Must Know Tongue Anatomy &

Pathology:
MCQs pt 2

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Q. A 67 yo female with a non-specific headache of 2 days duration now presents
with a painful lesion on her tongue. She has a low grade fever, neck discomfort
and malaise. She is on no medications, does not smoke or drink and except for
hypertension has been healthy. The image of her tongue is shown. what study
would you order next in her?

a. Tongue biopsy
b. Blood cultures
c. CT scan of the head and neck
d. ESR and CRP levels
e. CXR
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d
• The manifestations of GCA include headache in 90% of cases, polymyalgia
rheumatica (34%), jaw claudication (50%), amaurosis fugax, and blurred
vision (40%). Other findings include fever, increased erythrocyte
sedimentation rate, leukocytosis, and abnormalities in the temporal artery.
Ocular symptoms should also be highlighted due to the risk of vision loss, for
which treatment should be instituted promptly .
• Lingual manifestations such as edema, pallor, pain, and intermittent
claudication occur in up to 25% of cases and can be associated with a greater
risk of ischemic complications. However, tongue necrosis is rare, given the
rich blood supply to this tissue. GCA with tongue and/or scalp necrosis tends
to occur more in older people and develops with more visual symptoms
• The laboratory hallmarks of GCA include elevation in the erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP) level and thrombocytosis.
The ESR usually exceeds 50 mm/h and may exceed 100 mm/h, but may be normal
in 7-20% of patients with GCA
• GCA is known to cause severe tongue necrosis.
• of course, a temporal artery biopsy is next.
Q. A 65 yo presents with difficulty sleeping of 10 months duration. Exam
of his tongue reveals loss of papillae on the surface. If the tongue
enlargement is due to the most common cause in adults, what is the first
study you will order?

a. TSH levels
b. Pulse oximetry
c. Biopsy with Congo red stain
d. Chromosomal analysis
e. Barium swallow
c
• In adults, the most common cause of macroglossia is amyloidosis.
• Amyloidosis is a group of disorders characterized by extracellular deposition of
insoluble amyloid fibrils within tissues. This deposition of amyloid can be either
localized or systemic. The most common form of systemic disease is light chain
(AL) amyloidosis, which results from the deposition of monoclonal
immunoglobulin light chains.
• Amyloid involvement of the tongue is almost always secondary to systemic AL
amyloidosis and can occur in up to 40% of cases . Serious respiratory, eating and
speech problems can be caused by a lingual involvement. Treatment of this
condition is controversial and challenging.
Q. While walking past the Peds floor, you notice an infant with a
massively enlarged tongue. The pediatrician believes the infant has
a genetic disorder that is the most common cause of macroglossia.
What complications are these infants at risk for in life?

a. Dysplastic hips
b. Club foot
c. Neoplasms
d. Spina bifida
e. Osteomyelitis
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c
• In general, macroglossia, meaning large tongue, refers to the protrusion of the
tongue beyond the alveolar ridge or teeth
• Evaluation in patients with macroglossia should always start with a thorough
history in order to identify any undiagnosed acquired or congenital conditions.
• if macroglossia is caused by amyloidosis, microscopic examination with Congo red
staining may be warranted, showing classic apple-green birefringence under
polarized light. Thyroid function tests can also be obtained when hypothyroidism
is suspected. Laboratory studies can also be ordered to evaluate for angioedema.
• Macroglossia, a large tongue, is a very common (>90%) and prominent feature of
BWS. Infants with BWS and macroglossia typically cannot fully close their mouth
in front of their large tongue, causing it to protrude out.
• Most children (>80%) with BWS do not develop cancer; however, children with
BWS are much more likely (~600 times more) than other children to develop
certain childhood cancers, particularly Wilms' tumor (nephroblastoma),
pancreatoblastoma, and hepatoblastoma. Individuals with BWS appear to only be
at increased risk for cancer during childhood (especially before age four) and do
not have an increased risk of developing cancer in adulthood.
Q. This patient underwent carotid artery endarterectomy 24 hours
ago. During surgery, the hypoglossal nerve was damaged. Which
side was the patient’s surgery?
a. Left
b. Right
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left
• Hypoglossal nerve damage on one side produces flaccid paralysis of
the ipsilateral tongue musculature, accompanied by atrophy.
• An attempt to protrude the tongue results in deviation of the tongue
toward the weak side because of the unopposed actions of the intact
genioglossus muscle.
Q. In general, if a patient presents with a cancer
of the tongue, where would the location be?
A
B
C
D
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d
Squamous cell carcinoma (SCC) of the anterior two thirds of the tongue is the
second most common oral cancer, with the lateral border being the most
common location.
Squamous cell carcinoma of the dorsum of the tongue is exceedingly rare and
has been described in the past as a myth or misdiagnosis.
The clinical diagnosis of SCC on the dorsum of the tongue is difficult because it
may be mimicked by a wide variety of benign and premalignant lesions,
including granular cell myoblastoma, erosive lichen planus, medial rhomboid
glossitis, and amyloidosis. In this study we re-evaluate the entity of SCC of the
dorsum of the tongue.
Q. A 57 yo heavy smoker and drinker presents with a 2-month
history of a lesion on his tongue. If a malignancy is suspected,
which of the following workups may not be useful?
a. Chest x-ray
b. CT of head and neck
c. Bone scan
d. Biopsy
e. Panendoscopy
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c
• Because the incidence of distant metastases at presentation is low, the only laboratory
workup needed should be directed at the evaluation of the patients' underlying chronic
medical conditions. A complete blood count (CBC) is a useful general screen that helps
the consulting internist establish if further testing is warranted.
• Radiologic evaluation with computed tomography (CT) scanning and magnetic
resonance imaging (MRI) has revolutionized the assessment of patients with head and
neck tumors. Because of the higher soft tissue resolution with an MRI scan, the
assessment of the mobile tongue may be facilitated with this modality.
• Diagnostic procedures include tumor biopsy and panendoscopy, although routine use of
the latter, which includes a bronchoscopy, an esophagoscopy, and a laryngoscopy, has
been the subject of much controversy.
• Because risk of mets is non existent, a bone scan is not done.
Q. The nerve that supplies sensation to the area of the tongue
marked by the arrow, has its primary cranial nerve exit the skull via
what foramen?
a. Lacerum
b. Magnum
c. Ovale
d. Rotundum
e. Stylomastoid
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3wnYbiN0yDo
e
• The facial nerve, also known as the seventh cranial nerve, cranial nerve VII, or
simply CN VII, is a cranial nerve that emerges from the pons of the brainstem,
controls the muscles of facial expression, and functions in the conveyance of taste
sensations from the anterior two-thirds of the tongue.
• The nerve typically travels from the pons through the facial canal in the temporal
bone and exits the skull at the stylomastoid foramen.
• It arises from the brainstem from an area posterior to the cranial nerve VI
(abducens nerve) and anterior to cranial nerve VIII (vestibulocochlear nerve).
Q1. A 28 yo smoker presents with a 2 month history of painless
lesion on his tongue. He is on no medications and is otherwise
healthy. Your most likely diagnosis is?
a. Candida
b. Oral hairy leukoplakia
c. Geographic tongue
d. Lichen planus
e. Squamous cell cancer
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Q2. How can you tell if the lesion is candida or oral hairy
leukoplakia on the physical exam?

a. Candida lesions are intense

white
b. OHL lesions cannot be scrapped
c. Candida lesions only occur at
the side
d. OHL lesions have a rough
texture
e. OHL lesions are tender to touch
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1b,2b
• Patients with oral hairy leukoplakia (OHL) may report a non-painful white plaque
along the lateral tongue borders. The appearance may change daily. The natural
history of hairy leukoplakia is variable. Lesions may frequently appear and
disappear spontaneously. Hairy leukoplakia is often asymptomatic, and many
patients are unaware of its presence.
• Lesions may be either continuous or discontinuous along both tongue borders,
and they are often not bilaterally symmetric. Lesions are adherent, and only the
most superficial layers can be removed by scraping. There is no associated
erythema or edema of the surrounding tissue.
• Candida lesions usually cause discomfort that is worse when eating spicy foods
and hot beverages.
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