CHAPTER XXXII DIAGNOSIS OF DISEASES OF THE TONGUE As in all other cases of surgical diagnosis, before deciding upon the nature of any affection of the tongue, care must be taken to investigate the history of the case — whether congenital or acquired, of recent or more remote origin, rapid or slow in progress; the habits of the patient, particularly as regards irritation of the tongue by alcohol, tobacco, or the sharp edge of a tooth ; and the evidences of previous disease or concomitant affections, especially syphilis and tuberculosis. The investigation of the tongue itself should be conducted as follows : 1. The patient should be asked to open his mouth, and the surgeon should take note of the size and form of the tongue. The tongue may be considerably enlarged, so that it cannot be lodged within the mouth, or slightly enlarged and so compressed against the teeth as to be indented by them. On the other hand, the tongue may be absent altogether, or smaller than normal; it may be fissured or deeply scarred. 2. The patient should then be requested to protrude the tongue to the full, and the surgeon should notice whether it is protruded symmetrically and to the full extent. The patient should then be asked to turn up the tip of the tongue, and to move it from side to side, to show the freedom with which these movements are carried out. <Callout type="tip" title="Symmetry Check">A movement that is asymmetrical may indicate a unilateral condition or paralysis.</Callout> The mobilility of the tongue may be lessened by congenital malformations—tongue-tie, and defective development of the organ — by inflammatory and neoplastic infiltration of the extrinsic muscles of the tongue, by lessened elasticity of the mucous membrane passing from the tongue to the alveolus, the palate, and the larynx, or by paralysis of the muscles of the tongue. The movement of the tongue is im-symmetrical when either of these conditions is unilateral, or more intense on one side than the other. 3. Next observe the surface of the tongue, gently drying it with a clean handkerchief, if necessary. Note particularly its colour, whether livid or paler than normal: whiteness of the tongue (not 'fur') indicates thickening of the epithelium; the presence or absence of fur; the condition of the faillae, whether enlarged or absent; the presence of any other irregularities of the surface — cysts, veins, nodules, warts, or plaques — and the fact of ulceration or fissure. The foliate papilla at the side of the tongue, just where the anterior pillar of the fauces joins the tongue, is sometimes large and cleft; this must not be mistaken for disease. A careful comparison of the papillas on the two sides of the tongue will prevent this error. 4. Then determine by sight and by touch whether there is any tumour on or in the tongue. The features of a tumour of the tongue to be specially studied are its position—whether on the surface or deep in the substance of the tongue; if on the surface, whether it is pedunculated or sessile, and if its covering is smooth or papillated. The consistency of the tumour, its limitation to the tongue, or extension to the jaw, palate, and tonsil, are to be noted- <Callout type="risk" title="Tumour Risk">A deep ulcer may indicate a more serious condition like epithelioma.</Callout> 5. If there is an ulcer, the following points should be noted : — i. History and associated conditions. — Injury, whether from external violence, or from a sharp tooth or ill-fitting tooth-plate, is important; so is a history of dyspepsia, of former similar attacks, or of syphilis. Note any signs of chronic glossitis, of tuberculous or syphilitic lesions, or of mercurial stomatitis. ii. Age, — Children are subject to herpetic ulcers; in early manhood, syphilitic ulcers are frequent; at and after middle age epithelioma becomes common. iii. Duration. — Herpetic and dyspeptic ulcers are of short duration; syphilic ulcers are chronic; epithelioma is steadily progressive. iv. Position.— Gummatous, tuberculous, and dyspeptic ulcers are generally on the dorsum; epithelioma, herpes, and syphihtic fissures are commonest at the edge; chancre is generally near the tip; mercurial ulceration is on the under-surface. v. Number.— Herpet ic, dyspeptic, secondary syphi- litic, and tubercidous ulcers are usually multiple; a primary chancre, a gummatous ulcer, and epithelioma are nearly always single. vi. Depth.— Deep ulcers are the result of injury gumma, or epithelioma. vii. Base and edge.— Note whether the base is firm and infiltrated, sloughy or suppurating, irregular or fungating, and whether the edge is thick, everted or undermined, or the seat of tiny yellow tubercles' The importance of these signs is the help they give in recognizing the condition that preceded 'the ulceration. Any ulcer, whether on the tongue or elsewhere, when chronic, may become indurated Sloughing of the base of the ulcer is especially seen in syphilis; a thin, slightly undermined edge is met with in tubercle; and just after a gumma has sloughed out the edge of the deep ulcer left is undermined. A firm and infiltrated base and edge are especially indicative of cancer. viii. The discharge is purulent from tuberculous ulcers, often sanious and with a peculiar fetor in epithelioma. Salivation is a marked feature in all but the earliest stages of epithelioma and in mercurial ulceration. The discharge from primary and secondary syphilitic ulcers can be shown to contain the Spironema fallidum. ix. The teeth should be examined to detect any sharp edge, or rough mass of tartar, opposite the ulcer. Any denture should be carefully felt to see if there is a projecting edge. At the same time the cleanliness or otherwise of the teeth and the presence of pyorrhoea will be noted. 6. Examine the lymphatic glands.— To examine these glands, stand behind the seated patient, place the finger-tips under the chin and pass them back beneath the horizontal ramus of the jaw to the angle of the jaw, then feel beneath the anterior border of the sterno-mastoid muscle from the skull to the clavicle, and carefully compare the two sides. Now, standing in front of the patient, place one finger in the floor of the mouth, and fingers of the other hand beneath the jaw, and examine the tissues between the two hands. This is the most exact way of examining the submaxillary lymphatic glands and also of determining whether an enlarged gland is or is not fixed to the bone ; by this means small hard glands can often be recognized when they cannot be felt from outside. The lymphatics of the anterior part of the tongue pass into the glands beneath the jaw on the same side; those from the back of the organ pass into glands over the carotid sheath on both sides. 7. Microscopical examination and blood test. — In some cases it is necessary to examine microscopically the discharge from an ulcer for tubercle bacilli and for the Spironema pallidum. Occasionally it is well to cut out a portion of the edge of an ulcer or an entire nodule and to examine it for evidences of downgrowth of epithelium, and cell-nests. Wassermann's test may be used to confirm the diagnosis of a late syphilitic lesion. 8. Effects of treatment.— In some cases the result of treatment is so striking that it establishes the diagnosis at once. For instance, the removal of a jagged tooth or an ill-fitting plate may be followed in a few days by the healing of an ulcer, showing that it is traumatic; or the administration of iodide of potassium or of salvarsan may cause the rapid disappearance of a syphilitic lesion. It must be borne in mind, however, that iodides often cause an improvement in malignant growths; this must not be confused with the entire healing of a syphilitic lesion. Non-Ulcerative Affections of the Mucous Membrane 1. A milk-white deposit on the tongue, which can be scraped off, leaving the surface a little raw and which under the microscope shows spores and fibres of Candida albicans, is thrush. <Callout type="warning" title="Thrush Warning">Thrush can indicate underlying health issues that need attention.</Callout> 2. Slightly raised patches of mucous membrane having a pale-blue opalescent appearance are mucous patches. Find the Spironema pallidum and look for other evidences of syphilis. 3. A pale-pink rash in rings or crescentic patches spreading rapidly over the surface of the tongue, leaving the mucous membrane smooth and deeply red in colour, without pain, ulceration, or salivation and quite unaffected by treatment, is annulus migrans. 4. A black discoloration of the dorsum of the tongue, which is not removed by gently wiping the surface, is nigrities linguae. 5. If the surface of the tongue has lost its papillae and is red, smooth, with a glazed appearance, it is in the early stage of superficial glossitis, this is often spoken of as the 'smooth glazed tongue.' 6. If the surface of the tongue is devoid of papillae and white in colour, it is in a later stage of superficial glossitis, and the condition is called leucoplakia. When the epithelium is heaped up in uneven warty masses with wrinkles and furrows—a more advanced stage still of the same disease—it is known as ichthyosis lingua. This disease may affect a part or the whole of the papillary surface of the tongue, and the various stages may coexist. The destruction of the papillae, followed by more or less thickening of the epithelium, is the characteristic feature of the disease. It is liable to recurring attacks of ulceration, and especially to the development of epithelioma. 7. When a patch of leucoplakia becomes wart-like or ulcerated, and the edge and base of the ulcer are felt to be firm, and especially if at the same time the submental glands are enlarged, the disease is now epithelioma. 8. If the surface of the tongue is puckered or depressed along interlacing lines, and in these lines of micropapillae firm bands are felt the condition is phimic sclerosis. The sclerosis is deep down in the muscular tissue of the tongue; it may leave the mucous membrane quite healthy. 9. A pink or whitish projection from the surface of the tongue with a finely serrated margin, and no induration beneath or around its base, is a papilloma. The surface is not firm and no induration can be felt beneath or around its base; it may be pedunculated. Most common on the dorsum of the tongue, it may also be found on its under-surface. It may occur at any age. 10. A tiny nodule on the side or tip of the tongue which does not consist wholly of an outgrowth from its surface, particularly if its colour and its surface differ from that of the surrounding papillae, is to be regarded as an epithelioma, and should be widely excised and then examined microscopically in serial sections. Ulcers of the Tongue 1. If the ulcer is quite superficial, painful and tender, looking sharply punched-out, and especially if multiple, situated on the sides and tip, and there are similar ulcers on the lips or cheeks, it is herpes. Herpetic ulcers commence as small white blisters, rim a rapid course, and are accompanied by slight salivation. 2. A recurring superficial circular or oval ulcer on the dorsum of the tongue, with a smooth base, free from induration, and without glandular enlargement, is probably a dyspeptic ulcer, and the surgeon must inquire for symptoms of indigestion. 3. If the ulcer is situated on the side of the tongue, is ragged, deep, and irregular, without induration of its edge or base, and is opposite a mass of tartar, or an angle of a tooth, or the edge of a plate it is a traumatic ulcer. This diagnosis will be confirmed if on removing the local irritation the ulcer heals up. The glands are not enlarged If traumatic ulcers persist for some time the edge and base may become thickened to a limited extent they can then be distinguished from epithelioma only by the beneficial effect of removal of the local cause and by the absence of glandular enlargement A traumatic ulcer may become epitheliomatous / L U the tongue is swollen and there is salivation, with great fetor of the breath, and along the under-surface of the tongue and at the tip there are irregular superficial ulcers with greyish base, while the gums are swollen, softened or ulcerated, and receding from the teeth, it is a case of mercurial ulceration. The knowledge that the patient is exposed to the influence of mercury in some form will establish this diagnosis. 5. A single ulcer of recent origin near the tip of the tongue, with marked induration of the edge and base, and induration and swelling of several glands beneath the jaw, is probably a chancre. 6. A superficial crack or fissure on the side or tip of the tongue, multiple, chronic, or relapsing, is probably syphilitic ulceration. 7. Shallow sinuous fissures on the dorsum of the tongue, the intervening mucous membrane being healthy, are syphilitic. 8 If an ulcer on the dorsum of the tongue is deeply excavated, with a greyish, dirty, sloughy base, and if the history shows that there was at first a hard lump in the tongue which softened and burst, it is probably an ulcerated gumma. The diagnosis of chancre and of secondary syphilitic ulcers is made certain by finding the Spirochete pallidum in the discharge. The diagnosis of the ulcerated gumma is established by obtaining a positive Wassermann reaction and by the effect of treatment 9 If a painful ulcer on the tongue is superficial, has a thin, undermined edge, and a pale, shreddy base without surrounding induration, a tuberculous ulcer must be suspected. If the patient shows signs of phthisis, or if a scraping from the sore contains tubercle bacilli, this diagnosis becomes certain. The ulcers may be single or multiple, and may be found on the palate and fauces as well as on the tongue. 10. If an ulcer on the tongue of a middle-aged or elderly person has a firm base, thick or everted edge, and an irregular warty surface with a foul watery discharge, and there is enlargement of one or more of the lymphatic glands, it is an epitheliomatous ulcer. These ulcers are more common in men than in women, and are generally seated on the side of the tongue. They often extend into the floor of the mouth or on to the palate or gums. Even at an early stage there may be interference with the movement of the tongue, shown by deviation of the tip of the protruded organ to the affected side. As they spread (and their growth is continuous) they interfere more and more with the movements of the tongue, and may bind it down to the floor of the mouth or to the jaws. The disease usually begins in a crack, a wart-like papule, a blister, or in leucoplakia, and it may arise in the wall of a late syphiUtic or of a traumatic ulcer. Tumours of the Tongue 1. If a tumour is congenital in origin, livid or bright-red in colour, compressible, not fluctuating, it is a naevus. The diagnosis of this condition is usually quite obvious. 2. A branched villous growth from the surface of the tongue without any induration or swelling of the tongue itself is a wart or papilloma. 3. A pendulous or pedunculated firm growth, of rounded outline, and covered with smooth, healthy mucous membrane, is a nabroma. 4. A firm infiltrating tumour growing rapidly in the substance of the tongue, painless, and not causing trouble except from its size, is probably a gumma! This diagnosis is made certain if there is a positive Wassermann reaction, and antisyphilitic treatment is quickly curative. The tumours may be superficial and small, or seated in the muscular substance of the tongue, where they attain a larger size. They have a tendency to soften, and may fluctuate, and later still ulcerate. 5. If a nodule appears on the side or tip of the tongue, is felt to be in the mucous membrane and not merely a projection from its surface, and is firm, and has been noticed to grow, it is an epithelioma. If a nodule appears in or at the edge of a long-standing patch of leucoplakia, or around an ulcer in such a patch, it is an epithelioma. A lump on the side or tip of the tongue, even of some size, infiltrating the muscle, firm, with no tendency to softening, and with merely an abraded surface, is an epithelioma. In every case the diagnosis is confirmed if the associated lymphatic gland is enlarged. Epithelioma of the pharyngeal part of the tongue occurs as a firm infiltration which later on ulcerates; it very early interferes with the mobility of the tongue, but is apt to be overlooked until far advanced. In all cases of doubt in the diagnosis, the whole nodule or ulcer, or a sufficient portion of its edge, should be excised. Serial sections of the part removed should then be examined under a microscope. The essential features of lingual epithelioma are that the disease (i) always involves the mucous membrane, (ii) spreads into the muscular substance of the tongue, (iii) ulcerates on the surface, sometimes deeply, and (iv) infects lymphatic glands. 6. Other and rare solid lingual tumours are lipoma, enchondroma, plexiform neuroma, and sarcoma. 7. If a fluctuating tumour is found in the substance of the tongue, and there is a history of injury, and if the surrounding tissues are swollen
Key Takeaways
- Examine the size, form, and movement of the tongue to identify potential issues.
- Look for ulcers, tumors, and other abnormalities on the tongue's surface.
- Compare both sides of the tongue for symmetry and any irregularities.
- Check lymph nodes for swelling or changes in consistency.
Practical Tips
- Always take a thorough patient history before examining the tongue.
- Use a clean handkerchief to dry the tongue if necessary, but be gentle.
- Regularly check your own equipment for cleanliness to avoid cross-contamination.
Warnings & Risks
- Do not confuse chronic ulcers with traumatic ones without proper examination.
- Be cautious of symptoms that could indicate more serious conditions like syphilis or cancer.
- Avoid touching the ulcerated area directly unless necessary, as this can introduce bacteria.
Modern Application
While many of these techniques are still applicable in modern survival scenarios for triage and basic diagnosis, advancements in medical technology have improved diagnostic tools. However, understanding tongue examination remains crucial for recognizing early signs of infection or malignancy.
Frequently Asked Questions
Q: What is the first step in examining the tongue according to this chapter?
The first step is to ask the patient to open their mouth and note the size and form of the tongue. The tongue may be enlarged, compressed against the teeth, absent, or scarred.
Q: How can one differentiate between a traumatic ulcer and other types of ulcers on the tongue?
A traumatic ulcer is painful and tender, looks sharply punched-out, and heals up when local irritation is removed. It may be multiple and located on the sides and tip of the tongue.
Q: What are some signs that an ulcer might be syphilitic?
Syphilitic ulcers are chronic, often found at the edge or near the tip of the tongue, and may have a smooth base without induration. They can be confirmed by finding the Spirochete pallidum in the discharge.
Q: What is the significance of examining lymph nodes during a tongue examination?
Examining lymph nodes helps determine if there is an enlarged gland that might be fixed to the bone, which could indicate a more serious condition like cancer or syphilis.
Q: How can one identify an epithelioma on the tongue according to this chapter?
An epithelioma is identified by a firm base and edge, often with an irregular warty surface. It may be associated with enlargement of lymphatic glands and can arise from leucoplakia or other pre-existing conditions.