THE TONGUE In Clinical Diagnosis A Colour Atlas of The Tongue in Clinical Diagnosis D.W. BEAVEN S.E. BROOKS BATES Guide to Physical Examination Lynn s. Bickley רויטל רחימי, תום כספי פנימית ב', תל-השומר
Large Tongue In young: Down s synd. (fissured tongue) Cretinsm (congenital hypothyroidism) Congenital macroglossia In adults: Hypothyroidism Edentulous (lack of teeth) Acromegaly Amyloid Tumours Crohn s and gut disease Acute glossitis & Angio-neurotic oedema
Angioedema Down s syndrome Hypothyroidism Amyloidosis
Small Tongue In young:craniofacial or extracranial anomalies. Congenital small mandible syndrome. Lingual hypoplasia (e.g. Cri du chat). In adults: Uncommon to see glossal wasting. Pseudo-bulbar palsy (upper motor neuron). Bulbar palsies (lower MN).
Cri du chat Congenital small mandible syndrome
Coatings of the Tongue Fasting Poor or neglected health Smoking Soft-processed food diet Disuse of dentures
Heavy Smoking Hairy & dark tongue Processed food diet Diet & failure of immune mechanisms
Glossitis Any of the four types of papillae on the tongue can develop an acute inflammatory response with shedding of surface epithelium. The filiform papillae are most commonly effected.
Glossitis Major grouping of glossitis: Infections: bacterial, viral or fungal. Allergic or toxic. Drug induced. Nutritional: Vitamin B 12 Iron Folic acid Other B vitamins: niacin, riboflavin, pyridoxine
Drugs affecting the tongue
Acute glossitis due to malnutrition Iron& folate deficiency Painful tongue and loss of filiform papillae Chronic alcoholic tongue multiple B deficiency
Ulcers of the Tongue Trauma Recurrent Aphthous NSAID s Use of pharmacological drugs Connective tissue diseases & autoimmune disorders (e.g. Sjögren s syn.; Behcet s syn.; Magic syn.; SLE) General skin disorders (e.g. Lichen planus, Pemphigoid syn.) Gut diseases Neutropenia Reiter s disease & Sexually transmitted disease (e.g. HIV, Syphilis) Malignancy
NSAID induced Squamous cell carcinoma Aphthous Ulcer
Geographic Tongue Loss of filiform papillae in well defined areas which become surrounded by a white edge representing the injured or regenerating papillae. A map like appearance of the tongue.
Associated with Hayfever, eczema or asthma. Family history. Raised levels of IgE. Reiter s disease. Pustular psoriasis. Acute autoimmune disorders (e.g. SLE) More common in children (esp. Jewish & Japanese). In tongues with marked fissures.
Circumvallate papillae Migratory Non migratory Annular
General disorders Injuries (epilepsy, sports) Scurvy Leukaemias & Lymphomas Bleeding disorders Telangiectasia Drug eruptions Sarcoid disease Cyanosis Diabetes Crohn s disease Ulcerative colitis
Low platelet count Iron deficiency anaemia Pernicious anaemia
Chronic Lymphatic Leukaemia Telangiectasia
Infections Viral- Herpes, EBV, Coxsackie. Bacterial- TB. Fungal- Candidiasis. Sexually transmitted- Syphilis, Reiter s syndrome, HIV. Candidiasis or thrush is the most common infection. Causes are: -Elderly people -Steroids or antibiotics -Poorly controlled diabetes -Reduced resistance to infection
Herpes EBV (mononucleosis) Burkitt s lymphoma (EBV)
Tuberculosis+diabetes Syphilis Candida Herpes Zoster White patches due to growth of Candida albicans
Colour changes Pale Yellow- Anaemia, Jaundice. Orange- Obstructive jaundice. Strawberry Red- Scarlet fever, Pernicious anaemia. Blue- Central Cyanosis, Polycythemia, Raynaud s dis. Beefy Red- Vit. B deficiency. Pigmented- Addison s, Heroin, Melanoma, Thyroid. Black (hairy)- Metal poisoning.
Pernicious anaemia Jaundice Vitamin B deficiency Addison s disease
White Surface Lesions Lichen Planus: Chronic mucocutaneous disease of the skin and the oral mucosa. Presented as ulcerations. Radiation Injury Leukoplakia: Non specific white lesion. Dorsal- mostly benign. Ventral- more prone to be malignant.
White Surface Lesions Hairy Leukoplakia: whitish raised areas with feathery pattern. The sides of the tongue are most often affected. Seen in AIDS.
Ankyloglossia (tongue-tie) Turner s syndrome Klinefelter s syndrome Ehlers Danlos syndrome
Dehydration, saliva and the tongue Autoimmune diseases of the salivary glands- dry mouth: Sjögren s syndrome Sarcoidosis Illnesses which increase the metabolic rate may lead to an increased respiratory rate with mouth breathing and a parched tongue. Therefore, surface dryness of the tongue is a poor guide to the percentage water loss or the actual degree of total body dehydration. When the dorsum of the tongue is parch- other clinical measurements should be done: rising pulse, falling BP, turgor, low urine output etc.
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