and Spencer W. Beasley2
Department of Urology, Royal Children’s Hospital, Melbourne, Australia
Paediatric Surgery Department Otago, University Christchurch Hospital, Christchurch, New Zealand
This chapter describes abnormalities of the tongue, such as tongue-tie, macroglossia and lingual thyroid. There is a section on lesions in the floor of the mouth (ranula and submandibular calculus) as well as lesions of the gums and lips, including cleft lip and palate. Finally, there is a description of the signs in tonsillitis, quinsy and retropharyngeal abscess.
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Surgical conditions arising within the mouth form a heterogeneous collection (Table 11.1), and the approach to diagnosis, therefore, depends initially on inspection of the site of origin of the lesion. Specific points in the examination of each lesion are described separately according to their site.
Pathological conditions in the mouth
Site of origin
Floor of mouth
Mucus retention cyst
Submucous cleft palate
Tongue-tie is caused by a very short frenulum extending from the tip of the tongue to the floor of the mouth. The frenulum appears as a tight pale band which fetters the tip and, in severe cases, prevents protrusion of the tongue beyond the lower incisor teeth. The tongue may be anchored so closely to the floor of the mouth behind the lower gum that the frenulum is difficult to see.
It can cause interference with breastfeeding and speech but never affects swallowing as this is a function of the posterior part of the tongue.
The aim of examination is to determine how far the tongue can protrude. Articulation is impaired when the tongue cannot protrude past the teeth (Fig. 11.1), when attempts at poking it out simply result in it rolling up (Fig. 11.2). It is, therefore, its relationship to the incisor teeth which determines the necessity for surgical division of the frenulum. Many children with tongue-tie also have a tight maxillary frenulum.
Tongue-tie, with a short frenulum anchors the tip of the tongue to the floor of the mouth
Protrusion of the tongue as the diagnostic test for tongue-tie requiring treatment. Normally, the tongue protrudes well beyond the teeth (a), but in severe tongue-tie, the tongue cannot be protruded past the teeth and tends to roll up (b)
Macroglossia describes real or apparent enlargement of the tongue. It is a well-known feature of Down syndrome. Any space-occupying lesion inside the tongue will produce macroglossia. Alternatively, a normal tongue within a small oral cavity will appear relatively large as in Pierre-Robin syndrome (Table 11.2). Macroglossia may occur as part of a generalized syndrome, for example, hypothyroidism, Beckwith-Wiedemann syndrome or as a manifestation of local pathology, for example, a lymphatic anomaly with lymphangiomatosis.
The causes of macroglossia
Oedema and inflammation
Increased blood flow leading to overgrowth
Muscle overgrowth from fetal IGF-1
Normal tongue but small mandible
Large tongue-mechanism unknown
Inspection and palpation of the tongue should determine whether there is a space-occupying lesion. Where a localized lesion is found, further examination determines whether it is composed of lymphatic fluid (which may transilluminate or have multiple ‘blebs’ on the surface), blood (vascular spaces which empty on compression) or solid tissue (feels hard and may be due to a neurofibroma or rare tumour, e.g. rhabdomyosarcoma). When the tongue is enlarged uniformly, a general examination to identify the cause involves looking for organomegaly (Beckwith-Wiedemann syndrome) or features of Down syndrome (Fig. 11.3). Micrognathia and a rectangular defect in the palate confirm the diagnosis of Pierre-Robin syndrome (Fig. 11.4).
Macroglossia: diagnosis of the underlying cause may be evident on general examination, such as in Down syndrome or Beckwith-Wiedemann syndrome
Micrognathia (Pierre-Robin syndrome) as a cause of apparent macroglossia. The tongue is pushed up and interferes with palatal development, leading to the large cleft palate
The lingual thyroid is a rare congenital anomaly of the thyroid gland where it has failed to migrate from the floor of the oropharynx to the neck. It is located on the posterior aspect of the tongue producing a swelling which differs in colour and texture from the surrounding tongue. It is not always apparent until the patient is asked to protrude the tongue. It can be observed more easily if, on tongue protrusion, the anterior half of the tongue is held with a gauze swab (Fig. 11.5). The importance of the lingual thyroid is that it is the only thyroid tissue present and should not be excised. Part of the examination, therefore, involves looking at the lower part of the neck for evidence of normally sited thyroid tissue.
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