Tongue necrosis secondary to giant cell arteritis

Tongue necrosis is a rare clinical finding because of its rich vascularisation. Giant cell arteritis (GCA) is the most frequent cause of it, and when present, it is usually one side affected. We describe a patient with several months of constitutional syndrome; during that period, she develops headache followed by tongue necrosis, which lead to clinical suspicion of GCA, later confirmed by a temporal artery biopsy. Before the biopsy, she was treated with corticosteroids. We discuss this illness and tongue necrosis as a rare manifestation to consider.

Prevalence of feline chronic gingivostomatitis in feral cats and its risk factors

OBJECTIVES

This study investigated the prevalence of feline chronic gingivostomatitis in urban feral cats in South Korea and analysed its risk factors.

METHODS

Three hundred and forty-five feral cats that visited the hospital for neutering using a trap-neuter-return approach were screened for feline chronic gingivostomatitis based on clinical criteria. In addition, we determined if body weight, sex and the presence of tongue lesions are risk factors for feline chronic gingivostomatitis. The difference in severity due to the presence or absence of risk factors, and the relationship between gross findings and histopathological lesions, were analysed by grading lesion severity.

RESULTS

Feline chronic gingivostomatitis was diagnosed in 92 cats. Disease prevalence did not significantly differ with body weight and sex but was significantly related to tongue lesions.

CONCLUSIONS AND RELEVANCE

The prevalence of feline chronic gingivostomatitis in urban feral cats in South Korea was 26.6%. It was significantly more prevalent in cats that had tongue lesions. Severity was also significantly associated with tongue lesions. Feline chronic gingivostomatitis may be associated with an infectious agent that causes tongue lesions.

Pseudotumoral calcinosis of the spine in systemic sclerosis - an atypical location

Pseudotumoral calcinosis, particularly around the spine, is a rare complication of systemic sclerosis (SSc). The authors report a case of a 60-year-old woman with a limited cutaneous SSc observed for a 4-month history of back pain. Physical examination revealed a left paravertebral mass measuring around 7cm in the longest axis. The computed tomography (CT) showed the presence of calcified mass in the left paravertebral muscle, extending from the 12th dorsal to the 3rd lumbar vertebra. A diagnosis of pseudotumoral calcinosis secondary to SSc was made. Symptomatic treatment with analgesics allowed a significant improvement of clinical symptoms. Subcutaneous calcinosis is a common complication of SSc, however the pseudotumoral form remains extremely rare, particularly around the dorsolumbar spine. Treatment is limited to analgesic therapy or, in more severe cases, to surgical excision. Follow-up should be conducted to rule out complications.

[Ectopic thyroid gland: clinical features and diagnostics in children]

BACKGROUND

BACKGROUND: The frequency of ectopia of thyroid gland among all types of dysgenesis varies from 30 to 70%, its most common localization is the root of the tongue. Otorhinolaryngologists, oncologists, pediatricians can take lingual ectopia for hypertrophy of the lingual tonsil or fibroma of the tongue root, which leads to unreasonable surgical treatment. Thyroid scintigraphy plays a key role in the diagnosis of ectopia.

AIM

AIM: To assess the etiological structure of congenital hypothyroidism (CH) and demonstrate the clinical course in patients with ectopic thyroid tissue in the root of the tongue.

MATERIALS AND METHODS

MATERIALS AND METHODS: A group of patients with CH was examined. All patients underwent neck ultrasound and radionuclide imaging. The examination was carried out against the background of the abolition of hormone replacement therapy for 14 days or before its initiation. Patients with ectopia in the root of the tongue underwent videofibrolaryngoscopy. Some patients underwent a genetic study with using genes panel of a panel of candidate genes responsible for the development of CH using the NGS method. The molecular genetic study was conducted to some patients, next-generation sequencing with the genes panel.

RESULTS

RESULTS: The study included 73 patients with primary CH aged from 2 weeks to 17.3 years: 69 children were diagnosed based on the results of neonatal screening, 4 children with thyroid ectopia were first examined older than 6 years. The median age of patients at the time of the examination was 6.9 years [4.8; 10.0]. By data of ultrasound aplasia was diagnosed in 47.9% of patients, one child had hemiagenesis and ectopic thyroid tissue of various localization was detected in 26.0% of  children. In 24.7% of children thyroid tissue was found in a typical location. Scintigraphy confirmed thyroid aplasia in 65.7% of children. Examination revealed various variants of ectopically located thyroid tissue in 31 children (42.4%): thyroid ectopia in the root of the tongue in 25 children (80.6%), ectopia in the sublingual region in 5 children (16.2%), double ectopia was detected in 1 child. The median level of TSH in newborns with ectopic thyroid gland was 124 IU/ml and was significantly lower than in children with aplasia — 219 IU/ml, p<0.05. On the other side the level of TG in children with ectopia was significantly higher than in children with aplasia — 37.12 ng/ml versus 0.82 ng/ml, p><0.05. CONCLUSION: Combination of two methods is the best diagnostic approach to determine the etiology of CH — ultrasound and scintigraphy studies compensates deficiencies of each other. Our study demonstrates the importance of scintigraphy in children with CH and patients with the formation of the root of the tongue and the anterior surface of the neck in order to avoid unnecessary removal of the thyroid gland. In case of confirmation of thyroid ectopia in the root of the tongue and in the absence of symptoms of obstruction or bleeding, it is recommended to refer the patient to an endocrinologist for conservative treatment. ><0.05. On the other side the level of TG in children with ectopia was significantly higher than in children with aplasia — 37.12 ng/ml versus 0.82 ng/ml, p< 0.05.

CONCLUSION

CONCLUSION: Combination of two methods is the best diagnostic approach to determine the etiology of CH — ultrasound and scintigraphy studies compensates deficiencies of each other. Our study demonstrates the importance of scintigraphy in children with CH and patients with the formation of the root of the tongue and the anterior surface of the neck in order to avoid unnecessary removal of the thyroid gland. In case of confirmation of thyroid ectopia in the root of the tongue and in the absence of symptoms of obstruction or bleeding, it is recommended to refer the patient to an endocrinologist for conservative treatment.

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE): a rare presentation and case report

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a rare, benign, and self-limiting ulcerative lesion, with the tongue being the most common site of occurrence and traumatic inflictions being the common etiology. Case report: A 45-year-old female reported to the dental operatory with a complaint of pain on the left side of her tongue for the past 8 months. Her history revealed that a small ulcer had gradually grown to be 2 cm x 1.5 cm on presentation. She indicated that the ulcer often interfered with her maxillary left canine while occluding. She also gave a history of a tobacco chewing habit for 15 years which she stopped 6 years ago. Clinically she had a single erythematous ulcer with irregular borders and raised margins. The client was treated with surgical excision of the lesion. The excised lesion was confirmed histologically to have eosinophil rich cells and was diagnosed as TUGSE. Conclusion: TUGSE should be recognized and not neglected as it closely resembles malignancies of the oral cavity. It also has a good prognosis and heals rapidly after the surgical excision or on its own with time, which may range from a few weeks to a year.

The tongue features associated with type 2 diabetes mellitus

Diabetes mellitus (DM) is a public problem closely associated with numerous oral complications, such as coated tongue, xerostomia, salivary dysfunction, etc. Tongue diagnosis plays an important role in clinical prognosis and treatment of diabetes in the traditional Chinese medicine (TCM). This study investigated discriminating tongue features to distinguish between type 2 DM and non-DM individuals through non-invasive TCM tongue diagnosis.The tongue features for 199 patients with type 2 DM, and 372 non-DM individuals, serving as control, are extracted by the automatic tongue diagnosis system (ATDS). A total of 9 tongue features, namely, tongue shape, tongue color, fur thickness, fur color, saliva, tongue fissure, ecchymosis, teeth mark, and red dot. The demography, laboratory, physical examination, and tongue manifestation data between 2 groups were compared.Patients with type 2 DM possessed significantly larger covering area of yellow fur (58.5% vs 22.5%, P < .001), thick fur (50.8% vs 29.2%, P < .001), and bluish tongue (P < .001) than those of the control group. Also, a significantly higher portion (72.7% vs 55.2%, P < .05) of patients with long-term diabetics having yellow fur color than the short-term counterparts was observed.The high prevalence of thick fur, yellow fur color, and bluish tongue in patient with type 2 DM revealed that TCM tongue diagnosis can serve as a preliminary screening procedure in the early detection of type 2 DM in light of its simple and non-invasive nature, followed by other more accurate testing process. To the best of our knowledge, this is the first attempt in applying non-invasive TCM tongue diagnosis to the discrimination of type 2 DM patients and non-DM individuals.

[Failures and tongue rehabilitation]

When confronted with difficult-to-eradicate dysfunctions and parafunctions, speech therapy most often proves a reliable ally to control the functional environment of the dental arches. However, a number of factors ranging from psychological issues to anatomical ENT obstructions, from genetic anomalies to iatrogenic procedures, account for the occasional mixed results achieved using this approach. In addition, our own treatment results can also be jeopardized or even obliterated by a recalcitrant tongue or one which has been inadequately provided for. The author will analyze the different factors involved through a series of clinical cases in order to outline her thinking regarding this organ, which can be either a driving force behind our treatments or a force for destruction.

Pigmented fungiform papillae of the tongue (PFPT)

A 12-year-old African girl presented with multiple, sharply bordered hyperpigmented patches predominantly on the dorsal, tip and lateral aspects of the tongue since 1 year (Figs 1 and 2). On clinical examination, we found an obese adolescent girl with a BMI: 26.5 kg/m(2) ( > P97) with acanthosis nigricans of the neck. No medications were taken. Vitamin B12, liver tests and kidney function were normal. There was a decreased serum iron, 25OH vitamin D and zinc. Hyperinsulinism and heterozygosity for HbS (32%) were detected. Menarche: 12 years. No other family members were known with this anomaly.

An unusual presentation of a lingual dermoid cyst

Dermoid cysts are rare lesions of the head and neck that usually present in children as an asymptomatic, slowly growing mass. We report a case that demonstrates that dermoid cysts can present later in life as a recurrent acute infection. Our patient was a 48-year-old man with a 22-year history of recurrent abscesses of the tongue and floor of the mouth that had required a tracheotomy and multiple hospitalizations. Magnetic resonance imaging performed between acute episodes revealed the presence of a 1.8-cm lesion within the tongue musculature. The patient underwent resection, and pathology was consistent with a lingual dermoid cyst. At 2 years of follow-up, he experienced no recurrence of symptoms.

Ectopic salivary gland of the base of the tongue: a rare cause of neonatal respiratory distress

Neonatal upper airway obstruction is a life-threatening condition and requires rapid assessment and effective treatment. Malformations of the upper airway of a newborn can lead to acute respiratory distress. The aim of the present paper is to report the case of a newborn with respiratory distress due to a tongue base mass, which was removed surgically. The patient needed a tracheostomy tube for only three days and then could breathe spontaneously. However, he had swallowing problems, which decreased gradually over 9 months. Histopathologically, the mass was found to consist of mucous salivary glands, and was recorded as an ectopic salivary gland, which is extremely rare among the types of masses that may cause upper airway obstruction in a newborn.

Reversible oro-lingual dyskinesia related to lithium intoxication

PURPOSE

To report the first case of Taiwanese with lithium intoxication presenting as oro-lingual dyskinesia.

CASE REPORT

A 68-year-old man had bipolar disorder with chronic lithium treatment. He had acute conscious disturbance, atrial flutter, myoclunus of limbs, and oro-lingual dyskinesia. Biochemistry study revealed elevated blood urea nitrogen, creatinine, and lithium level (3.43 Eq/L). The lithium is discontinued and he received conservational treatment. Along with reduction of serum lithium level, his involuntary movement subsided following by clear consciousness. He had no residual neurological deficit in 3 years of follow up.

CONCLUSION

Oro-lingual dyskinesia is a rare presentation of lithium intoxication. This case reminds us such diagnostic possibilities especially in elder patients who receive a chronic lithium therapy.

Long-term results of brachytherapy in early mobile tongue cancer with 10-year minimal follow-up

AIM

To retrospectively analyze the long-term toxicities of low-dose-rate interstitial brachytherapy (LDR-BT) with related prognostic factors for patients with early mobile tongue cancer (T1/2N0M0) at a minimum of 10 years' follow-up.

PATIENTS AND METHODS

The records of 187 patients treated with LDR-BT between 1980 and 2000, out of whom 25 were treated with additional prior external beam irradiation, were reviewed.

RESULTS

Overall survival at 15 and 20 years was 88.4% and 76.2%, respectively. Complications included tongue ulcer (26%), tongue erosion (3%), tongue atrophy (2%), bone exposure (15%), and osteoradionecrosis (4%). No patient presented xerostomia or taste disorders. Multivariate analysis revealed that tongue ulcer and the use of spacer were significantly associated with bone exposure and osteoradionecrosis. Local recurrence was demonstrated in 15 (8%) cases, 93% of which were salvaged by operation. Fifty patients (27%) experienced neck metastasis.

CONCLUSION

LDR-BT is an acceptable treatment option, with low rates of long-term toxicity.

Lingual thyroid: a rare cause of difficult intubation

This case report is about a patient with an oropharyngeal mass presenting to our hospital for biopsy under general anesthesia. Because of the great risk of failure of mask ventilation and direct laryngoscopy, an awake fiberoptic intubation was performed successfully. The biopsy revealed a thyroid tissue leading to the diagnosis of ectopic lingual thyroid.

Follicular variant of papillary carcinoma arising from lingual thyroid

Malignant transformation of ectopic lingual thyroid tissue is an uncommon event; only 43 cases have been reported in the literature. Only 10 of these cases were papillary carcinomas, in contrast to normal thyroid gland neoplasms, of which papillary tumors form the predominant group. We present a case of a follicular variant of papillary carcinoma originating from the lingual thyroid, along with a review of the literature. Our patient was treated with surgical excision followed by (131)I therapy. To date, only 2 other cases of a follicular variant of lingual thyroid tumor have been reported.

Infected lingual osseous choristoma. Report of a case and review of the literature

Osseous choristoma is a rare, benign lesion of the oral cavity occurring usually in the tongue. It appears as a tumorous mass of normal bony structure with mature cells in an ectopic position. The case of a 72 years Caucasian male is presented and analyzed along with 52 similar cases reported in the English literature between 1967 and 2007. Lingual choristoma shows a female predilection, whereas the commonest anatomic location is the posterior third of the tongue, occurring at or close to the foramen caecum and the circumvallate papillae. Histologically the lesions show signs of a well-circumscribed mass of vital bone located under the surface oral epithelium. Some lesions represent developmental malformations, whereas others may be reactive lesions after trauma or chronic irritation. Treatment of lingual osseous choristoma consists of simple excision.

Lingual hematoma threatening airway obstruction in a patient on oral anticoagulation with warfarin

Warfarin sodium is a commonly used oral anticoagulant agent. It has been well documented that, when effective anticoagulant therapy is employed in treating thromboembolic disease, hemorrhage is a possible complication that can be spontaneous without a history of trauma. The numerous sites of bleeding are the genitourinary and gastrointestinal tracts, the central nervous system, the nose (epistaxis), the penis (priapism), the retroperitoneum, wounds (surgical or traumatic), and subcutaneous tissues during warfarin therapy, but the hemorrhage rarely causes bleeding compromising a patient's airway. We report a case of a spontaneous lingual hematoma that developed during oral anticoagulation therapy. This life-threatening complication of warfarin therapy and its successful management without surgery indicates that observation, close monitoring and reversal of anticoagulation can be a reasonable management option.

Partial atrophic tongue other than median rhomboid glossitis

A group of 23 patients with partial atrophic change of the tongue was examined for candidiasis. All of them reported pain in the tongue on eating hot or spicy food. The intensity of the tongue pain was evaluated before and after treatment using a visual analogue scale. Of the 23 patients, 10 (43.5%) had predisposing factors for candidiasis such as diabetes mellitus and anaemia. In the culture examination, candidal species were isolated in 65.2%, all Candida albicans. Direct cytological examination performed in 10 of the 23 patients revealed fungal pseudohyphae in 8 patients. After antifungal treatment, tongue pain had disappeared or improved markedly in 82.6%. Simultaneously, the filiform papilla of the atrophic site was observed to have begun to regenerate in these patients. Candida infection should be suspected in patients with partial atrophic tongue associated with pain on eating.

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.

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.

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.