Swollen tongue (macroglossia) is an uncommon complaint, yet on examination, it is occasionally found. Is it possible to think of more than two or three causes? In most instances this is difficult, yet there is a key to recalling the many causes.
This symptom affords the opportunity to introduce yet another method of arriving at a differential diagnosis, the histopathologic method. First, analyze the tissues of the tongue and then decide what can happen to enlarge them. These tissues are the mucosa, submucosal tissue, muscle, supporting tissue, blood vessels, and nerves. What pathologic process can enlarge each of these? Increase in size and number of the cells; infusion of serous fluids, pus, or blood; infiltration of a foreign protein or fat; and infiltration of foreign cells could cause such enlargement. These are all included in Table 54.
The mucosa can increase the number of cells in carcinoma of the tongue. It is swollen with a serous fluid in reaction to things put in the mouth such as hot food, mercury, and aspirin. Other less-well-understood sources of fluid in the mucosa are erythema multiforme and pemphigus. The submucosal and supporting tissue may be enlarged by serous fluid in angioneurotic edema, by purulent fluid in acute diffuse glossitis (usually caused by Streptococcusorganisms), or by hemorrhagic fluid in leukemia, scurvy, and other hemorrhage disorders. The subcutaneous and supporting tissue can also be infiltrated by a mucoprotein in myxedema and cretinism and by amyloid in primary amyloidosis. There may be infiltration of neoplastic cells in leukemia and lymphoma.
The muscle hypertrophies in acromegaly. Distention of the blood vessels may cause macroglossia in CHF and pulmonary emphysema. A few conditions may be left out by this approach. The tongue, for example, seems large in Down syndrome, but this is caused by the fact that it hangs out and appears larger than it really is. The tongue is large and smooth in riboflavin deficiency and sprue.
If the clinician prefers, an excellent differential can be achieved by using the mnemonic VINDICATE.
Approach to the Diagnosis
The diagnosis of macroglossia depends on the presence of other physical findings (almost invariably present) associated with the disorders mentioned above, and, in most cases, the results of a systematic workup. A lingual biopsy is valuable in primary amyloidosis.
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Swollen tongue |
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TABLE 55. Syncope |
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Other Useful Tests
1. CBC (leukemia)
2. Sedimentation rate (glossitis)
3. Culture and sensitivity (abscess, glossitis)
4. VDRL test (gumma)
5. Thyroid profile (hypothyroidism)
6. Growth hormone assay (acromegaly)
7. Skull x-ray (screen for pituitary adenoma)
8. Blood smear (leukemia)
9. Circulation time (CHF)
10. Tests for vitamin deficiency
11. Coagulation studies (scurvy, leukemia)
12. Lingual biopsy (amyloidosis)
