bistologically classified as mucoepi-
demoid tumors, acinic cell tumors, and adenocarcino- Idiopathic lesions
mas, they cannot be distinguished elinieally.
Sarcoma. Sarcomas of the tongue are extremely Hairy tongue. This condition is characterized by a lack
rare, with only sporatic cases of fibrosarcoma,'' be- of normal papillary desquamation resulting in hyper-
mangiopericytoma,'*' alveolar soft-part sarcoma," h- trophy of the filiform papillae, wbich gives the dorsum
posarcoma,"' rbabdomyosarcoma," leiomyosarcomaj^" of the tongue a hairy appearatiee. The color will vary
synovial sarcoma,^' cbondrosarcoma,^^ and neuro- from yellowish-white to brown or black depending on
genic sarcoma" being reported. Because of tbe paucity the extrinsic staining. Among the contributing factors
of such eases, there are no distinguishing characteris- are tobacco; certain foods, beverages, and medieations-
Fig 12 Patient with tertiary syphilis si^ow- Fig 13 Tuberculous ulcer of the Icngue. Fig 14 Hsiry ieukupiakia in a patient with
ing atrophy o( Ihe tcngue papiliae and sec- Rather than having firm, raised margins like AiDS.
ondary leukoplakia characteristic ol a squamojs ceii carcinoma (see Fig 9), the
syphiiitic glossitis. tuberculous uicer is flat and less firm.
the papillae usually begin on the tip and lateral bor- Metaboiic diseases
ders, and then involve the remainder of the dorsum.
Angular cheilitis is a commonly associated finding. Diabetes mellitus. In the diabetic with orai manifesta-
The anemic patient often complains of weakness and tions, the presence of changes in the tongue is second
dyspnea on exertion, and the skin tends to he pale. only to periodontai disease, A feeling of burning and
Oral complaints of pernicious (vitamin B-12 defi- dryness are the earliest lingual symptoms. Central lin-
ciency) anemia also involve mainly the tongue, which gua! papillary atrophy may occur and almost half of
becomes a fiery red because of papillary atrophy. all uncontrolled diabetic patients will show evidence
However, rather than being smooth, as in iron defi- of candidiasis (see page 334),
ciency anemia, the tongue often has a lobulated ap- Hypothyroidism. Patients with hypothyroidism not
pearance (Fig 16), Pain and a burning sensation gener- only can have dry mouth, but there may also be
ally are present early, and there may also be a macroglossia caused by infiltration of the tongue with
disturbance in taste. The skin may have a yellow tinge, mucoproteins and mucopolysaccharides (myxedema).
Plummer-Vinson syndrome, also known as The enlargement of the tongue can sometimes cause
sideropenic dysphagia, is a hypochromic, microcytic difficulties in eating and speaking, and may even lead
form of anemia. It is characterized mainly by difficulty to protrusion is some patients.
in swallowing, but there is also atrophy of the papillae Acromegaly. Macroglossia occurs in about 50% of
in SO^/o to 70% of the cases, giving rise to a painful, red persons with acromegaly due to an increase in the size
or pale tongue, Fissuring of the tongue may also be of the muscle fibers, as well as byperplasia of the ep-
present, as well as lingual leukoplakia, which is con- ithelium and connective tissue. When the tongue is
sidered a precancerous lesion in these patients. greatly enlarged, it presses against the teeth causing
Leukemia. Patients with a chronic form of lingual indentations and spacing and labial tilting of
leukemia, which usually occurs in adults, may show the teeth.
few clinical oral signs and symptoms in the early Vitamin B deficiency. Although deficiencies in six
stages of the disease. In the later stages, superficial ul- of the 12 B-complex vitamins can be associated with
cérations of the tongue as well as the oral mucosa are lingual changes, only niacin and folie acid deficiencies
seen, and areas of ecchymosis may also be present. are generally encountered clinically. The lingual
Patients with acute forms of leukemia have more changes in niacin deficiency (pellegra) are among the
frequent oral manifestations than those with chronic earliest manifestations noted. First, the tip and mar-
leukemia. Because the tongue is often exposed to gins of the tongue become red and swollen. Then, in
trauma, it is prone to develop ulcérations from even the more advanced cases, tbe papillae are lost, and the
minor types of injury due to the altered body defense red color becomes even more intense. As swelling of
mechanisms, Leukemic ceil infiltrations may also be the tongue increases, indentations of the teeth may be
present in the tongue of these patients, causing an ir- seen along the lateral margins. The signs and symp-
regular enlargement. toms of folie acid deficiency are similar to tbose of
niacin deficiency except that neuroiogic symptoms do
Fig 15 Ttie painful, red, smooth tongue of Fig 16 Red, iobulated tongue in a patient Fig 17 Multipie yeilowistinoduies on the
a patient with severe iron deficiency anemia, with pernicious anemia. iaterai borders ol the tongue characteristic
ot arnyioidosis.
Quintessenceinfernatlonai 339
• Laskin étal
TABLE 2 Classification of lingual lesions TABLE 3 Benign and malignant neoplasms of the
according to their clinical characteristics tongue
Lesion/etiology Usuai iocation Neoplasm Usuai location
I.Vesiculo-bullous Benign
Primary herpes simplex Generalized Fibroma Dorsal/lateral
Recurrent herpes simplex Lateral borders Papilloma Dorsai/ialeral
Erythema multitorme Generalized Lipoma Any surface
Mucous membrane pemphigoid Generalized Rh ab do myoma Any surface
Pemphigus vulgaris Generalized Leiomyoma Any surface
2. Utoerative Neuroma Dorsal
Squamous cell carcinoma Posterior laterai border Neurofibroma Dorsal/lateral
Pyogenic granuloma Dorsal Neurilenimoma Dorsal/lateral
Traumatio uicer Laterai/dorsai Granular cell tumor Dorsal
Aphthcus ulcer Latera i/vent ral Malignanl
Erythema multiforme Generalized Squamous cell carcinoma Posterior lateral border
Lichen planus Dorsal Salivary gland tumor Posterior dorsal/base;
Primary herpes simplex Generalized ventral lip
Recurrent herpes simplex Lateral border Sarcoma Any surface
Mucous membrane pemphigoid Generalized Metastatic tumor Dorsal (posterior)
Pemphigus vuigaris Generalized
Tuberculosis Dorsal
Leukemia Dorsal/lateral TABLE 4 Congenital and developmental tongue
Primary syphilis (chancre) Dorsal lesions
Tertiary syphilis (gumma) Dorsal
3. Atrophie Lesion Usual location
Chronic candJdiasis Dorsal Fissured tongue Dorsal
(median rhomboid glossitis) Lingual thyroid Dorsal (posterior midline)
Benign migratory glossitis Dorsai Lymphangioma Dorsal
(geographic tongue) Hemangioma Dorsal
Vitamin B deficiency Dorsal Median rhomboid glossitis Dorsal
Anemia Dorsal (Candid i as is)
Diabetes mellitus Dorsal
Lichen planus Dorsal
4. Cystic
Thyroglossal duct cyst Dorsal (posterior midline)
Mucous extravasation cyst Ventral
Derm oid cyst Dorsal (midline)
specific infections, metabolic disorders, or blood When the diagnosis cannot be definitively estab-
dyscrasia as an etiologic factor. Tbe order in whicb iisbcd on tbe basis of tbe history and clinical findings,
tbese tests should be done wili depend on the ciini- a biopsy is indicated. This is particuiariy important
cian's index of suspicion. wbcn there is a possibility that the lesion may be ma-
The location of a lesion and its physical characteris- lignant. A useful rule is to consider every lesion sus-
tics can also be essentiai factors in determining its di- pected of being neopiastic as a malignancy until
agnosis and possible etiology. Certain lesions tend to proven otherwise by bistologic examination.
be found most often in specific areas because of
anatomic considerations, greater exposure of tbe site
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