Overview of macroglossia and its treatment

Etiological diagnosis of macroglossia: Systematic review and diagnostic algorithm

BACKGROUND

The objective of this literature review was to list the different etiologies of macroglossia reported in the literature, to identify characteristics that might guide diagnosis, and to create a diagnostic algorithm.

METHODS

The bibliographic search was carried out between October 2019 and July 2020 in the PubMed research base using the keywords "macroglossia" (MESH) and/or "tongue enlargement".

RESULTS

Of the 1711 references identified, 615 articles were excluded, and 1096 abstracts were reviewed. We classified the different etiologies identified according to their mechanism and whether they were congenital or acquired. The etiologies are divided into the following categories: genetic malformation syndromes, non-syndromic congenital malformations, endocrinopathies, neuromuscular diseases, storage disorders, infectious, inflammatory, traumatic, and iatrogenic diseases.

CONCLUSION

Based on this review, we propose a diagnostic algorithm for macroglossia according to the characteristics described. The most common diagnoses among acquired causes were amyloidosis (13.7%), endocrinopathies (8.8%), myopathies (4%) and tongue tumors (6.7%). The most common congenital causes were aneuploidy, lymphatic malformations, and Beckwith-Wiedemann syndrome, which is the main cause of congenital macroglossia, even if it appears isolated.

Evaluation of test-retest reliability and concurrent validity of the Italian version of the pediatric evaluation of disability inventory in children with down syndrome: A cross-sectional study

PURPOSE

Down Syndrome (DS) is a common genetic disorder caused by trisomy 21. Due to cognitive challenges associated with DS, individuals often experience difficulty performing activities of daily living (ADLs), at levels that can range from mild to significant. This study aimed to measure psychometric properties of the Italian version of the Pediatric Evaluation of Disability Inventory (PEDI-I) in the DS population.

METHODS

The PEDI-I was administered to children with DS. The internal consistency was examined using Cronbach's Alpha. Test-retest reliability was demonstrated by intraclass correlation coefficient (ICC) and Bland-Altman plots. The concurrent validity was evaluated with the Italian version of the Barthel Index.

RESULTS

The PEDI-I was administered to 54 children with DS. Cronbach's Alpha showed statistically significant values (0.899 -0.986). The ICC confirmed the reproducibility of the scale with a range of (0.988 -1), while Bland-Altman plots showed a smallest detectable change of (0.18-1.63). The Pearson Correlation Coefficient with the Barthel Index showed statistically significant values for all PEDI-I subscales (range 0.75-0.95).

CONCLUSION

The study provides evidence of good test-retest reliability and convergent validity when used in children with DS. Other psychometric proprieties need to be investigated in future studies.

Intralesional Sclerotherapy with Bleomycin in Lymphatic Malformation of Tongue an Institutional Experience and Outcomes

Introduction

The management of lymphatic malformations (LMs) continues to improve with advancement in molecular genetics, imaging, and treatment options. However, the management of tongue LMs remains a challenge due to the location, function involved, and long-term disabilities. We propose injection sclerotherapy with bleomycin in the management of spectrum of tongue LMs.

Methods

Children with LMs involving the tongue were prospectively treated with bleomycin sclerotherapy. Outcome measured was the efficacy of sclerotherapy, complications, and functional outcome.

Results

A total of 11 children underwent sclerotherapy with bleomycin for varying tongue lesions. Excellent outcome was seen in children with macroglossia. Eight children with isolated (focal) lesions had a resolution of symptoms with a clearance of lesions. Specific complications related to bleomycin toxicity were not encountered in our series during the follow-up of 4 years.

Conclusion

In our series, children with macroglossia had an excellent outcome with normalization of tongue size and function. Children with focal tongue lesions also had good to excellent outcome. We recommend treatment of tongue LM with bleomycin sclerotherapy as the first line of management. Ease of treatment, early intervention, and excellent response makes it a favorable treatment option.

Beckwith-Wiedemann Syndrome Review: A Guide for the Neonatal Nurse

Beckwith-Wiedemann syndrome (BWS) is the most common pediatric overgrowth syndrome. Features characteristic of the BWS phenotype include both physical attributes, such as macroglossia, abdominal wall defects, gigantism, nevus flammeus, visceromegaly, and mid-face hypoplasia, as well as biochemical abnormalities such as hypoglycemia. It is essential for the neonatal nurse to be able to recognize BWS in the patient's early years of life because of the increased frequency of medical complications, malformations, and the increased risk of embryonic malignancies. This article focuses on the presentation of BWS as an aid to early detection.

Severe macroglossia after posterior fossa and craniofacial surgery in children

Massive swelling of the tongue can occur after posterior fossa and craniofacial surgery. Several hypotheses have been proposed to explain the occurrence of such severe postoperative macroglossia, but this phenomenon is still poorly understood. Severe postoperative macroglossia can be a life-threatening condition due to upper airway obstruction. Three cases of severe postoperative macroglossia that occurred after cervical spine, craniofacial, and posterior fossa surgical procedures are reported here. These cases required specialized maxillofacial management and a prolonged stay in the intensive care unit. Causal factors involved in this condition are reported, in order to highlight appropriate prevention and treatment options adapted to the management of paediatric patients. An overview of the current literature on severe postoperative macroglossia in paediatric populations is also provided.

[Congenital macroglossia: clinical features and therapeutic strategies in paediatric patients]

Congenital macroglossia is a condition that consists in an enlarged tongue that in resting position protrudes beyond the alveolar ridge. It has been classified in two categories: true macroglossia, which occurs in congenital or acquired forms, and relative macroglossia. As this alteration may be due to different causes, its incidence is not known. It is more frequently associated to Beckwith-Wiedemann syndrome, to mucopolysaccharidosis diseases and to Pompe's disease, and it has been less frequently associated to lymphangioma, hemangioma or isolated muscular hypertrophy. Macroglossia is characterized by an enlarged and thick tongue that may have fissures and ulcers, may cause language alterations, difficulties for feeding and swallowing, sialorrhea and recurrent infections of the upper airway or even its obstruction. Its clinical evaluation must include a complete clinical chart with careful physical exploration and a pedigree of that may identify the presence or absence of a hereditary associated syndrome. Macroglossia management is complex. More than twenty different surgical options to reduce the tongue size have been proposed, however, so far there is not a general agreement in this respect. The objective of this work is to review clinical and surgical aspects related to macroglossia from the point of view of non-surgical pediatricians and genetists, addressed to the different medical specialists, including the maxillofacial surgeons involved in the management of these patients.

Current surgical management of macroglossia

PURPOSE OF REVIEW

To discuss the current surgical management of macroglossia.

RECENT FINDINGS

Traditional surgical management of severe macroglossia has been with anterior wedge or keyhole resection. Long-term follow-up has been limited, and only recently have assessments been done regarding functional and aesthetic outcomes. New methods including double stellate and combination approaches have shown promise, though with limited case size reports. Addressing macroglossia in three dimensions may be the most effective way of achieving positive positional, speech and aesthetic outcomes, but comparative studies are lacking. Other causes of macroglossia, such as vascular malformations, can be managed with less aggressive measures such as laser and radio-frequency ablation.

SUMMARY

The aggressiveness of the management should match the severity of the symptoms. The anterior wedge resection and modified keyhole incisions are the most well studied operative strategies. Short and long-term outcome data are limited, and neither method is definitively superior. Less aggressive measures are options for less severe macroglossia. Surgical management of macroglossia should be tailored to each individual patient and in accordance to surgeon experience and expertise.

Treatment of a tongue lymphangioma with sirolimus after failure of surgical resection and propranolol

Lymphangiomas of the tongue are rare, and their treatment is problematic. A 10 year-old patient with tongue lymphangioma who was previously treated with surgery and propranolol with no response was treated with sirolimus in our department. We used sirolimus with a dose of 1.6 mg/m(2)/day. After 3 months of treatment, the mass had decreased by more than 60%. We continued the treatment for 1 year with a maximum response of 70% decrease in mass. Disease remained stable 6 months after stopping therapy, the latest time of follow-up. Sirolimus appears to be effective in lymphangioma but requires further study.

Reduction glossectomy for large tongues

Pathological enlargement of tongue is caused by several conditions and diseases. In several instances, surgery remains the only viable option for complete cure. Persistent bleeding, compromised neuro-motor-sensory functions during the postoperative period are the most common complaints encountered after macroglossia correction. The tongue is a muscular organ, whose complex neuroanatomy is being unraveled slowly. Various types of macroglossia resections in unique clinical situations have been proposed by several clinicians till date. There has never been unanimously accepted resection for the treatment of macroglossia. This review article attempts to preview the cosmetic and functional components for resection designs.

[A tongue biopsy led to the diagnosis]

A 76-year-old patient in otherwise good health presented with a 2-year history of bilateral painless submandibular swelling and macroglossia. A standard ENT examination revealed no additional symptoms. Tongue biopsy led to the diagnosis of amyloidosis, serum immunofixation identified AL amyloidosis and a kappa light chain gammopathy resulting from multiple myeloma as the underlying cause.

Surgical treatment of macroglossia in patients with Beckwith-Wiedemann syndrome: a 20-year experience and review of the literature

Macroglossia is observed in the majority of paediatric patients diagnosed with Beckwith-Wiedemann syndrome and surgical treatment may be indicated. A 20-year retrospective study was performed to evaluate all patients with Beckwith-Wiedemann syndrome who underwent tongue reduction surgery at the authors' institution. A literature review was performed. Surgical treatment was indicated and carried out in 23 patients with a yearly average varying from 0 to 3 subjects. The mean follow-up time was 7 years. Primary indications for surgical treatment of macroglossia included significant tongue protrusion in 30% (n=7), and a combination of clinical problems in 70% (n=16). In all cases, the procedure was performed by the same surgeon using an anterior, V-shaped, wedge resection technique. Two patients had direct postoperative complications. No recurrence of macroglossia was observed in this study. Reported clinical outcome during follow-up demonstrated a satisfactory resting tongue position in all patients. Review of the literature demonstrated variability in surgical indications and techniques, and postoperative outcome. The results of this study indicate that the anterior wedge resection is a simple, effective and safe technique in the surgical treatment of paediatric patients, diagnosed with Beckwith-Wiedemann syndrome, suffering from macroglossia.

Management of lymphatic malformations

Lymphatic malformation results from an error in the embryonic development of the lymphatic system. Clinically, lymphatic malformation is characterized by the size of the malformed channels: microcystic, macrocystic, or combined (microcystic/macrocystic).This article describes the clinical features, diagnosis, and management of lymphatic malformations.

Craniofacial and upper airway development

Development of the craniofacial and upper airway structures is a complex choreography of mesenchymal and epithelial tissues responding to soluble growth factors and transcription factors in a tightly regulated sequence. Interruption of the development process or mutation of required transcription or growth factors leads to congenital anomalies of the facial and airway structures. Oftentimes, these patients suffer life-long consequences, require multiple medical and surgical interventions, and have significant associated morbidity and mortality. Furthering our understanding of the basic developmental mechanisms of craniofacial and upper airway development will lead to improved diagnostic and treatment strategies to improve the care of these patients.