Tongue Lesions: Diagnostic Challenges and Therapeutic Strategies

Preface
Acknowledgments
Contents
1: Embryology of the Tongue
1.1 Development of the Tongue
1.1.1 Anterior Two-Thirds: From First Arch
1.1.2 Posterior Third: From Third Arch
1.2 Development of Taste Buds and PapillaE
1.3 Development of the Nerve Supply
1.4 Summary of Tongue Development
References
2: Surgical Anatomy of the Tongue
2.1 Overview: Key Facts About the Tongue
2.2 Structure of the Tongue
2.2.1 Important Relations
2.2.2 Anterior Two-Thirds
2.2.3 Terminal Sulcus (Sulcus Terminalis Linguae)
2.2.4 Posterior Third
2.2.5 Lingual Frenulum
2.2.6 Muscles of the Tongue
2.2.6.1 Intrinsic Tongue Muscles
2.2.6.2 Extrinsic Tongue Muscles
2.3 Blood Supply and Lymphatic Drainage
2.3.1 Arterial Supply
2.3.2 Venous Drainage
2.3.3 Lymphatic Drainage
2.4 Innervation of the Tongue
2.4.1 Motor Innervation: The Hypoglossal Nerve (CN-XII)
2.4.2 Tactile Sensory Innervation: The Lingual Nerve (CN-V3)
2.4.3 Taste Innervation
2.4.4 Lingual Nerve Injuries
References
3: Histology of the Tongue
3.1 Lingual Papillae
3.2 Taste Buds (Caliculi Gustatererius)
References
4: Physiology of the Tongue
4.1 Functions of the Tongue
4.1.1 Tongue: Tool to Taste Food
4.1.2 Tongue’s Role in Mastication
4.1.3 Removal of Hard and Ill-Tasting Substances
4.1.4 Swallowing Food
4.1.5 The Tongue: An Organ for Sucking
4.1.6 Tongue as an Organ of Speech
4.1.7 Intimacy
4.1.8 Medication Delivery
4.1.9 The Tongue: An Indicator of Health
4.2 Taste (Gustatory) Pathway
4.2.1 Neuronal Pathway for Taste
4.3 Taste Disorders
4.3.1 Types of Taste Disorders
4.3.1.1 Dysgeusia
4.3.1.2 Hypogeusia
4.3.1.3 Ageusia
4.3.2 Etiology of Taste Disorders
4.3.3 Symptoms
4.3.4 Diagnosis
4.3.4.1 History-Taking
4.3.4.2 Investigations
4.3.5 Prevention
4.3.6 Treatment
4.3.7 Prognosis
References
5: Congenital Anomalies
5.1 Aglossia
5.2 Hemiglossia (Half-Tongue)
5.3 Microglossia
5.3.1 Definition
5.3.2 Epidemiology
5.3.3 Etiology
5.3.4 Clinical Picture and Treatment
5.4 Macroglossia
5.4.1 Definitions
5.4.2 Epidemiology
5.4.2.1 Frequency
5.4.2.2 Gender
5.4.2.3 Race
5.4.3 Etiology
5.4.3.1 Causes of Pseudo-Macroglossia
5.4.3.2 Causes of True Macroglossia
5.4.4 Clinical Presentation
5.4.5 Clinical Evaluation
5.4.6 Complications
5.4.7 Treatment
5.4.7.1 Medical Therapy
5.4.7.2 Sclerotherapy/Embolisation
5.4.7.3 Mechanical Therapy
5.4.7.4 Surgical Treatment
5.5 Bifid (Cleft) Tongue
5.5.1 Etiology
5.5.2 Treatment
5.6 Double Tongue/Accssory Tongue
5.6.1 Double Tongue
5.6.2 Accessory Tongue
5.7 Ankyloglossia
5.7.1 Definition
5.7.2 Prevalence
5.7.3 Etiology
5.7.4 Classification
5.7.4.1 Anterior/Posterior [21–23]
5.7.4.2 Complete/Partial [21–23]
5.7.4.3 Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) [24, 25]
5.7.4.4 Coryllos Classifications of Tongue-Tie [27]
5.7.4.5 Kotlow Classification of Tongue-Tie
5.7.5 Clinical Presentation
5.7.5.1 Feeding and Swallowing Difficulties
5.7.5.2 Speech Impairment/Development Disorders [34]
5.7.5.3 Gingival Recession/Dental Caries
5.7.5.4 Other Reported Problems
5.7.5.5 Social Concerns
5.7.6 Identification of Ankyloglossia (Tongue-Tie) [37]
5.7.7 Treatment
5.7.8 Prognosis
5.7.9 Pearls for Clinical Practice [44]
5.8 Black Hairy Tongue
5.9 Fissured Tongue
5.9.1 Definition
5.9.2 Epidemiology
5.9.3 Etiology
5.9.4 Treatment
5.10 Lingual (Sublingual) Varices
5.11 Lingual Thyroid Nodule
5.11.1 Definition
5.11.2 Pathogenesis
5.11.3 Epidemiology
5.11.3.1 Other Rare Sites
5.11.3.2 Clinical Presentation
5.11.4 Differential Diagnosis
5.11.5 Treatment
References
6: Tongue Trauma
6.1 Common Tongue Injuries
6.1.1 Etiology
6.1.2 Sequelae
6.1.3 Management
6.1.3.1 To Suture or Not?
6.1.3.2 Principles of Management
6.1.3.3 Injuries of the Dorsal Surface
6.1.3.4 Penetrating Injuries
6.1.3.5 Lateral or Tip Injuries
6.1.3.6 Large Lacerations or Avulsion
6.1.3.7 Injuries of the Tongue Base
6.1.3.8 Tongue Injuries in Children with Coagulopathy
6.1.3.9 Postoperative Care
6.2 Complex Tongue Lacerations
6.2.1 Introduction
6.2.2 Etiology
6.2.3 Operative Management - Repair
6.2.3.1 Goals of Repair
6.2.3.2 Indications of Repair
6.2.3.3 Contraindications
6.2.3.4 Anesthesia
6.2.3.5 Positioning
6.2.3.6 Preparation
6.2.3.7 Technique
6.2.3.7.1 Three-Layer Technique
6.2.3.7.2 Two-Layer Technique
6.2.3.7.3 One-Layer Technique
6.2.4 Aftercare
6.2.5 Complications
6.3 Tongue Bites
6.3.1 Introduction
6.3.2 Etiology
6.3.3 Treatment
6.3.3.1 Indications
6.3.3.2 Procedure
6.3.4 Prognosis
6.4 Tongue Biting During Sleep
6.4.1 Introduction
6.4.2 Etiology
6.4.2.1 Bruxism
6.4.2.2 Facial Muscle Spasms
6.4.2.3 Illicit Drug Use
6.4.2.4 Lyme Disease
6.4.2.5 Nighttime Seizures
6.4.2.6 Rhythmic Movement Disorder
6.4.2.7 Sleep Apnea
6.4.3 Symptoms
6.4.4 Treatment
6.4.5 Prevention
6.4.5.1 Sleep Study
6.4.5.2 Mouth-Guard
6.4.5.3 Reduction of Stress
6.4.5.4 Avoidance of Illegal Drugs
6.4.5.5 Medications
6.5 Tongue Burn: Burning Mouth Syndrome
6.5.1 Introduction
6.5.2 Prevalence
6.5.3 Etiology of Tongue Burn
6.5.3.1 Tongue Burn (from Food or Liquid)
6.5.3.2 Burning Mouth Syndrome (BMS)
6.5.4 Pathogenesis of BMS
6.5.4.1 Peripheral and Central Neuropathies
6.5.4.2 Psychological Factors
6.5.5 Symptoms
6.5.5.1 Tongue Burn
6.5.5.2 Burning Mouth Syndrome
6.5.6 Complications
6.5.6.1 Tongue Burn
6.5.6.2 Burning Mouth Syndrome
6.5.7 Diagnosis
6.5.7.1 Tongue Burn
6.5.7.2 Burning Mouth Syndrome
6.5.8 Treatment
6.5.8.1 Tongue Burn
6.5.8.2 Burning Mouth Syndrome
6.5.8.2.1 Topical and Systemic Medications
6.5.8.2.2 Psychological/Psychiatric Intervention
6.5.9 Prevention
6.5.9.1 Tongue Burn
6.5.9.2 Burning Mouth Syndrome
6.5.10 Prognosis
6.5.10.1 Tongue Burn
6.5.10.2 Burning Mouth Syndrome
6.6 Conclusion
References
7: Tongue Piercing
7.1 Introduction
7.2 Historical Review
7.3 Types of Piercing Jewellery
7.4 Complications of Tongue Piercing
7.4.1 Hemorrhage
7.4.2 Nerve Injury
7.4.3 Painful Ulceration and Inflammation
7.4.4 Infection
7.4.5 Bacterial Endocarditis
7.4.6 Transmission of Communicable Diseases
7.4.7 Allergic Reactions
7.4.8 Dental and Gum Alterations
7.4.9 Formation of Bacterial Plaque
7.4.10 Tissue Alteration
7.4.11 Sialorrhea
7.4.12 Panoramic X-ray Alteration
7.4.13 Aspiration
7.4.14 Other Complications
7.5 Conclusions and Recommendations
References
8: Inflammation (Glossitis)
8.1 Overview
8.1.1 Introduction
8.1.2 Clinical Presentation
8.1.3 Diagnosis
8.1.4 Etiology
8.1.4.1 Allergic Reaction
8.1.4.2 Mechanical Irritation or Injury to the Mouth
8.1.4.3 Exposure to Irritants
8.1.4.4 Infections
8.1.4.5 Anemias
8.1.4.6 Vitamin B Deficiencies
8.1.4.7 Other Diseases/Conditions
8.1.5 Classification (Types) of Glossitis [13]
8.1.6 Epidemiology
8.1.7 Prevention
8.1.8 Treatment
8.2 Atrophic Glossitis
8.2.1 Synonyms
8.2.2 Definition
8.2.3 Etiology
8.2.4 Treatment
8.3 Median Rhomboid Glossitis (MRG)
8.3.1 Incidence
8.3.2 Etiology and Pathogenesis
8.3.3 Clinical Features
8.3.4 Diagnosis
8.3.5 Treatment
8.4 Benign Migratory Glossitis (Geogrpahic Tongue)
8.4.1 Synonyms
8.4.2 Definition
8.4.3 Prevalence
8.4.4 Etiology
8.4.5 Clinical Features and Diagnosis
8.4.6 Potential Complications
8.4.7 Treatment
8.4.8 Prognosis
8.5 Geometric Glossitis
8.5.1 Definition
8.5.2 Clinical Presentation
8.5.3 Etiology
8.5.4 Treatment
8.6 Strawberry Glossitis
8.6.1 Definitions
8.6.2 Etiology
8.6.3 Treatment
References
9: Swellings of the Tongue
9.1 Classification
9.2 Causes of Acute Tongue Swellings
9.3 Causes of Chronic Tongue Swellings
9.4 Ranula
9.4.1 Definition
9.4.2 Anatomical Classification
9.4.3 Epidemiology
9.4.4 Etiology
9.4.5 Pathophysiology
9.4.6 Clinical Presentation
9.4.6.1 History-Taking
9.4.7 Clinical Examination
9.4.7.1 Complications
9.4.8 Evaluation/Investigations
9.4.8.1 Ultrasonography (US)
9.4.8.2 Computed Tomography (CT) Scan
9.4.8.3 Magnetic Resonance Imaging (MRI)
9.4.8.4 Biopsy
9.4.9 Differential Diagnosis
9.4.9.1 Oral (Simple) Ranula
9.4.9.2 Plunging (Cervical) Ranula
9.4.10 Treatment
9.4.10.1 Oral Ranulas: Treatment Options
9.4.10.1.1 Surgical Excision
9.4.10.1.2 Marsupialization/Micro-marsupialization
9.4.10.1.3 Laser Ablation, Cryosurgery, and Electrocautery
9.4.10.1.4 Intralesional Injection of a Sclerosant Agent
9.4.10.2 Plunging Ranulas: Treatment Options
9.4.10.3 Postoperative Care
9.4.10.4 Intra- and Postoperative Complications
9.4.10.4.1 Intraoperative Complications
9.4.10.4.2 Postoperative Complications
9.4.10.5 Recurrence
9.4.11 Prognosis
9.5 Sublingual Dermoid Cyst
9.5.1 Etiology: Classification
9.5.2 Anatomical Classification
9.5.3 Epidemiology
9.5.4 Pathology
9.5.5 History-Taking
9.5.6 Physical Examination
9.5.7 Complications
9.5.8 Evaluation/Investigations
9.5.8.1 Ultrasonography (US)
9.5.8.2 Computed Tomography (CT) Scan
9.5.8.3 Magnetic Resonance Imaging (MRI)
9.5.8.4 Cytology/Histology
9.5.9 Differential Diagnosis
9.5.9.1 Infections
9.5.9.2 Neoplasms
9.5.9.3 Cystic Lesions
9.5.10 Treatment
9.5.11 Prognosis
References
10: Neoplastic Lesions of the Tongue
10.1 Classification
10.2 Benign Tumors
10.2.1 Granular Cell Tumors
10.2.2 Fibroepithelial Polyp (Traumatic Fibroma)
10.2.3 Papilloma
10.2.4 Mixed Salivary Tumor (Minor Salivary Glands)
10.2.5 Lingual Thyroid Nodule
10.2.6 Hemangioma
10.2.7 Lymphoepithelial Cysts
10.3 Malignant Tumors
10.3.1 Squamous Cell Carcinoma (SCC)
10.3.2 Alveolar Soft Part Sarcoma (ASPS)
10.3.2.1 Pathogenesis
10.3.2.2 Incidence
10.3.2.3 Clinical Presentation
10.3.2.4 Imaging
10.3.2.4.1 Computed Tomography (CT) Scan
10.3.2.4.2 Magnetic Resonance Imaging (MRI)
10.3.2.4.3 Angiography
10.3.2.5 Differential Diagnosis
10.3.2.6 Histopathology
10.3.2.7 Management
10.3.2.8 Prognosis
10.3.3 Synovial Sarcoma of the Tongue
10.3.3.1 Incidence: Location
10.3.3.2 Clinical Manifestations
10.3.3.3 Investigations: Diagnosis
10.3.3.3.1 Tumor Markers
10.3.3.3.2 Imaging
10.3.3.3.3 Histopathology
10.3.3.4 Management
10.3.3.4.1 Surgery
10.3.3.4.2 Chemoradiotherapy
10.3.3.4.3 Radiotherapy (RT)
10.3.4 Myoblastic (Myofibroblastic) Sarcoma
10.3.4.1 Pathology
10.3.4.2 Clinical Behavior
10.3.4.3 Differential Diagnosis
10.3.4.4 Treatment
10.3.5 Spindle Cell Sarcoma (SCS)
10.3.5.1 Introduction
10.3.5.2 Etiology: Pathogenesis
10.3.5.3 Stages of SCS
10.3.5.4 Clinical Presentation: Treatment
10.3.5.5 Prognosis
10.3.6 Kaposi Sarcoma (KS)
10.3.6.1 Introduction
10.3.6.2 Epidemiology
10.3.6.3 Etiology
10.3.6.3.1 Transmission
10.3.6.4 Pathology
10.3.6.5 Clinical Picture
10.3.6.5.1 Skin
10.3.6.5.2 Mouth
10.3.6.5.3 Gastrointestinal Tract
10.3.6.5.4 Respiratory Tract
10.3.6.6 Diagnosis
10.3.6.7 Differential Diagnosis of Kaposi Sarcoma
10.3.6.8 Classification
10.3.6.9 Prevention
10.3.6.10 Treatment
References
11: Tongue Manifestations of Systemic Diseases
11.1 Overview
11.2 Gastrointestinal (GI) Diseases
11.2.1 Inflammatory Bowel Disease (IBD)
11.2.2 Pyostomatitis Vegetans (PSV)
11.2.3 Chronic Liver Disease (CLD)
11.2.4 Celiac Disease
11.3 Nutritional Diseases
11.3.1 Water-Soluble Vitamin Deficiency
11.3.2 Fat-Soluble Vitamin Deficiency/Toxicity
11.3.3 Mineral Deficiencies
11.4 Hematological Disorders
11.4.1 White Blood Cell (WBC) Disorders
11.4.1.1 Leukemia
11.4.1.2 Lymphoma
11.4.1.3 Cyclic Neutropenia
11.4.2 Platelet Disorders
11.4.3 Red Blood Cell (RBC) Disorders
11.4.3.1 Anemias
11.4.3.2 Hemochromatosis
11.4.3.3 Congenital Erythropoietic Porphyria (CEP)
11.4.3.4 Thalassemias
11.4.3.4.1 Sickle Cell Disease (SCD)
11.4.3.4.2 Polycythemia Vera
11.5 Autoimmune Diseases
11.5.1 Sjogren’s Syndrome (SS)
11.5.2 Kawasaki Disease
11.5.3 Systemic Lupus Erythematosus (SLE)
11.5.4 Scleroderma
11.6 Pulmonary Conditions
11.6.1 Granulomatosis with Polyangitis (GPA)
11.6.2 Sarcoidosis
11.7 Multi-system Conditions
11.7.1 Amyloidosis
11.7.2 Human Immunodeficiency Virus (HIV) Disease
11.7.2.1 Candidiasis
11.7.2.2 Herpes Simplex Virus (HSV)
11.7.2.3 Hairy Leukoplakia (HL)
11.7.2.4 Kaposi Sarcoma (KS)
11.7.2.5 Cytomegalovirus (CMV)
11.7.2.6 Human Papillomavirus (HPV)
11.7.2.7 Aphthous-Like Ulcerations
11.8 Cutaneous Diseases
11.8.1 Psoriasis
11.8.2 Acanthosis Negricans (AN)
11.9 Neurological Diseases
11.9.1 Neurofibromatosis (NF) Types 1 and 2
11.10 Endocrine Diseases
11.10.1 Diabetes Mellitus (DM)
11.10.2 Thyroid Gland Disorders
11.10.3 Parathyroid Gland (PTG) Disorders
11.10.4 Adrenal Gland Disorders
11.11 Renal Diseases
11.12 Drug-Induced Conditions
11.12.1 Aphthous Stomatitis
11.12.2 Dry Mouth (Hyposalivation or Xerostomia)
11.12.3 Lichen Planus (LP)
11.12.4 Candidiasis (Secondary to Inhaled Steroids)
11.13 Psychiatric Disorders
References
12: Tongue Discoloration
12.1 Black Hairy Tongue (BHT)
12.1.1 Definition
12.1.2 Synonyms
12.1.3 Epidemiology
12.1.4 Pathogenesis
12.1.5 Etiology
12.1.5.1 Soft Diet
12.1.5.2 Tobacco, Tea, and Coffee Consumption
12.1.5.3 Alcohol Intake and Intravenous (IV) Drug Use
12.1.5.4 Poor Oral Hygiene
12.1.5.5 Hyposalivation or Dry Mouth
12.1.5.6 Overgrowth of Microorganisms
12.1.5.7 Certain Diseases and General Debilitation [8]
12.1.5.8 Certain Medications
12.1.5.9 Radiotherapy
12.1.5.10 Oral Hygiene Products
12.1.5.11 Melanoglossia
12.1.6 Clinical Presentation
12.1.6.1 Symptoms and Local Examination
12.1.6.2 General Examination
12.1.7 Diagnosis
12.1.8 Differential Diagnosis
12.1.8.1 Pseudo-Black Hairy Tongue
12.1.8.2 Oral Hairy Leukoplakia
12.1.8.3 Pigmented Fungiform Papillae
12.1.8.4 Acanthosis Nigricans
12.1.9 Prevention and Treatment
12.1.10 Complications
12.1.11 Prognosis
12.1.12 Pearls for Clinical Practice
12.2 Orange Tongue
12.2.1 Etiology
12.2.1.1 Poor Oral Hygiene: Food Debris
12.2.1.2 Overgrowth of Fungi (Oral Thrush) and Bacteria
12.2.1.3 Certain Medications
12.2.1.4 Acid Indigestion/Heartburn
12.2.1.5 Mold in the Environment
12.2.1.6 Excess Beta-Carotene (Carotenemia)
12.2.2 Clinical Presentation
12.2.3 Treatment
12.3 Strawberry (Bright Red) Tongue
12.3.1 Introduction
12.3.2 Symptoms
12.3.3 Etiology
12.3.3.1 Kawasaki Disease
12.3.3.2 Scarlet Fever
12.3.3.3 Food or Drug Allergy
12.3.3.4 Vitamin B12 Deficiency
12.3.3.5 Toxic Shock Syndrome
12.3.4 Complications
12.3.5 Differential Diagnosis: Glossitis
12.3.6 Treatment
12.3.7 Prognosis
12.4 Yellow Tongue
12.4.1 Introduction
12.4.2 Etiology
12.4.2.1 Oral Hygiene Products with Oxidizing Agents
12.4.2.2 Poor Oral Hygiene
12.4.2.3 Tobacco Use
12.4.2.4 Mouth Breathing or Dry Mouth
12.4.2.5 Black Hairy Tongue
12.4.2.6 Oral Thrush
12.4.2.7 Geographic Tongue
12.4.2.8 Certain Foods
12.4.2.9 Certain Medications and Drugs
12.4.2.10 Piercing, Tooth Extraction, or Tonsillectomy
12.4.2.11 Yellow Tongue with Other Diseases [72, 73]
12.4.2.11.1 Urinary and Respiratory Tract Infections
12.4.2.11.2 Scarlet Fever
12.4.2.11.3 Jaundice
12.4.2.11.4 Eczema and Autoimmune Conditions
12.4.2.11.5 Chronic Gastritis
12.4.2.11.6 Postnasal Drainage
12.4.2.11.7 Malignancy
12.4.2.11.8 Infectious Mononucleosis (IMN)
12.4.2.11.9 Human Immunodeficiency Virus (HIV)
12.4.2.11.10 Yellow Under-Tongue
12.4.3 Risk Factors
12.4.4 Symptoms
12.4.5 Complications
12.4.6 Prevention and Treatment Options
12.5 White Tongue
12.5.1 Etiology
12.5.1.1 Poor Oral Hygiene
12.5.1.2 Leukoplakia: Oral/Tongue Cancer
12.5.1.3 Oral Lichen Planus (LP)
12.5.1.4 Oral Thrush
12.5.1.5 Geographic Tongue
12.5.1.6 Syphilis
12.5.2 Clinical Presentation: Diagnosis
12.5.2.1 Leukoplakia
12.5.2.2 Oral Lichen Planus
12.5.2.3 Oral Thrush
12.5.2.4 Geographic Tongue
12.5.2.5 Syphilis
12.5.3 Treatment
12.5.3.1 Good Oral Hygiene
12.5.3.2 Other Measures
12.5.3.2.1 Probiotics
12.5.3.2.2 Baking Soda Scrub
12.5.3.2.3 Raw Garlic
12.5.3.3 Specific Treatment
12.5.4 Prognosis
12.6 Green Tongue
12.6.1 Introduction
12.6.2 Etiology
12.6.2.1 Previously Discussed Causes [11, 69, 91, 92]
12.6.2.2 Oral Cancer [93]
12.6.2.3 Other Causes
12.6.3 Diagnosis
12.6.4 Treatment
12.6.4.1 Treatment of the Cause
12.6.4.2 Proper Oral Hygiene
12.6.4.3 Scraping of the Tongue
References
13: Tongue Fissures
13.1 Overview
13.1.1 Definition
13.1.2 Etiology
13.1.3 Characteristics of Fissured Tongue
13.1.4 Symptoms of Fissured Tongue
13.1.5 Diagnosis
13.1.6 Treatment of Fissured Tongue
13.1.6.1 Oral Hygiene
13.1.6.2 Flossing
13.1.6.3 Hydration
13.2 Congenital Tongue Fissures
13.2.1 Etiology
13.2.1.1 Melkersson-Rosenthal Syndrome
13.2.1.2 Down Syndrome
13.2.1.3 Cowden’s Syndrome
13.2.2 Diagnosis and Treatment
13.3 Acquired Tongue Fissures
13.3.1 Trauma [6, 7]
13.3.1.1 Tongue Bites
13.3.1.2 Cuts
13.3.1.3 Lacerations
13.3.1.4 Teeth Grinding
13.3.2 Benign Migratory Glossitis
13.3.3 Oral Psoriasis
13.3.4 Syphilitic Tongue Fissures
13.3.5 Nutritional Deficiency
13.3.5.1 Folic Acid (Vitamin B9)
13.3.5.2 Biotin (B7 or B8 in France)
13.3.5.3 Riboflavin (Vitamin B2)
13.3.6 Malignant Tongue Fissure
References
14: Ulcers of the Tongue
14.1 Classification
14.2 Traumatic Ulcers
14.2.1 Dental Ulcers
14.2.1.1 Etiology
14.2.1.2 Location
14.2.1.3 Clinical Picture and Diagnosis
14.2.1.4 Treatment
14.2.1.5 Prognosis
14.2.2 Frenular Ulcers
14.2.2.1 Synonyms
14.2.2.2 Definition
14.2.2.3 Etiology
14.2.2.4 Location
14.2.2.5 Clinical Picture
14.2.2.6 Treatment
14.3 Inflammatory Ulcers
14.3.1 Herpetic Ulcers (True Herpes Linguis)
14.3.1.1 Etiology
14.3.1.2 Classification of HSV
14.3.1.3 Epidemiology of HSV
14.3.1.4 Site
14.3.1.5 Clinical Picture
14.3.1.6 Pathophysiology
14.3.1.7 Laboratory Tests
14.3.1.8 Differential Diagnosis
14.3.1.9 Management
14.3.1.9.1 Antiviral Medications
14.3.1.9.2 Topical Antivirals
14.3.1.9.3 Alternative Medicine
14.3.2 Tuberculous (TB) Ulcers
14.3.2.1 Etiology
14.3.2.2 Site
14.3.2.3 Clinical Picture
14.3.2.4 Diagnosis
14.3.2.5 Differential Diagnosis
14.3.2.6 Treatment
14.3.3 Syphilitic Ulcers
14.3.3.1 Transmission
14.3.3.2 Clinical Presentation
14.3.3.2.1 First Stage: Primary Syphilis
14.3.3.2.2 Second Stage: Secondary Syphilis
14.3.3.2.3 Late Stage
14.3.3.3 Diagnosis
14.3.3.4 Treatment of Oral Syphilis
14.3.4 Chronic Superficial Glossitis
14.3.4.1 Clinical Stages
14.3.4.2 Treatment
14.3.5 Chronic Ulcerative Stomatitis (CUS)
14.3.5.1 Definition
14.3.5.2 Clinical Picture
14.3.5.3 Diagnosis
14.3.5.4 Treatment
14.4 Dyspeptic (Aphthous) Ulcers
14.4.1 Introduction
14.4.2 Clinical Presentation
14.4.3 Classification (Types of Aphthous Ulcers)
14.4.3.1 Minor Aphthae
14.4.3.2 Major Aphthae
14.4.3.3 Herpetiform Aphthae
14.4.4 Etiology/Pathogenesis
14.4.4.1 Genetic Predisposition
14.4.4.2 Mechanical Injury
14.4.4.3 Microelement and Vitamin B12 Deficiencies
14.4.4.4 Stress
14.4.4.5 Food Allergies
14.4.4.6 Microbial Factors
14.4.4.7 Tobacco Smoking
14.4.4.8 Immunopathogenesis
14.4.4.9 Hormonal Defects
14.4.4.10 Drugs
14.4.4.11 Systemic Diseases
14.4.5 Management and Treatment of Aphthous Stomatitis
14.4.6 First-Line Therapy/Topical Therapy
14.4.6.1 Topical Gels, Creams, and Pastes
14.4.6.2 Topical Anesthetic
14.4.6.3 Topical Antimicrobials
14.4.6.4 Topical Antibiotics
14.4.6.5 Topical Corticosteroids
14.4.6.6 Topical Anti-Inflammatory Agents
14.4.6.7 Topical Analgesic/Anti-Inflammatory Spray and Rinses
14.4.6.8 Topical Hyaluronic Acid
14.4.7 Second-Line Therapy/Systemic Therapy
14.4.7.1 Levamisole
14.4.7.2 Thalidomide
14.4.7.3 Pentoxifylline
14.4.7.4 Colchicine
14.4.7.5 Zinc Sulfate
14.4.7.6 Azathioprine
14.4.7.7 Methotrexate
14.4.7.8 Prednisone
14.4.7.9 Vitamin B12
14.4.7.10 Dapsone
14.4.7.11 Rebamipide
14.4.7.12 Irsogladin
14.4.7.13 Cyclosporine a (CyA)
14.4.7.14 Adalimumab
14.4.7.15 Acyclovir
14.4.7.16 Montelukast
14.4.7.17 Infliximab (Remicade)
14.4.7.18 Etanercept (Enbrel)
14.4.7.19 Clofazimine
14.4.7.20 Penicillin G Potassium
14.5 Malignant Ulcers
14.5.1 Historical Perspectives
14.5.2 Classification of Oral Tumors
14.5.2.1 Malignant Tumors of the Oral Cavity
14.5.2.1.1 Squamous Cell Carcinoma (SCC)
According to Macroscopic Features
According to Microscopic Features
14.5.2.1.2 Rare Malignant Tumors
14.5.2.2 Precancerous Lesions of the Oral Cavity
14.5.2.3 Benign Tumors and Conditions of the Oral Cavity
14.5.2.3.1 Benign Tumors
14.5.2.3.2 Benign Conditions
14.5.3 TNM Staging Classification of Oral Cavity Carcinoma
14.5.4 Epidemiology and Demographics
14.5.4.1 Incidence of Tongue Cancer
14.5.4.2 Gender
14.5.4.3 Race
14.5.4.4 Age
14.5.5 Etiology/Risk Factors
14.5.5.1 Precancerous Lesions
14.5.5.1.1 Oral Leukoplakia
14.5.5.1.2 Oral Erythroplakia
14.5.5.1.3 Oral Erythro-Leukoplakia
14.5.5.1.4 Oral Lichen Planus
14.5.5.1.5 Oral Submucous Fibrosis and Actinic Cheilitis [158]
14.5.5.2 Risk Factors
14.5.5.2.1 Major Tongue Cancer Risk Factors
Tobacco Smoking
Alcohol Ingestion
Human Papillomavirus (HPV)
Plummer-Vinson Syndrome (PVS)
Stem Cell Transplantation
14.5.5.2.2 Other Less Potent Risk Factors
Lifestyle: Betel Nut Intake
Genetic Factors
General Factors
Unproven Risk Factors
14.5.6 Pathogenesis
14.5.6.1 WHO Grading for Oral Cancer Dysplasia
14.5.6.2 Precancerous Conditions
14.5.6.3 Genetics
14.5.7 Pathology
14.5.7.1 Gross Pathology
14.5.7.2 Microscopic Pathology
14.5.7.2.1 Microscopic Types of Tongue Cancer
Primary Tumor
Secondary Tumor
14.5.7.2.2 Histopathology of SCC and Its Variants [171]
Conventional Type
Acantholytic Subtype
Basaloid Subtype
Spindle (Fusiform) Cell Subtype or Sarcomatoid
Verrucous Subtype
14.5.8 Tumor Spread
14.5.8.1 Local (Direct) Spread
14.5.8.2 Lymphatic Spread
14.5.8.3 Hematogenous Spread
14.5.9 Diagnosis of Tongue Cancer
14.5.9.1 History-Taking and Symptoms
14.5.9.1.1 History-Taking
14.5.9.1.2 Symptoms
14.5.9.2 Physical Examination
14.5.9.2.1 Head Examination
14.5.9.2.2 Neck Examination
14.5.9.3 Clinical Presentation of Complications
14.5.9.3.1 Terminal Events
14.5.9.3.2 Direct Surgical Complications
14.5.9.3.3 Complications of Chemotherapy [174]
14.5.9.3.4 Complications of Radiation Therapy [175]
14.5.9.3.5 Complications of Chemotherapy and Radiation [176]
14.5.9.4 Laboratory Investigations
14.5.9.5 Plain X-Ray
14.5.9.6 Computed Tomography (CT) Scan
14.5.9.7 Positron Emission Tomography (PET)-CT Scan
14.5.9.8 Magnetic Resonance Imaging (MRI)
14.5.9.9 Ultrasonography
14.5.9.10 Other Diagnostic Studies
14.5.9.10.1 Evaluation Under Anesthesia (EUA)
14.5.9.10.2 Tumor Biopsy
14.5.9.10.3 Panendoscopy
14.5.10 Staging
14.5.10.1 Assessment of T-Category
14.5.10.2 Assessment of N-Category
14.5.10.2.1 Anterior Tongue
14.5.10.2.2 Lateral Tongue
14.5.10.2.3 Posterior Tongue
14.5.10.3 Assessment of M-Category
14.5.11 Differential Diagnosis
14.5.12 Prevention of Tongue Cancer
14.5.12.1 Primary Prevention
14.5.12.1.1 Screening
14.5.12.1.2 Prevention
14.5.12.2 Secondary Prevention
14.5.12.2.1 Follow-Up: Monitoring
14.5.12.2.2 Natural Components
14.5.12.2.3 Synthetic Retinoids
14.5.12.2.4 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
14.5.12.2.5 Endothelial Growth Factor Receptor (EGFR) Inhibition
14.5.12.2.6 Human Papilloma Virus (HPV)-Related Oro-Pharyngeal Carcinoma Vaccine
14.5.13 Treatment of Tongue Cancer
14.5.13.1 Overview
14.5.13.2 Radiation Therapy (RT)
14.5.13.2.1 Indications
Indications of Adjuvant Therapy [225]
14.5.13.2.2 Techniques of Radiation Therapy [226]
External Beam Radiotherapy (EBRT)
Brachytherapy
Orthovoltage Radiotherapy
14.5.13.2.3 Treatment of Nonsurgical Candidates
14.5.13.3 Chemotherapy
14.5.13.3.1 Targeted Therapy
14.5.13.4 Surgical Treatment
14.5.13.4.1 Surgical Approach
14.5.13.4.2 Management of the Neck
14.5.14 Prognosis
14.5.14.1 Prognostic Factors
14.5.14.1.1 Stage of the Tumor
14.5.14.1.2 Tumor Thickness
14.5.14.1.3 Perineural Invasion
14.5.14.1.4 Positive Surgical Margins
14.5.14.1.5 Cervical Lymph Node Metastases
14.5.14.1.6 Extracapsular Extension
14.5.14.1.7 Site of Tongue SCC
14.5.14.1.8 Other Factors
14.5.15 Summary: Tongue Cancer
References
15: Glossectomy
15.1 Introduction
15.2 Indications and Contraindications
15.2.1 Indications
15.2.2 Contraindications
15.3 Classification of Glossectomy
15.3.1 Classification of Glossectomy by Laterality
15.3.2 Classification of Glossectomy by Resected Volume
15.3.3 Recently Proposed Classification
15.3.3.1 Type I Glossectomy (Mucosectomy)
15.3.3.1.1 Definition
15.3.3.1.2 Indications
15.3.3.2 Type II Glossectomy (Partial Glossectomy)
15.3.3.2.1 Definition
15.3.3.2.2 Indications
15.3.3.3 Type IIIa Glossectomy (Hemiglossectomy)
15.3.3.3.1 Definition
15.3.3.3.2 Indications
15.3.3.4 Type IIIb Glossectomy (Compartmental Hemiglossectomy)
15.3.3.4.1 Definition
15.3.3.4.2 Indications
15.3.3.5 Type IVa Glossectomy (Subtotal Glossectomy)
15.3.3.5.1 Definition
15.3.3.5.2 Indications
15.3.3.6 Type IVb Glossectomy (Near-Total Glossectomy)
15.3.3.6.1 Definition
15.3.3.6.2 Indications
15.3.3.7 Type V Glossectomy (Total Glossectomy)
15.3.3.7.1 Definition
15.3.3.7.2 Indications
15.3.3.8 Impact of Glossectomy Classification on Neck Dissection
15.4 Surgical Preparation
15.4.1 Equipment
15.4.2 Personnel
15.4.3 Preoperative Assessment
15.4.3.1 History-Taking
15.4.3.2 Physical Examination
15.4.3.3 Laryngoscopy and Imaging
15.4.4 Securing the Airway
15.4.5 Examination Under Anesthesia (EUA)
15.4.6 Draping
15.5 Surgical Approach
15.5.1 How to Choose the Appropriate Approach
15.6 Surgical Technique
15.6.1 Transoral Conventional Glossectomy
15.6.1.1 Indications and Contraindications
15.6.1.2 Operative Technique
15.6.2 Glossectomy via Transoral Robotic-Assisted Surgery (TORS)
15.6.2.1 History
15.6.2.2 Indications
15.6.2.3 Operative Technique
15.6.2.4 Outcome of TORS as a Cancer Treatment
15.6.2.5 Complications
15.6.2.6 Current Challenges
15.6.3 Transoral Laser Surgery (TOLS)/Transoral Laser Microsurgery (TLM)
15.6.3.1 Indications
15.6.3.2 Contraindications
15.6.3.3 Operative Technique [56, 63, 64]
15.6.3.4 Complications
15.6.4 Glossectomy via Lip-Split Mandibulotomy
15.6.4.1 Indications and Contraindications
15.6.4.2 Operative Technique [74]
15.6.4.3 Complications
15.6.5 Glossectomy via Trans-Cervical Pull-Through with Visor Incision
15.6.5.1 Indications and Contraindications
15.6.5.2 Operative Technique [74]
15.6.5.3 Complications
15.7 Complications/Risks of Glossectomy
15.7.1 Bleeding/Hematoma
15.7.2 Infection
15.7.3 Dysarthria (Difficult Speech) and Dysphagia
15.7.4 Alteration of Tongue Sensation
15.7.5 Aspiration
15.7.6 Urgent or Emergent Tracheostomy
15.7.7 Salivary (Oro-cutaneous) Fistula
15.7.8 Osteoradionecrosis
15.7.9 Positive Margins
15.7.10 Recurrence
References
16: Surgical Management of the Neck
16.1 Overview
16.2 Relevant Anatomy
16.2.1 Level I
16.2.2 Level II
16.2.3 Level III
16.2.4 Level IV
16.2.5 Level V
16.2.6 Level VI
16.3 Classification of Neck Dissection
16.3.1 Radical Neck Dissection (RND)
16.3.2 Modified Radical Neck Dissection (MRND)
16.3.3 Selective Neck Dissection (SND)
16.3.3.1 SND for Oral Cavity Cancer
16.3.3.2 SND for Oropharyngeal, Hypopharyngeal, and Laryngeal Cancer
16.3.4 Extended Neck Dissection
16.4 Neck Dissection: Indications and Contraindications
16.4.1 Indications
16.4.2 Contraindications
16.4.2.1 Absolute Contraindications
16.4.2.2 Relative Contraindications [38, 39]
16.5 Neck Dissection: Operative Technique
16.5.1 Preparation
16.5.2 Anesthesia and Position
16.5.3 Incision
16.5.4 Raising Skin Flaps
16.5.5 Identifying Marginal Mandibular Nerve
16.5.6 Dissection
16.5.6.1 Superior Dissection
16.5.6.2 Inferior Dissection
16.5.6.3 Medial Dissection
16.5.7 Closure
16.6 Complications of Neck Dissection
16.6.1 Nerve Complications
16.6.1.1 Spinal Accessory Nerve (SAN)
16.6.1.2 Marginal Mandibular Nerve (MMN)
16.6.1.3 Phrenic Nerve
16.6.1.4 Sensory Branches of the Cervical Roots
16.6.1.5 Greater Auricular Nerve
16.6.1.6 Lingual Nerve
16.6.1.7 Vagus Nerve
16.6.1.8 Hypoglossal Nerve
16.6.1.9 Sympathetic Trunk
16.6.2 Wound Complications
16.6.3 Air Leak
16.6.4 Vascular Complications
16.6.4.1 Intraoperative Bleeding
16.6.4.2 Hematoma
16.6.4.3 Internal Jugular Vein (IJV) Complications
16.6.4.4 Carotid Artery Complications (Rupture/Blowout)
16.6.4.5 Chylous Fistula
16.6.5 Cardiac Arrhythmias
16.6.6 Facial/Cerebral Edema
16.6.7 Late Complications
References
17: Reconstruction After Glossectomy
17.1 Introduction
17.2 Defects: Etiology and Classification
17.3 Reconstruction Options
17.3.1 Goals of Reconstruction
17.3.2 Overview
17.3.2.1 Regional Flaps
17.3.2.1.1 Pectoralis Major Myocutaneous Flap/Myofacial Flap
Advantages
Disadvantages
Indications
Contraindications
Technique
17.3.2.1.2 Platysma Flap
Indications
Contraindications
Potential Complications
Technique
17.3.2.2 Free Tissue Transfer
17.3.2.2.1 Radial Forearm Free Flap (RFFF)
Advantages
Disadvantages
Indications
Contraindications
Potential Complications
Technique
17.3.2.2.2 Anterolateral Thigh Free Flap (ALTFF)
Advantages
Disadvantages
Indications
Contraindications
Potential Complications
Technique [16, 18, 19]
17.3.2.2.3 Rectus Abdominis Free Flap (RAFF)
Advantages
Indications
Contraindications
Technique
17.3.2.3 Reinnervation
17.4 Reconstruction Outcomes
17.4.1 Speech Outcomes
17.4.1.1 Intelligibility
17.4.1.2 Factors Affecting Speech
17.4.2 Swallowing Outcomes
17.4.2.1 Objective Evaluation of Swallowing
17.4.2.2 Recovery Time
17.4.2.3 Postoperative Diet
17.4.2.4 Factors Affecting Postoperative Swallow
17.4.3 Quality-of-Life (QOL) Outcomes
17.5 Reconstruction: Management Plan
17.5.1 For Defects Involving the Tongue Only ± Floor of the Mouth
17.5.1.1 Reconstruction After Partial Glossectomy
17.5.1.2 Reconstruction After Hemiglossectomy
17.5.1.3 Reconstruction After Subtotal, Near Total, or Total Glossectomy
17.5.2 For Concurrent Tongue and Mandible Defects
17.5.3 For Concurrent Tongue and Oropharyngeal or Hypopharyngeal Defects
17.6 How to Improve Outcomes
17.6.1 Preoperative Measures
17.6.2 Intraoperative Measures
17.6.3 Postoperative Measures
17.6.4 Surveillance/Follow-Up
17.7 Summary
References
18: Tongue Replantation After Trauma
18.1 Overview
18.2 Tongue Replantation: Animal Model
18.2.1 Introduction
18.2.2 Surgical Technique [14]
18.2.2.1 Resection
18.2.2.2 Replantation
18.2.2.3 Closure
18.2.3 Clinical Implications
18.3 Tongue Replantation in Humans
References
19: Tongue Allotransplantation
19.1 Introduction
19.2 Relevant Anatomy and Physiology
19.3 Current Modalities of Tongue Reconstruction
19.4 Challenges of Tongue Reconstruction
19.4.1 Tongue Movement
19.4.2 Tongue Sensation
19.4.3 Appropriately Sizing
19.4.4 Status of the Larynx
19.4.5 Reinnervation
19.5 Tongue Allotransplantation
19.5.1 Animal Models
19.5.2 Human Tongue Allotransplantation
19.5.3 Challenges in Human Tongue Allotransplantation
19.5.3.1 Donor Tissue Procurement
19.5.3.2 Timing of Allotransplantation
19.5.4 Immunosuppression for Composite Tissue Allotransplantation
19.6 Conclusion
References