Filippi / Hitz Lindenmüller The Tongue

1. Auflage 2019
ISBN: 978-0-86715-902-8
Verlag: Quintessence Publishing Co, Inc
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, 216 Seiten

As the largest organ in the oral cavity, the tongue not only plays a primary role in masticatory and speech function-it is also a significant indicator of health, demonstrating signs of both oral pathologies and diseases that can affect the entire body. Because no health care provider gets the opportunity to examine a patient's tongue as often as the dentist, it is essential for dentists to recognize when there may be a problem with the tongue and what the problem is. In addition to an overview of tongue anatomy and general diagnosis and treatment recommendations, this book contains an atlas of more than 50 specific diseases and health concerns that may present signs and symptoms in the tongue. Each is outlined in a quick-reference table describing etiology, prognosis, and more and is accompanied by photographs of different ways the condition can present. A true diagnostic aid, this guide will allow clinicians to identify and address any abnormality a patient's tongue may exhibit.

Autoren/Hrsg.

Filippi, Andreas

Hitz Lindenmüller, Irène

Leseproben

 4 

DIAGNOSTICS

Inga Mollen
Irène Hitz Lindenmüller

HISTORY TAKING AND CLINICAL EXAMINATION

For both the patient and the practitioner, the journey from symptom to interpretation of a visible or palpable finding can take a relatively long time. A focused and systematic examination procedure can help in making a prompt diagnosis. There are various methods available for diagnostic purposes; however, examination of the patient always starts with taking the history (ie, family history, personal history, specific history). This involves asking questions about the patient’s state of health, medications, infectious diseases, possible allergies, smoking habits, alcohol consumption, and other habits that involve the tongue (eg, tongue thrusting, rubbing the tongue on sharp edges of teeth or dentures) (Fig 4-1). Patients are also asked whether they frequently consume harsh mouthwashes, chewing gum, strongly flavored sweets, or tobacco products. These factors can lead to dry mouth and a burning tongue sensation. Deficiencies and disturbed absorption of vitamins and trace elements can also cause symptoms in the tongue area and should be investigated in consultation with the patient’s general practitioner.

Fig 4-1 Mechanical irritation of the left side of the tongue due to pressing and rubbing the tongue against the sharp-edged palatal cusps of the posterior maxillary teeth. This resulted in mechanically induced hyperkeratosis on the left border of the tongue.

As well as a thorough and systematic clinical inspection of the tongue, the rest of the oral cavity should also be included in the clinical examination. Based on this full examination, important conclusions can be drawn about possible diagnoses and differential diagnoses because a finding affecting the tongue does not always occur in isolation but may be linked to dermatologic or systemic diseases. Tongue and regional lymph nodes are palpated, comparing left and right for consistency, mobility, size, fluctuation, and tenderness to identify palpable abnormalities. To obtain complete results, the clinical examination should always be performed in the same systematic manner. It is important to ensure good lighting when carrying out the clinical inspection. So that the tongue can be inspected in its entirety, the patient should stick it out, or it should be gently pulled out with a swab and moved to the right and left (Fig 4-2). This means the tongue can be viewed fully from the margin to the lateral lingual tonsils in the far dorsal position. The anterior floor of the mouth and underside of the tongue can be easily assessed if the patient touches the maxillary anterior teeth with the tip of the tongue and with the mouth open (Fig 4-3). Changes or abnormalities in mobility can be identified as the patient independently moves the tongue (Fig 4-4).

Fig 4-2 (a to c) It is often helpful to pull the tongue out with a swab because this facilitates clinical evaluation of the entire border of the tongue as far as the lateral tonsil.

Fig 4-3 The patient placing the tip of the tongue against the palatal surfaces of the anterior maxillary teeth makes it easy to assess the ventral surface of the tongue and the floor of the mouth. This also helps to compare symmetry.

Fig 4-4 This patient is unable to stick his tongue out straight—it deviates to the left. The reason is a bone metastasis of a lung carcinoma infiltrating the base of the skull and impairing the left hypoglossal nerve. Changes in mobility can easily be identified in this way and the necessary investigations carried out.

Based on the history and clinical data recorded, the findings are assigned to a common principal symptom or to a syndrome. A working diagnosis is then reached by comparing potential differential diagnoses with the patient’s age and gender, statistical frequency, risk factors, and so forth.1,2 The glass spatula test and fungal diagnostics may additionally be used for further diagnostic investigation.

Glass spatula test (diascopy)

If there are color changes (eg, red, purple, blue, brownish), a glass spatula can be used to investigate any vascular change. Under pressure from a glass spatula, blood vessel malformations close to the surface (eg, hemangioma/vascular malformation) as well as vessels dilated due to inflammation (eg, erythema) lose color (Fig 4-5). Applying pressure to capillaries gives rise to relative bloodlessness, making it possible to assess any color change more accurately. If there is swelling that cannot definitely be attributed to a venous malformation (eg, salivary gland cyst), applying pressure with a glass spatula will not cause any decrease in color. The same applies to pigmented lesions (eg, nevus).3,4

Fig 4-5 (a and b) There is a suspicion of a vascular malformation at the apex of the tongue. (c) When there is a vascular malformation (in this case, a hemangioma), pressure pushes the blood from the superficial into the deeper vessels. Applying pressure with a glass spatula makes this phenomenon clearly visible and, in terms of differential diagnosis, helps to distinguish it from findings that are not vessel-related, such as salivary gland cysts or nevi.

Fungal diagnostics

A typical clinical picture is usually sufficient to diagnose fungal infections. A smear (fresh specimen) can be taken if the suspected clinical diagnosis needs to be confirmed, for findings that are similar in differential diagnostic terms, or if an antifungal treatment proves unsuccessful.5 The regions affected by a fungal infection usually exhibit a whitish thrush membrane that is stippled, often in patches or covering a wide area and capable of being scraped off (see Candidiasis section in chapter 5). The material is removed with a sterile swab (fresh specimen) and then sent promptly in a suitable transport medium (eg, M40 Transystem, Copen) to a microbiology laboratory where it is tested for fungal species (saccharomyces or blastomyces) (Fig 4-6).

Fig 4-6 (a) The patient suffers from burning tongue, especially in the horizontal fissures and at the tongue border. She is a smoker. The swab is wiped over the affected areas several times with pressure. (b) The swab together with the sample material is placed in the vessel provided (eg, M40 Transystem). (c) The labeled transport medium should be sent promptly to a microbiology laboratory.

However, reddened areas on the tongue can also be colonized by fungal species. In this form, the tongue has a glassy-reddened surface and does not have a white coating that can be wiped off. It is important to ensure that the specimen is obtained from the inflamed, reddened area. If a conventional biopsy is planned, the biopsy specimen can be tested for a fungal infection in the pathology laboratory with the aid of periodic acid–Schiff staining in addition to histologic staining (hematoxylin-eosin staining). In this case, it is not necessary to do an additional smear investigation beforehand.4

BLOOD TESTS

If findings affecting the tongue and oral mucosa remain unexplained, further diagnostic investigation by means of a blood count can provide additional information about the cause of a disease. Interest focuses particularly on the presence of anemia and its cause, evaluation of diabetes, and any deficiency in vitamins and trace elements. Should rare diseases be suspected (eg, pemphigus vulgaris [PV], Sjögren syndrome), a blood test can usually deliver fast and minimally invasive information before a biopsy is taken.

A blood count without differential count (EDTA blood) involves testing the number of red blood cells (RBCs), white blood cells (WBCs), and platelets as well as hemoglobin (Hb) concentration, hematocrit (Hct), and RBC indices (ie, MCH, MCHC, MCV) (Table 4-1).6 The complete blood count also includes differentiation of the WBCs into particular subgroups (differential blood count).

Table 4-1 Blood count without differential count6

Parameter

Abbreviation

Normal range

White blood cells (leukocytes)

WBC (Leu)

3.9–10.0/µL

Hemoglobin

Hb

M:14–18 g/dL F: 12–16 g/dL

Hematocrit (packed cell volume)

Hct (PCV)

M: 40%-52% F: 35%-47%

Red blood cells (erythrocytes)

RBC (Ery)

4.4–6.0/µL

Mean corpuscular Hb (or mean cell Hb)

MCH

27–34 pg

Mean corpuscular volume (or mean cell volume)

MCV

80–100 fL

Mean corpuscular Hb concentration (or mean cell Hb concentration)

MCHC

31.5–36 g/dL

Platelets (thrombocytes)

Pt (Thr)

150,000–400,000/µL

F, female; M, male

The differential blood count breaks down the composition of the WBCs into subgroups (bands/stabs, polymorphs, eosinophilic,...