New method for evaluation of tongue-coating status

The purpose of this study was to determine the viability of Tongue Coating Index, which is a new method for evaluating tongue-coating status. To determine the reliability and reproducibility of our new evaluation criteria (Score 0: Tongue coating not visible; Score 1: Tongue coating thin, papillae of tongue visible; Score 2: Tongue coating very thick, papillae of tongue not visible), 10 observers evaluated 20 photographs of tongues. Each tongue surface was divided into nine sections. Observers evaluated each section according to our new criteria and each score for tongue-coating status was recorded in the pertinent section of the Tongue Coating Record form. They repeated the same evaluation 2 weeks after the first evaluation. The relationship between the scores obtained and number of oral microorganisms was investigated in 50 edentulous patients. Tongue coating was collected from the tongue surface after evaluation of tongue-coating status. The total number of anaerobic bacteria and the number of Candida species were counted from the specimens collected. Interobserver agreement and intraobserver agreement were 0.66 and 0.80 by Cohen's kappa, respectively. No significant difference was observed in the number of Candida species among the three scores. The number of total anaerobic bacteria, however, was significantly different among the scores (P < 0.05). Therefore, we conclude that our method for evaluating tongue-coating status offers new criteria that are superior in reliability and reproducibility, and that also reflect the total number of anaerobic bacteria present on the dorsum of the tongue.

Acute upper airway obstruction from acquired angioedema

C1 esterase inhibitor deficiency is an unusual cause of acute upper airway angioedema. This case of angioedema is secondary to acquired C1 esterase inhibitor deficiency associated with neoplastic disease and triggered by the use of angiotensin converting enzyme inhibitors. It was sufficiently severe to require emergency airway management. A guide to the evaluation and management of angioedema is presented.

[Simultaneous pulmonar, laryngeal and lingual affectation by Mycobacterium tuberculosis]

The incidence of tuberculosis has lately increased in developed countries. The most frequent affectation is the pulmonar one and in the ORL area the laryngeal. The lingual affectation is exceptional. We present a case of a man 39 years old, with bilateral pulmonar, left vocal cord and mobile tongue affectation, negative Mantoux, positive spit culture and presence of acido-alcohol resistent bacillus in lingual and laryngeal biopsies. After antituberculosis treatment during 6 months the laryngeal and lingual lesions disappeared. We have only found two cases published of simultaneous tuberculosis in these three localisations in the last 30 years.

Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study

PURPOSE

Ankyloglossia ("tongue-tie") occurs in nearly 5% of neonates, but its clinical significance relating to breast-feeding difficulties is controversial. We tested the hypothesis that in infants with ankyloglossia referred because of breast-feeding difficulties, frenotomy alleviates the symptoms.

METHODS

Twenty-five mothers of healthy infants with ankyloglossia were recruited because of sore nipples. Infants were randomized to either of 2 sequences: (1) frenotomy, breast-feeding, sham, breast-feeding (n = 14) or (2) sham, breast-feeding, frenotomy, breast-feeding (n = 11). The mothers as well as all personnel taking care of the child after each sham or frenotomy procedure were masked as to the study sequence. In every sequence, and after each sham or frenotomy procedure, a standardized latch score and pain score were obtained from the mother.

RESULTS

There was a significant decrease in pain score after frenotomy than after sham (P = .001). There was also a nearly significant improvement in latch after the frenotomy in these mothers (P = .06).

CONCLUSION

Frenotomy appears to alleviate nipple pain immediately after frenotomy. We speculate that ankyloglossia plays a significant role in early breast-feeding difficulties, and that frenotomy is an effective therapy for these difficulties.

Carcinome vesiculo-papillaire sur thyroïde linguale

OBJECTIVES

The management of diagnosis, treatment and outcome of malignant neoplasm arising in a lingual thyroid.

MATERIAL AND METHODS

We report a case of papillary-follicular carcinoma arising in a lingual thyroid.

RESULTS

Lingual carcinoma causes dysphagia and pain due to oropharyngeal obstruction. Surgical pharyngotomy with a trans-hyoid approach provides good access to the lesions. Therefore, the eutopic thyroid was present, in pretracheal position, without neoplastic proliferation.

CONCLUSIONS

Carcinoma arising in lingual thyroid is an extreme rare entity. Its diagnosis is histologic. Its treatment is surgical associated with radio-iodine therapy.

Lymphatic malformations of the tongue base

PURPOSE

In light of the paucity of literature on lymphatic malformations of the tongue base, our aim was to present our experience and long-term outcomes of patients with this rare and challenging pathologic entity.

METHODS

Medical records of 25 patients treated by the 3 senior authors (RGA, MTC, and RTC) between 1974 and 2003 were retrospectively reviewed, and comprehensive clinical data were collected and analyzed.

RESULTS

Twenty-one patients (13 female and 12 male infants) were diagnosed either prenatally or at birth. Of these patients, 18 required early airway stabilization; 17 required tracheotomy. Four patients were diagnosed after 1 year of age and had no airway problems. Follow-up ranged from 2 days (owing to death) to 28 years, with a mean of 10 years. In 21 patients, pathology was extensive, involving contiguous anatomical areas such as the anterior tongue, larynx, pharynx, and floor of mouth. Multiple resections and debulking procedures were performed to restore function and improve cosmesis. Four patients died, all with laryngeal involvement. Of the 14 survivors who had tracheotomies, only 5 are decannulated. Normal oral feeding has been achieved in 14 patients and normal speech, in 8 patients. Cosmesis has improved with time. Orthodontic and dental problems are common, and 9 patients have significant macrognathia.

CONCLUSIONS

Although most patients with lymphatic malformations of the tongue base achieve normal oral feeding, airway, speech, and cosmesis issues remain problematic throughout life. Laryngeal involvement signifies extensive disease and is the most significant risk factor for serious complications and death.

Evaluation of intubation using the Airtraq or Macintosh laryngoscope by anaesthetists in easy and simulated difficult laryngoscopy--a manikin study

The Airtraq Laryngoscope is a novel intubation device which allows visualisation of the vocal cords without alignment of the oral, pharyngeal and tracheal axes. We compared the Airtraq with the Macintosh laryngoscope in simulated easy and difficult laryngoscopy. Twenty-five anaesthetists were allowed up to three attempts to intubate the trachea in each of three laryngoscopy scenarios using a Laerdal Intubation Trainer followed by five scenarios using a Laerdal SimMan Manikin. Each anaesthetist then performed tracheal intubation of the normal airway a second time to characterise the learning curve. In the simulated easy laryngoscopy scenarios, there was no difference between the Airtraq and the Macintosh in success of tracheal intubation. The time taken to intubate at the end of the protocol was significantly lower using the Airtraq (9.5 (6.7) vs. 14.2 (7.4) s), demonstrating a rapid acquisition of skills. In the simulated difficult laryngoscopy scenarios, the Airtraq was more successful in achieving tracheal intubation, required less time to intubate successfully, caused less dental trauma, and was considered by the anaesthetists to be easier to use.

Epiglottic and Base-of-Tongue Prolapse in Children: Grading and Management

OBJECTIVES

A distinct entity of airway obstruction from epiglottic and base-of-tongue (EBT) prolapse in the pediatric population is defined. Laryngopharyngeal findings, swallowing dysfunction, and gastroesophageal reflux disease are described in a group of children with EBT prolapse. A new grading system is also presented.

STUDY DESIGN

A prospective study was conducted of laryngopharyngeal findings in children with EBT prolapse, a description of a new grading system, and review of the pediatric literature.

METHODS

Fourteen children with EBT prolapse were prospectively studied with flexible fiberoptic nasopharyngolaryngoscopy. A new grading system for EBT prolapse was developed. Grade 0 is a normal airway. Grade 1 is prolapse of the epiglottis against the posterior pharyngeal wall but with normal position of the tongue. Grade 2 is prolapse of the epiglottis and base of tongue with only the epiglottic tip visible. Grade 3 is glossoptosis with no portion of the epiglottis visible. The diagnostic modalities and treatments for EBT prolapse are reviewed.

RESULTS

Of the 14 children studied, seven (50%) had grade 1, four (29%) had grade 2, and three (21%) had grade 3 EBT prolapse. Swallowing dysfunction (five of 14, 38%) and gastroesophageal reflux disease (13 of 14, 93%) were also prevalent.

CONCLUSION

The new grading system was applied successfully to describe the severity and sites of airway obstruction in 14 children with EBT prolapse. Swallowing dysfunction and gastroesophageal reflux disease occur in this population. Although surgical therapies are sometimes effective, lack of consistent success and the risk of aspiration with procedures other than tracheotomy may lead some to conclude that continuous positive airway pressure or tracheotomy are the safest options.

[Tongue mobility in ankyloglossia with regard to articulation]

A sound is created as a result of several breathing, phonetic and articulation positions and movements which take place in the articulation system consisting of both mobile and immobile elements. The tongue is one of the mobile elements of the articulation system. Full range of tongue mobility is required to form sounds correctly. If mobility of the tongue is reduced, sounds may slightly, moderately or highly deviate from proper ones. Serious deviations in articulate structure of sounds (such as non-vibrating front part of the tongue in the /r/ phoneme) are easy to notice since they change phoneme structure of the sound. Slight deviations (e.g. non-vibrational or non-mediumistic action of the tongue) may be unnoticed because speech is still comprehensible although it is formed with compensatory positions and movements of breathing, phonetic and articulation apparatus. There are some phonemes that require a wide range of tongue mobility to be formed correctly, while others require less tongue mobility. In the Polish language, phonemes that require the most mobile tongue are: trembling /r/, lateral /l/, humming /sz, z, cz, dz/, and soft /i, j, ś, ź, ć, dź/. In order to diagnose abnormalities, organs of speech need to be observed directly (photographs, films) or indirectly (videoradiography). One of the factors that restrict (to a slight, average or high degree) tongue mobility is the short frenulum. According to the general opinion "the tongue frenulum has no influence on tongue mobility". However, persons with ankyloglossia form at least one of the above-mentioned phonemes incorrectly to a slight, medium or high degree and frenotomy is required to make improvement of speech by a speech therapist effective. In opinion of many physicians and speech therapists " frenotomy is usually pointless because a new scar is formed that makes the frenulum even shorter than before". I have found in my research that tongue mobility improves after each frenotomy and no adhesions are formed after simple horizontal cutting of the frenulum with scissors (local anesthesia) if the wound is not sutured. It is often necessary to carry out several frenotomies to achieve full articulating mobility of the tongue.

[When the tongue impairs breathing]

Ätiologisch ist im vorliegenden Fall ein Angioödem mit Mastzelldegranulation unwahrscheinlich. Einerseits wegen fehlendem Exanthem und Pruritus und andererseits fehlte ein suffizientes Ansprechen auf hochdosierte Steroidgabe oder Adrenalin. Der wiederholt normale Wert von C1-INH im Serum sowohl quantitativ und auch qualitativ spricht gegen das Vorliegen eines C1-Esteraseinhibitor-Mangel. Aufgrund der Anamnese und des klinischen Verlaufs bleibt als wahrscheinlichste Ursache für das Angioödem die bereits lange Jahre etablierte und in der Dosierung unveränderte ACE-Hemmer-Therapie, obwohl eine derartige Manifestation nach langjährigem ACE Hemmer Einsatz sehr selten ist.

Lingual frenulum: quantitative evaluation proposal

The purpose of this study was to establish a quantitative method to classify lingual frenulum as normal and altered.

METHODS

98 people were included in this study. All measurements were made with maxium opening of the mouth. A digital caliper was used to measure the length of the frenulum under three conditions: a) with the tongue tip on the incisal papilla; b) with the tongue sucked up and maintained against the hard palate; and c) with tongue stretching over a spatula.

RESULTS

Observations indicated that the most useful and statistically significant way of measuring frenulum length was achieved with maximum mouth opening and the tongue tip on the incisal papilla.

CONCLUSION

This quantitative method was demonstrated to be effective for identifying and distinguishing normal and altered frenular length.

Addisonian pigmentation of the oral mucosa

Cutaneous pigmentation is a hallmark of Addison disease. When present, the hyperpigmentation generally localizes to sun-exposed surfaces. This case highlights a less well-recognized cutaneous feature that is pathognomonic for the disease: oral mucous membrane hyperpigmentation. We describe this unique type of discoloration in detail and contrast it with other forms of oral pigmentation.

Improved Ankyloglossia Correction With Four-Flap Z-Frenuloplasty

Ankyloglossia, or tongue-tie, is the result of a short, tight, lingual frenulum causing tethering of the tongue tip. Although most cases resolve or are asymptomatic, some patients develop articulation problems and other concerns related to poor tongue-tip mobility. In this study, we evaluated the treatment of patients greater than 3 years of age with persistent articulation problems related to ankyloglossia (n = 16). All patients underwent surgical correction either via a novel application of the 4-flap Z-frenuloplasty (n = 11) or via the more traditional horizontal-to-vertical frenuloplasty (n = 5). Frenulum length, tongue protrusion length, and speech evaluations (4-grade scaling) were documented preoperatively and at follow-up. For the 4-flap Z-frenuloplasty, 91% of patients showed at least 2 orders of improvement in speech, 64% showed complete resolution of articulation errors, and 9% demonstrated no improvement in speech. Frenulum length and tongue protrusion gained 37.5 +/- 13.5 mm (P < 0.001) (315% increase) and 36.2 +/- 7.6 mm (P < 0.001), respectively. In contrast, with the horizontal-to-vertical frenuloplasty, only 40% showed 1 order of improvement in speech, and 60% had no change in articulation. Frenulum length and tongue protrusion gained 11.2 +/- 4.15 mm (98% increase) and 13.2 +/- 2.6 mm (P = 0.0003), respectively. Our data indicated that the 4-flap Z-frenuloplasty was superior to the horizontal to vertical frenuloplasty with respect to tongue lengthening, protrusion, and articulation improvement for patients with symptomatic ankyloglossia.

An overview of oral frena and their association with multiple syndromic and nonsyndromic conditions

The development of abnormal oral frena is an important diagnostic feature of several syndromic states. Five such syndromes are reviewed which include Ehlers-Danlos syndrome, infantile hypertrophic pyloric stenosis, holoprosencephaly, Ellis-van Creveld syndrome, and oral-facial-digital syndrome. Each syndrome exhibits relatively specific frena abnormalities, ranging from multiple, hyperplastic, hypoplastic, or absent. 1-8 In addition to abnormal oral frena observed in syndromic conditions, anomalous frena are encountered without other associated phenotypic features of genetic or chromosomal states. 9 This paper is a review of the above stated frena deformities and their management.

Tongue disease in advanced AIDS

OBJECTIVE

This study describes the involvement and the histological alterations found in the tongues of 92 autopsied patients who died with AIDS.

MATERIALS AND METHODS

Sex, age, CD4 cell count and clinical history were obtained from the files of 92 patients who died with AIDS. All the tongues were examined for macroscopical alterations and stained using H&E, Gomori-Grocott, Ziehl-Neelsen, PAS, Brow-Hopps and Mucicarmine. Histological autopsy findings were grouped based on a protocol that was designed following the World Health Organization recommendations.

RESULTS

The mean age of the patients who died of AIDS and CD4 cell count were 36 years and 82 cells microL(-1), respectively. Histological alterations of the tongues were found in 75% of the cadavers. The most common lesions were hairy leukoplakia (HL) (42 cases), candidosis (31 cases) and non-specific chronic glossitis (29 cases), followed by concomitant lesions (28 cases), non-specific chronic ulceration (17 cases), melanotic pigmentation (13 cases), herpes simplex (10 cases), lymphoepithelial cysts (two cases), cryptococcosis (two cases), mycobacteriosis (one case), histoplasmosis (one case), cytomegalovirus infection (one case) and non-Hodgkin Lymphoma (one case). HL with oral candidosis (n = 13) were the most common concomitant lesions.

CONCLUSION

These findings indicate that the tongue is a favorite site to occurrence of reactive, infectious and concurrent lesions in the end-stage of AIDS patients.

Ankyloglossia in the infant and young child: clinical suggestions for diagnosis and management

Since the recommended time for a child's first dental visit is early, it is essential that pediatric dentists be familiar with all possible pathologies occurring during this early period of life. The parents of infants and toddlers who notice in their child a "tongue-tie" (ankyloglossia) are likely to turn first to their pediatric dentist for advice and help. Treatment options such as observation, speech therapy, frenotomy without anesthesia, and frenectomy under general anesthesia have all been suggested in the literature. The purposes of this report are to describe ankyloglossia, its clinical significance, and the timing of treatment. The frenotomy procedure is presented for the pediatric dentist with clinical suggestions for the diagnosis and management of ankyloglossia.

Sedation and fiberoptic intubation of a neonate with a cystic hygroma

The flexible bronchoscope (FB) has been used to secure the difficult airway in pediatric patients. Difficult intubations in patients with cystic hygromas have been performed in awake patients or after the induction of general anesthesia. A recent case report acknowledges the challenges of performing intubations in pediatric patients under sedation because of their inability to fully cooperate. The following case demonstrates the two step-two fiberoptic bronchoscopic tracheal intubation performed using sedation and topical anesthesia in a neonate with a difficult airway.

Decreased tongue mobility -- an explanation for difficult endotracheal intubation?

Established parameters predictive of difficulty in airway management were inconclusive in five ear, nose and throat (ENT) patients. All presented with degrees of tongue fixation - restriction of movement. Initially, experienced anaesthetists concluded that conventional endotracheal intubation would present no problems. Later, there were adjustments to this conclusion, with the ultimate being that four of the patients underwent fibre-optic intubation: one electively, two after repeated failed conventional attempts and one after a failed attempt of retrograde intubation. The last patient underwent elective retrograde intubation. All intubations were performed uneventfully in anaesthetized or sedated patients under spontaneous respiration. We found that tongue fixation was a direct cause of failed conventional endotracheal intubation, and recommend that a detailed tongue status investigation should be routine during Mallampati evaluation. Any abnormality should be seen as predictive of difficult/impossible conventional direct laryngoscopic intubation.