Today with the help of our wonderful ENT expert discussant, Dr. Josh Stramiello, we went over the diagnostic approach and work-up to tongue lesions, specifically ulcerative lesions in the outpatient setting. We started with a case of a young man with incidentally noted atropic areas of his tongue. He was asymptomatic and without constitutional symptoms. Ultimately he was diagnosed with geographic tongue, the most common outpatient tongue condition that is benign and self-limiting. We used this as a launching point to go through other common tongue conditions that internists should be aware of, infectious (candidiasis, EBV-oral hair leukoplakia, HSV, VZV), inflammatory/autoimmune (SLE, Crohn’s/UC, Behcet’s, sarcoidosis, amylodosis) and pre-malignant/malignant (leukoplakia, erythroplakia, oral lichen planus, SCC) and benign conditions (geographic tongue, median rhomboid glossitis and black hair tongue).
Teaching points:
1) Remember on physical exam to use a good light sources and tongue depressor to look at the oral cavity. Don’t be afraid to put on gloves and palpate the tongue. Use gauze to help grip and mobilize it to check both the dorsal and ventral aspects!
2) Send patients with possible leukoplakia, oral lichen planus and erythroplakia (as well as SCC/adenocarcinoma) to ENT for surgical evaluation. Erythroplakia has a 20% chance of being cancer on biopsy and 80% of future malignant transformation.
3) Risk factors for SCC include: HPV exposure, heavy tobacco use, and etoh use, so be sure to screen them in your history. Most pre-malignant and malignant lesions are on the lateral or ventro-lateral aspects of the tongue so be suspicious of solitary, nonhealing lesions in those areas!
Thanks again for lending your time and expertise, Dr. Stramiello!
