 FIG. 23-1. Reddish-blue hemangioma of the lower lip. |
TABLE 23-1. Common local causes of halitosis | ||||||||||||||||||||||||
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TABLE 23-2. Congenital disorders of oral cavity | ||||||||||||||||||||||||||||||||||||||||||
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Disorders of the Tongue and Oral Cavity
Disorders of the Tongue and Oral Cavity
Jerome S. Schwartz
Jessica W. Lim
Gady Har-El
Physical examination of the tongue and oral cavity requires bright illumination, keen observation, and manual palpation. Adequate lighting is an important tool to assess areas of discoloration, edema, and irregularity indicative of an infectious, hematologic, or neoplastic abnormality (Fig. 23-1). Cranial nerve testing includes assessment of taste, gag reflex, tongue sensation and mobility, and jaw movement. Examination of overall oral hygiene, dentition, and salivary flow are especially important. Complete examination of the oral cavity must include palpation of the tongue, floor of the mouth, buccal mucosa, and retromolar trigone for masses, tenderness, or induration.
BAD BREATH
Halitosis, or bad breath, is a symptom, not a disease. Identification of the pathophysiologic condition is important in developing the appropriate treatment plan. Patients may have a bad or specific taste in the mouth. They may be referred by family, friends, or other physicians who notice the problem. An otolaryngologist may be the first to notice a foul odor during a routine examination.
Bad breath can emanate primarily from many regions in the upper aerodigestive tract. To differentiate oral and nasal causes, the physician can separate expired mouth air from nasal air by pinching the nose closed and having the patient expire through the mouth and then by having the patient close the mouth and exhale through the nose. A thorough history and physical examination are necessary in the evaluation of halitosis.
The cause of halitosis may be a local or a systemic condition. Table 23-1 lists some of the common local etiologies. Systemic causes of halitosis result from pulmonary excretion of malodorous substances dissolved in the bloodstream. Contrary to popular belief, the characteristic breath odors of garlic, onions, and alcohol originate in the blood, which picks up the scents from the small intestine and transfers them to alveoli and to the pores of the skin. Bad breath may arise from systemic diseases such as hepatic failure (sulfur odor), uremia (ammonia odor), and diabetic ketoacidosis (acetone breath).
A patient may report halitosis that is not detectable by others. Temporal lobe seizures may be responsible for this condition. The patient may also be experiencing delusions of halitosis in which the patient is aware of a foul odor emanating from his or her mouth. Those delusions may be associated with depression, schizophrenia, and organic brain syndrome.
CONGENITAL DISORDERS
The mobile portion of the tongue develops from fusion of the lateral lingual swellings around the midline tuberculum impar. The latter recedes with further development. The copula forms the base of the tongue. Between the tuberculum impar and the copula is the thyroglossal duct, the primordium of the thyroid gland. The duct fibroses and the foramen cecum remains as a swelling or dimple on the tongue to indicate its origin. This developmental scheme facilitates understanding of some congenital abnormalities of the tongue (Table 23-2).
INFECTIONS
Candidiasis
Candidiasis is the most common fungal cause of mucositis and pharyngitis. Many local and systemic factors predispose a person to candidal infection. Local factors include physical irritation from dentures, use of steroid inhalers, preexisting infection, and poor oral hygiene. Systemic factors include nutritional deficits, diabetes, systemic steroid therapy, malignant tumor, chemotherapy, acquired immunodeficiency syndrome, prolonged antibiotic treatment, and even pregnancy. Pseudomembranous candidiasis (thrush) is the most common form. It appears as soft, white plaques that can be removed, leaving an erythematous epithelial surface. Candidiasis is rarely painful, but severe cases with mucosal erosion can produce a burning sensation. Spread to the larynx and pharynx can cause dysphagia and odynophagia.
