Clin. Radiol.

(1972) 23, 434-444

THE TONGUE AND MOUTH IN ACROMEGALY

G. M. A R D R A N and F. H. KEMP
From the Nuffield Institute of Medical Research, OxJbrd, OX2 6HF

The radiographic criteria we described previously were studied for the assessment of
enlargement of the tongue in a series of patients with acromegaly. Acromegaly produces
enlargement of the tongue and in the size and form of the mouth cavity. When a patient
has a large tongue, he must make adjustments to accommodate it to provide an adequate
airway. This means the bulk of the tongue moves forwards. The mouth cavity may also be
increased in size.
The mouth cavity may also be enlarged by changes in the alignment of the teeth, by
increase in the depth of the alveolar processes and by growth and changes in the form of the
mandible. However, other factors such as thickening of the soft tissues on the under
surface of the soft palate may tend to make the mouth smaller.
In some patients, pharyngeal tonsillar masses which appear larger than normal were
seen and there was considerable enlargement of the lingual tonsil which contributed
significantly to the bulk of the tongue.
Our findings suggest that the removal of teeth, correction of'jaw deformity or surgical
reduction of tongue size might improve the appearance, in those patients in whom
progression of the disease may be arrested.

TEXTBOOKS state that the tongue may grow bigger CLINICAL OBSERVATIONS
with the development of acromegaly and that there Four of the 6 patients in Group 1 were said by
are changes in the form and size of the jaws. No-one the physicians to have a large tongue; none had
knows how these manifestations are related. a protruding tongue. One of the patients was
Radiographic criteria for the assessment of the edentulous. The facial characteristics and general
tongue size relative to the jaws and surrounding physical features of all these patients were typical
soft parts have been given (Ardran and Kemp, of acromegaly.
1972a). The purpose of this investigation was to In all these patients we noted that the tongue
apply these criteria to the examination of the tongue filled the open mouth; they were unable t o fatten
in acromegaly. the tongue as normal individuals can, and none of
them could make a spoon shape. Two of them
MATERIAL showed some evidence of a central furrow. When
The patients studied were in two categories: the jaws were closed, we found on parting the
1. A series of 6 patients who were studied clinically patient's lips with the fingers, that the tongue did
and radiographicaUy. not protrude over the lower incisors but it did
2. A review of the films of patients referred to the bulge through the gaps where the teeth had been
Department of Neuro-surgery over the period extracted. The tongue extended beyond the upper
1937-69 (17 patients). incisor teeth in those patients whose lower jaw
projected forward. Clinically it was difficult to be
sure of the relationship of the tongue to the gums
METHOD in the edentulous patient.
The 6 patients in the first group were observed All patients were able to protrude their tongue.
clinically and questioned about breathing, speech One could direct it upwards, downwards and to
and swallowing. Lateral radiographs were taken both sides as in a normal individual. We gained the
of the face and neck at rest, with the jaws closed, impression that the ability to protrude the tongue
and with the tongue protruding and when saying in the acromegalic subject was reduced: this was a
'ee' and 'ss'. Cinefluorographic films at 25 frames point we could not establish with certainty since
per second were taken of phonation and swallow- we had no follow up or serial studies. In 3 of the
ing. patients whose tongue was enlarged, we noticed
434
 THE T O N G U E AND MOUTH IN A C R O M E G A L Y 435

Fm. 1 FIG 2
F~G. 1--Normal female aged 19, adult proportions. A relatively large tongue fills the mouth, obliterates the valleculae and the
pharyngeal cavity is narrowed. Notice the following points:- Hard palate in line with the arch of the atlas. Apices of the upper
teeth close to the line of the hard palate. Normal shaped mandible. Lower border of the mandible opposite the disc between
C2 and C3. FIG. 2 ~ Same patient as 1. Mouth wide open. The position of angles relative to the spine does not significantly
change.

FIG. 3 FIe. 4
F~G. 3--Normal male aged 20 years. A relatively small tongue. Mandible normal size. Body of mandible is slightly bent down-
wards at the level of the third molar teeth. The angles of the jaw are forward from the spine though at the correct level. The posi-
tion of the angles of the mandible relative to the spine indicates failure of the development of adult proportions. In other
respects the patient's development is normal. Fro. 4---Female aged 66 years - edentulous, wearingplastie dentures. Hard palate in
line with the arch of the atlas. Mouth small. Note the changes in the mandible, the most important are (a) atrophy ofthealveolar
processes (b) slender body of the mandible (c) shortening of the ascending rami, the angles being situated at the level of the
base of the odontoid peg. The angles of the jaws are forward relative to the spine as in 3 : they are not significantly straight-
ened. (Compare with Fig. 1). This is an extreme example of atrophy of the jaw in an edentulous patient showing many features
which are the opposite of acromegaly.
436 CLINICAL R A D I O L O G Y
that the tongue, when protruded straight out,
overlapped the angles of the mouth.
None of the patients had any impairment of
breathing: most of them preferred to sleep turned
to one side but 3 patients stated that they had no
difficulty in sleeping on their back. All patients
had some impairment of speech and had recognized
that their speech had changed since the onset of
the disease. None of the patients had any difficulty
in making themselves understood, either in
conversation, when using the telephone or when
shouting. It appeared that most of the patients
had more difficulty with certain consonants than
in the production of vowel sounds, but there was
one patient who was an exception to this rule.
None of the patients disclosed any difficulty in
swallowing but when questioned, revealed that they
did have some difficulty in clearing the mouth of
saliva and of food residues.
One patient who had had the disease established
for at least 20 years felt that there had been
occasions when his tongue had grown a little bigger.
Another patient who had also had the disease
established for many years, said that in recent years
her tongue had grown smaller. Both of these
patients had very large tongues.
RADIOGRAPHIC FINDINGS
Our criteria for normal proportions of tongue size
in relation to the mouth in the fully developed adult
are summarised as follows: (Figs. 1, 2 and 3).
1. With the jaw closed the tongue fills or almost
fills the mouth cavity.
2. The tongue is contained within the dental arches.
3. The hyoid bone is aligned roughly parallel to the
lower border of the mandible with the tips of the
greater cornua in line with the anterior borders of
the vertebra appear close to the disc between
C3 and C4.
4. The normal pharyngeal airway during quiet
breathing is approximately half the diameter of
the trachea.
5. The valleculae usually contain some air, and the
epiglottis is not tipped back enough to narrow
the laryngeal vestibule.
6. Lower borders of the mandible when projected
backwards are in line with the disc between C2
and C3. The posterior borders of the rami
appear close to the posterior wall of the pharynx.
There are minor variations in different subjects
which may be due to alignment accentuated by
variation in radiographic positioning.
7. On swallowing the tongue clears the mouth
without significant residue: the hyoid bone is
elevated up to the lower border of the mandible.
Figs 4 and 5 of an edentulous subject are intro-
duced for comparison with the normal and
acromegalic illustrations.
The radiographic signs of a relatively large tongue
are:
1. With the jaws closed, the tongue fills the mouth
cavity.
2. The tongue may protrude - through the teeth
and/or through the lips.
3. The hyoid bone is low in position.
4. Narrowing of the pharyngeal airway.
5. Obliteration of the valleculae. Tilting of the
epiglottis backwards. Narrowing of the vestibule
of the larynx.
6. Movement of the mandible forwards relative to
the spine.
7. On swallowing the tongue usually leaves a small
residue in the mouth. The hyoid bone is not
elevated to the lower border of the mandible.
It may be displaced further forwards than
normal.
Of the 6 patients on whom we made detailed
studies of the tongue, all satisfied our criteria for
enlargement of the tongue (Figs. 6, 7, 8, 9, 10 and
11). Some patients had antero-posterior radio-
graphs of the skull and face available: these were
useful to study the alignment and spacing of the
teeth. We did not feel justified in taking antero-
posterior radiographs of the tongue and mouth
since it was at once apparent that it would be
necessary to coat the tongue and buccal cavity
with a contrast medium and make multiple tomo-
graphic exposures.
Our studies also provided some additional
information about the methods these patients use to
compensate for enlargement of the tongue in order
to avoid significant narrowing of the airway: these
will be discussed. Our studies of speech were of
limited value. We gained the impression from the
cinefluorograms that the patient's movements were
slower than normal but it was difficult to analyse
these at 25 frames per second. Vowel sounds were
not produced in a normal manner in that the tongue
shape did not conform to the pattern seen in normal
individuals, but the variations in shape were not
gross. The cinefluorograms of swallowing were
compared with those of normal individuals. These
revealed that none of the acromegalic patients
used their tongue in the normal manner. These
abnormalities were analysed and related to the
movement of the hyoid bone: the significance of
these findings will be discussed.
Several of these patients had persistent
pharyngeal tonsilar masses. Three had large
 FIG. 5 FIG. 6
Jaws closed as much as possible. Further reduction in the size of the mouth
Fro. 5 - - S a m e p a t i e n t as 4. D e n t u r e s removed,
cavity. Pharyngeal cavity increased in size. Movement of jaw and tongue forwards. Some inferior protrusion of mandible
relative to maxilla. FIG. 6--A f e m a l e a g e d 60 y e a r s - a c r o m e g a l y - a t rest. The lips are closed for social purposes ; the jaws are
not apposed. Partially edentulous. Large tongue. Hard palate in line with the arch of the atlas. Upper alveolus normal; tissue
lining hard palate thickened. Mandible rather small. Angles of mandible at normal level. Body of the mandible bent forwards
at the level of the former site of the third molars and in this region relatively small. Features of the jaws are not those
characteristically described in acromegaly.

Fro. 7 Fro. 8
Fro. 7 - - S a m e p a t i e n t as 6. Jaws closed: teeth in contact. Inferior over jaw confirmed. The features of a large tongue are now
clearly defined: it fills the mouth, obliterates the valleculae; tip of the epiglottis bent backwards narrowing the pharyngeal
airway. It is important to check the size of the tongue by asking the patient to close the jaws. If the jaw is deformed and there is
open bite this may be impossible. FIG. 8 - - F e m a l e a g e d 69 a c r o m e g a l y - a t rest - no dentures. Large tongue. Maxilla and
mandible widely separated. Body of mandible bent down. The film which is slightly oblique was selected to show the deformed
condyle of the mandible. The alveolar processes have disappeared, the body of the mandible is not as atrophic as might be
expected. Unerupted molar tooth indicates that it fails to respond to the pituitary stimulus.
 FIG. 9 FIG. 10
FIG, 9--Male aged 43 - acromegaly - at rest jaws closed but open bite. Hard palate line above the arch of the atlas. Angles of the
mandible at the level of the base of the odontoid peg. Relatively large tongue indluding large lingual tonsil. Epiglottis displaced
backwards: laryngeal vestibule narrowed: pharyngeal airway small. Upper teeth displaced downwards below the line of the
hard palate: thickening o f t h e s o f t tissues below the hard palate. Occlusion limited by apposedmolar t e e t h b u t anterior open bite.
Gross hypertrophy of the alveolar process in the incisor region of the mandible, elevating the teeth with comparatively little
overgrowth of the alveolus in the molar region. Gross thickening of the cortex of the bone. FIG. 1O--Male aged 69 - acromegaly.
Edentulous. Hard palate in line with the arch of the atlas, thickening the soft tissues lining the hard palate and thick soft palate.
Some downgrowth of upper alveolus. Angles forwards and low in position. Large inferior dental canals. The striking feature of
this patient is the massive size of the mandible with nearly normal shape in a patient who has been edentulous for years.

FIG. 11 FIG. 12
FIG. 11--Female aged 52 - acromegaly. Hard palate normal. Upper teeth have been removed - wearing upper denture. Maxilla
relatively small. Mandible massive. Angles of mandible higher than average but not forward. Gross overgrowth of the
body of the mandible in contrast to relatively short rami: increase in the antero-posterior size of the rami.
FIG. 12--Male aged 38 - acromegaly. Striking projection of the lower jaw forwards: hard palate in line with the arch of the
atlas. Down growth of upper alveolus and antrum. Unerupted molar. Angles of mandible at normal level relative to spine.
Overgrowth of the alveolus in the incisor and premolar region of the mandible but not in the molar region.
 THE T O N G U E AND M O U T H IN A C R O M E G A L Y
Number Age Sex Clinical type
61 F Hypertrophic
66 M Hypertrophic
42 M Hypertrophic
33 M Hypertrophic
53 F Hypertrophic
69 F Hypertrophic
lingual tonsils. The significance of these adenoids
and tonsils Will be discussed.
All patients showed some changes in the shape
and form of the bony structures constituting the
mouth cavity: these were very variable.
Some of the clinical and radiographical findings
are briefly summarised in Table 1.
The films of the 17 patients taken from the
archives were not in all respects adequate for our
purpose but many films did provide additional
data to supplement our findings. We were parti-
cularly interested to find 3 patients who had very
large soft palates.
We also studied 2 patients clinically and radio-
graphically in whom the possibility of acromegaly
had been considered, but since their clinical and
radiographic features were in some respects not
typical, we did not include them in our series. Both
of these patients had a small tongue.
DISCUSSION
Atkinson (1932) who reviewed the records of
1,319 cases of acromegaly taken from the literature,
stated that the enlargement of the tongue was the
commonest feature of acromegaly after increase in
the size of extremities. 'In some cases it is too large
for the mouth and hangs out of it and hinders
speaking and eating and the patient bites into it'.
The tongue was described in 581 cases: it was
normal in 29 cases (5 ~ ) ; big in 550 (95 ~ ) and soft
in 1 : Tanzi (1892) was the only author who reported
a small tongue.
While in some patients with acromegaly the
tongue is huge, in many patients it is not so pro-
nounced and opinions differ as to whether it is
enlarged or not. No-one seems to have weighed
the tongue.
Atkinson (1932) stated that the increase in size
is due to the muscular tissues, to increase in thick-
ness of the mucous membrane and to the very large
papillae.
Our material is not sufficient to enable us to
answer all the questions relating to the size of the
439
TABLE 1
Clinical assessment Duration of disease
State of disease of tongue size history
Progressive Large 5 years
Intermittent Large 40 years
Progressive
Progressive Not enlarged 5 years
Progressive Not enlarged Since childhood
Progressive Enlarged 23 years
Stationary Enlarged Many years unreliable
tongue and the changes in the size of the mouth in
acromegaly, but it does seem to indicate the
probable answer to some of the issues and how a
larger series of cases might be studied.
Our primary purpose, namely to study the radio-
graphic criteria we have previously laid down for
the assessment of tongue size (Ardran and Kemp,
1972a) was satisfied.
Objective clinical evidence that the tongue is
enlarged is often difficult to evaluate and we could
find no rules in the published literature. We suggest
that the following points are of value. In acromegaly
the tongue appears to fill the open mouth and the
subject has difficulty in flattening his tongue: these
two observations taken together appear to be
significant. When the jaws are apposed it may be
possible to recognise that the tongue bulges
through the teeth or through gaps in the teeth but it
may be difficult to evaluate this sign if the subject is
edentulous or if there is a considerable protru-
sion of the mandible forwards. We have noted
that the protruded tongue may obscure the angles
of the mouth but this is not a feature in all patients.
Subjective evidence that the tongue is not func-
tioning properly may be obtained by questioning
the patient's relatives about speech. Many patients
have difficulty in clearing the mouth of food or
saliva but they seldom volunteer this information:
it is not a pronounced feature as in patients with
motorneurone disease. Our cinefluorographic
studies of the speech showed that these patients
seldom perform properly.
Swallowing was clearly abnormal. The normal
subject clears a single mouthful of fluid barium
suspension by raising the tip of the tongue to the
back of the upper incisor teeth and then by apposing
the tongue to the hard and soft palate from the
front backwards and so expresses the bolus into
the pharynx. These movements are associated
with the normal sequence of movement of the
hyoid bone (Ardran and Kemp, 1970). In the
acromegalic with a large tongue the root of the
tongue and the hyoid bone are situated in a
relatively low position. The tongue has to move
440 CLINICAL
forward to make space in the pharynx to
accommodate the bolus as it descends from the
mouth but since the bulk of the tongue is increased,
the hyoid bone is not raised normally. In most
cases the patient must swallow with the teeth apart.
In swallowing the fore-part of the tongue is used to
plug the gap between the teeth and it may be
protruded through the upper and lower teeth to
the back of the lips. At this stage the hyoid bone
may be moved further forward than is normal. In
these circumstances most of the clearance of the
mouth has to be made by the elevation of the middle
third of the tongue to the palate. The tongue does
not perform as efficiently as is usual and a residue
is left. The tongue movements in the mouth in
acromegaly are comparable to those of a normal
individual swallowing with the tip of his tongue
protruding through his teeth.
In the phase of expulsion of the bolus from the
pharynx the tongue in the acromegalic patient is
not free to arch backwards as in the normal
individual because it must maintain closure in the
front of the mouth. It appears that despite its
bulk it is proportionately inadequate for this
purpose.
In a previous communication (Ardran and Kemp,
1972b) we stated that the size of the tongue can be
correlated with the size of the tonsils, basing this
theory mainly on the fact that the small tongue is
associated with persistent large pharyngeal
tonsils, the tonsils acting as space-fillers to compen-
sate for the inadequate bulk of the tongue. In
acromegaly we have an apparent contradiction of
our theory for some of these patients have large
pharyngeal tonsils and 3 of our patients had
exceptionally large lingual tonsils (Figs. 8, 9 and
10). Our material is too small to argue with
certainty but it appears that this paradox is
explained by the fact that the tongue in acromegaly
is inadequate to provide for the expulsion of the
bolus in the pharynx. We are not suggesting that
the needs of functional adaptation entirely explain
the size of the lymphoid tissues but it may be one
reason for the discrepancy in size in some patients.
Increase in the lymphoid tissue of the pharynx and
tonsils was noted by Reinhardt and Creutsfeldt
(1913) and it may be in response to the disease.
The above mentioned theory may also explain
why some patients have a thick soft palate (Fig.
10), in one patient three times normal thickness.
The normal soft palate is a comparatively thin
structure when it is lowered to the tongue as the
tail of the bolus is squeezed from the mouth. In
acromegaly, when there are no enlarged tonsils,
there may be a large thick soft palate. Our cine-
RADIOLOGY
fluorograms of swallowing suggest that in these
circumstances the volume occupied by the soft
palate is a useful addition to the volume of the
tongue. The volume of space to be occupied by
the tongue, tonsils and soft palate during the phase
of expulsion in swallowing is obviously influenced
by forward displacement of the mandible analogous
to normal behaviour in infancy.
It may be that the size of the tongue in
acromegaly varies at different stages in the disease.
To evaluate this question properly, it would be
necessary to consider whether the disease was
progressive, stationary, or in remission and whether
the muscular features were normal, hyper-
trophied or atrophic (cachetic). Due allowance
would also have to be made for the effects of
increasing age and associated disease.
One of our patients in whom the disease has been
apparently stationary for many years asserted that
her tongue had grown smaller. It may be that the
tongue had got smaller with the resultant
diminution of muscle bulk as a result of ageing: her
skeletal muscle certainly seemed to have lost bulk
and tone. Another patient said that his tongue had
varied in size over the years. The question of the
activity of the disease is important if steps are
contemplated to reduce tongue size by partial
excision, for it is known that the procedure fails if
the disease is progressing.
None of our patients showed protrusion of the
tongue through the lips as described by Atkinson
(1932): it is evident that the patient would not
allow this to happen unless he were mentally
defective or unable to compensate for his large
tongue in other ways. When the tongue is
protruded, the back of the tongue is brought
forward, so that the pharyngeal cavity is increased
in size but this effect is not so great if the patient
has persistent infantile proportions with large
pharyngeal tonsils and adenoids.
Most acromegalic patients are able to keep their
tongue within the confines of the mouth but they
do this by lowering the mandible and keeping the
lips closed: it may be that this is why the lips are
sometimes everted and hypertrophied. If the subject
is asked to close the jaws, the tongue is displaced
backwards and narrows the pharyngeal and laryn-
geal airways (Figs. 6 and 7).
Additional accommodation for the tongue is also
provided by lowering the floor of the mouth
relative to the mandible. This fact is readily
appreciated if the subject closes the jaws and the
position of the hyoid bone relative to the cervical
spine is noted. However, it may be difficult to
assess if there is an appreciable degree of open bite.
 THE TONGUE AND MOUTH
The hyoid bone is also moved forward relative to
the spine and this brings the epiglottis forwards
so that the vestibule of the larynx is widened. This
is a point of considerable importance if the epiglottis
has been pressed backwards by a large lingual
tonsil (Figs. 8, 9 and 10).
In some patients with acromegaly, there is a
sustained forward movement of the mandible
relative to the spine comparable to the movement
obtained by digital displacement of the mandible
forwards during anaesthesia, or the similar displace-
ment which may be made voluntarily by most
normal subjects. This change in position brings the
back of the tongue forwards and widens the airway:
it also produces forward projection of the lower
teeth relative to the upper. It may be that this
deformity explains the feature described by Chalk
(1856) as a 'partial dislocation of the lower jaw
due to a large tongue' (Fig. 12).
The deformity described in the above paragraph
is not present in all acromegalic subjects and may
be seen in others with large tongues: it also occurs
in 'normal' individuals possibly due to defective
maturation. Two of our acromegalic patients
showed other evidence of failure to reach normal
facial development.
When the mandible is lowered the condyles move
forwards in the glenoid sockets and when the
mouth is widely opened the condyles move forward
beneath the pre-articular tubercles. Similar dis-
placement of the condyles relative to the glenoids
is associated with the displacement of the mandible
forwards. It may be that this displacement, when
sustained, explains the malformation of the con-
dyles described in many patients.
The effect of these compensatory mechanisms is
to ensure that in most patients with acromegaly the
airway is normal in size or at least adequate for the
patients' purpose. Many patients have a relatively
narrow airway though they experience no difficulty
in sleeping. We have not studied patients in the
terminal phases of the disease. The reduced size of
the airway may be a feature contributing to death
if they develop cardio-respiratory failure. Wright,
et. al. (1970), who studied the cause of death in 55
patients with acromegaly, found 'the excess of
deaths due to respiratory failure was an unexpected
finding for which there was no obvious explanation'.
The size of the tongue cannot be considered
without reference to the size of the mouth. It may
be that changes in tongue size are in part causal
and in part compensatory. Changes in the form
and shape of the jaws were recognised in the earliest
descriptions but the causes were not understood.
Chalk (1856) and Benda (1902) thought that the
IN ACROMEGALY 441
changes were due to the large tongue, an opinion
not shared by Muschan (1909). Atkinson (1932)
thought that the cases of Burchard (1901) and
Whyte (1893) in which the tongue was enlarged
and the jaw normal in size, proved that the tongue
was not responsible for the changes in the form of
the jaw.
Textbooks imply that changes in the jaw are
characteristic of the disease and suggest that there
are typical radiographic features. Our experience is
small but certain facts are evident. Firstly, the
skeletal changes as seen in the jaws do not conform
to the single pattern: this is supported by Atkin-
son's review. Secondly, the changes in the jaws
are influenced by the presence or absence of the
teeth.
It is said that the teeth may be enlarged but we
have no evidence of this. Graves (1904) believed
that separation of the anterior teeth was a certain
sign of acromegaly and an early feature of the
disease. It has been suggested that this feature is
most evident in the upper jaw. Separation of the
teeth has been attributed to overgrowth of the
alveolar processes: this we can confirm in both
upper and lower jaws (Figs. 11, 13 and 14). We
have recognised two types of dental separation (a)
separation of the teeth due to overgrowth of the whole
alveolus in the area in question (Figs. 15 and 16),
and (b) by localised disproportional overgrowth
of the alveolus resulting in 'fanning' of the affected
teeth, whereby the crowns are separated more than
the apices (Figs. 15 and 16). Both types of separa-
tion take place mainly in the incisor and pre-molar
regions: the molar teeth may be tightly packed
together. The normal inclination of the teeth out-
wards may also be increased. All these deformities
result in the increase in size of the forepart of the
mouth.
In some cases recorded in the literature the whole
of the mandible is enlarged so that the lower teeth
overlap the upper teeth when the mouth is closed.
Likewise the upper jaw may be greatly enlarged and
the lower jaw proportionately small. The dental
changes may show some degree of asymmetry
which may be associated with considerable distor-
tion of the jaws: we have one case where the result
of jaw deformity was asymmetrical, which was
associated with dental extractions on one side only.
Prognathism or increase in the promontary of
the chin is due to a number of factors including
localised thickening of the bone over the promon-
tary, forward movement of the mandible relative to
t he spine and to growth in length of the body of
the mandible (Fig. 14). A similar condition may
effect the maxilla but this is rare.
442 CLINICAL RADIOLOGY

FIG. 13 FIG. 14
FIG. 13--Male aged 32 - acromegaly. Line o f h a r d p a l a t e within n o r m a l limits. D o w n g r o w t h o f u p p e r alveolus w i t h a n t r u m
a n d teeth. Angles o f the m a n d i b l e a r e r o u n d e d a n d f o r w a r d s f r o m the spine. O v e r g r o w t h o f the alveolus in the m a n d i b l e in all
regions especially incisor. T h i c k e n i n g o f the cortex o f the m a n d i b l e . FIG. 14--Male aged 45 - acromegaly. F e a t u r e s similar to
N o . 13 p r o n o u n c e d p r o g n a t h i s m .

FiG. 15 FIG, 16
FIG. 15--Male aged 31 - Acromegaly. S e p a r a t i o n o f the u p p e r incisors b u t n o ' f a n n i n g ' . FIG. 16 Female aged 46 - Acrome-
galy, U p p e r a n d l o w e r incisors s e p a r a t e d a n d ' f a n n e d ' o u t w a r d s . S e p a r a t i o n o f the teeth is m o s t m a r k e d in the u p p e r incisor region.
 THE TONGUE AND MOUTH
Another deformity is 'open bite'; in this condition
there is a gap between the front teeth when the
jaws are closed, resulting in difficulty in incising
food (Fig. 9). We believe that it is primarily due
to downward displacement of the maxillary molars
which obstruct closure like a block in the hinge of
an open door. The development o f a mechanical
block is also influenced by the misalignment of the
teeth resulting from displacement of the mandible
forwards, and by lack of growth of the rami down-
wards.
The jaw deformities described in acromegaly
include straightening of the angles of the mandible
analogous to the deformity which may result
when all teeth are extracted from a normal subject.
Some of our patients had no such deformity (Fig.
10). Likewise, it is not true that all edentulous
patients (without acromegaly) show this deformity.
This teaching stems from the days when most
patients from whom all teeth had been extracted
wore no or ill-fitting dentures. If a well fitting
denture is worn the mandible may show consider-
able reduction in size but the angles are not
necessarily straightened (Figs. 4 and 5). The
explanation for the development of straightening
of the angles is probably the same in both normal
and acromegalic subjects. After removal of all
teeth in an otherwise normal individual, the tongue
is large relative to the reduced oral cavity. If no
dentures are worn the jaws are brought closer
together in an attempt to masticate food, and to do
this the mandible is brought further forwards
than is normal. As the alveolar processes and the
body of the mandible atrophy this tendency
becomes more pronounced.
Another feature of our acromegalic patients was
considerable variation in growth of different parts of
the mandible. Published accounts suggest that the
whole of the mandible is enlarged and thickened,
but this is not so. The alveolar processes supporting
the teeth may be considerably enlarged but this
overgrowth does not take place uniformly: it is
most marked in the incisor region, and in the molar
region may not occur at all: the result is that the
molar teeth are frequently crowded and mal-
aligned (Fig. 13). In many patients with
acromegaly, the rami of the mandible are normal
in length or shorter than average (Fig. l 1). This
can best be appreciated by studying the level of
the angles of the mandible relative to the spine.
In most acromegalic patients the lower border of the
mandible is frequently deformed and cannot be
used as an index, but in most subjects the position
of the angle relative to the spine can be estimated.
In only one of our acromegalic patients were the
IN ACROMEGALY 443
angles of the mandible lower than normal, indicat-
ing that the rami were overgrown (Fig. 10).
In some patients with acromegaly the body of
the mandible is bent or bowed downwards: this
deformity takes place in front of the angles approxi-
mately at the level of the third molar teeth: the
deformity may be very pronounced and may result
in a considerable enlargement of the oral cavity
(Figs. 6, 13 and 14). Normal persons may show
slight deformities of the body of the mandible of a
similar nature.
All parts of the mandible do not respond to
pituitary hormone. For two reasons we believe
that the factors responsible are the same as those
which result in failure of proportional growth in
'normal' individuals, and that these factors are
operative prior to the development of the
acromegaly. Firstly, the patterns of defective
growth or hypoplasia which affect part of the jaws
which result in crowding and malalignment of
teeth and failure of some teeth to erupt (Figs. 8 and
12) are the same in acromegaly as in 'normal'
individuals and, secondly, these affected segments
of jaw do not appear to respond by growth and
eruption of the teeth as the acromegaly develops.
In some acromegalics, the appearances of bone
texture were near normal, in others there was
considerable thickening of the cortex analogous to
the thickening seen so often i n normal subjects
after dental extraction. In several patients the
cortical bone was relatively thin. Some patients
showed considerable thickening of the cancellous
tissue: definition of the apices of the teeth was
obscured. Several patients showed considerable
enlargement of the inferior dental canals which we
infer was probably due to enlargement of the
inferior dental arteries (Figs. 10 and 13), It is
known that the vessels in acromegalic bones are
often bigger than normal. In none of our patients
was there any indication that the thickness of the
bones had reduced the size of the mouth cavity. We
have also noted that extraction of the teeth in
acromegalic patients is not necessarily associated
with atrophy of the bone.
In summary, we feel that the only bony feature
which is specifically related to the development of
acromegaly is overgrowth of parts of the jaw,
especially of the promontory and the incisor and
pre-molar regions, the latter including overgrowth
of the alveolar processes resulting in separation
of the teeth. There may be enlargement of the
inferior dental canals. In some patients there is
failure of the bone to show normal atrophy after
teeth have been removed.
Changes in the size of the mouth may be
444 CLINICAL
influenced by the soft tissues. Atkinson (1932)
stated that the mucous membrane of the mouth
was frequently thickened, especially that covering
the soft palate. Naunyn (1894) cites a case where
there was a large mass of soft tissue situated in the
roof of the mouth over the junction of the hard and
soft palates. The salivary glands, including the
sublingual glands may be enlarged but none of our
patients showed any significant encroachment of
the mouth and mouth cavity thickening of the soft
tissues.
It is tempting to put forward the view that
enlargement of the tongue influences the size and
shape of the jaws in acromegaly. We know that in
normal individuals growth of the tongue and jaw
are related: this must be so or normality would
not result.
Our findings have some bearing on treatment in
acromegaly. As in normal individuals, extraction
of the teeth may result in the reduction of the size
of the mouth cavity. This observation suggests
that if all teeth are to be extracted from an acro-
megalic with a large tongue, it might be well to
exercise careful supervision of the airway during the
phase of recovery from the anaesthetic.
There can be no doubt that the presence of teeth,
their arrangement and inclination, influence the
resultant deformity. Once the teeth are malaligned
the effect of bite and chewing will exert much
greater influence than the pressure made by the
tongue.
At the present time it appears that the only
measure which helps these patients is total dental
extraction. Such subjects were the least deformed
of our patients. They managed well without teeth.
It may be that if the output of the pituitary could
be controlled, the dental deformity could be
reduced by suitable extractions or by operative
correction of the jaw deformities. In suitable cases,
part of the tongue could be removed. We feel that
these patients should be under the care of an oral
RADIOLOGY
surgeon skilled in the management of such
problems.
Aeknowledgements.--Our thanks are due to our clinical
colleagues and especially Dr. D. Hockaday for access to the
patients and their records. Miss E. Emrys-Roberts was
responsible for much of the radiographic and technical
assistance. Mr. S. Ashington was responsible for the
photographic reproductions.
REFERENCES
ARDRAN, G. M. & KEMP, F. H. (t972a). A Functional
assessment of relative tongue size. American Journal of
Roentgenology, 114, 282.
ARDRAN, G. M. & KEMP, F. H. (1972b). A function for
adenoids and tonsils. American Journal of Roentgenology -
in the press.
ARDRAN, G. M. & KEMP, F. H. To be published.
ATKINSON,F. R. B. (1932). Acromegaly. John Bale, Sons
and Danielsson Limited, London.
BENDA, C. (1902). Akromegalie. Deutsche Klinik am
Eingange Des Zwanzigsten Jahrhunderts, 3, 261.
BURCHARD,O. (1901). Ein Fall von Akromegaliecombiniert
mit myxoedema. St. Petersberg Medicinische Wochen-
schrift, n.f. XXVI, 481.
CHALK,W. O. (1856). Partial dislocation of the lower jaw
from an enlarged tongue. Transactions of the Pathological
Society, London, 8, 305-308.
GRAVES, W. (1904). Ueber Luckenbildung zwischen den
einzelnen Zahnen, ein Fruhdiagnostischem und bisher
wenig bekanntes Zeichen der Akromegalie. Monatschr.
Psychiatrie u. Neur., Berl., XVI, 18.
LUSCI-IAN, VON F. (1909). Akromegalie und Caput ro-
genaeum. Zeitschrift fur Ethnologie, XLI, 698-702.
NAUNYN, . (1894). Akromegalie. Unterelsassischer
Aerzteverein in Strassburg, 1894, April 28th. Deutsche
Medicinische Wochenschrift, 20, 87.
REINHARDT, A. t~ CREUTZFELDT, H. G. (1913). Beitrag zur
Lehre vonder Akromegalie. Beitrage zue Pathologischen
Anatomie und zer allgemeinen Pathologie, Jena, LVI,
465-99.
TANZI,E. (1891). Due casi di acromegalia (Con due figure
intercalate nel testo). Rivista Clinica Milano, 30, 533-550.
WHVTE, J. M. (1893). A case of acromegaly. Lancet,
I, 642-644.
WRIGHT, A. D., HILL, D. M., Lowv, C. & FRASER, T. R.
(1970). Mortality in Acromegaly. Quarterly Journal of
Medicine, 39, 1-16.