Manual of Surgery Volume II Part 56

_Sclerosing glossitis_ is the term applied by Fournier to a condition in which there is an abundant new formation of granulation tissue in the substance of the tongue, leading to the appearance of tuberous ma.s.ses on the dorsum. These tend to be oval in outline, are elevated above the normal mucous membrane, and present a dull red mammilated or lobulated surface, comparable to the surface of a cirrhotic liver.

They are firm, elastic, and insensitive.

A _gumma_ is usually situated on the dorsum and more often towards the centre than at the edges. As it seldom implicates the floor of the mouth or the base of the tongue, the tongue can usually be protruded freely. It forms an indolent swelling, which tends to break down slowly and to ulcerate. So long as it remains unbroken it does not cause pain, and there is no enlargement of the adjacent lymph glands.

Two forms are met with--the superficial, and the deep or parenchymatous.

A _superficial_ gumma appears as a small hard nodule under the mucous membrane, varying in size from a pin's head to a pea. The mucous membrane over it is redder than normal, and in the early stages retains its papillae but later becomes smooth. It tends to break down early, forming a superficial ulcer. Superficial gummas are often multiple.

The _deep_ or parenchymatous form varies in size from a hazel-nut to a walnut, and feels like a hard body in the substance of the tongue.

The mucous membrane over the swelling is of normal colour, but is usually devoid of papillae. The gumma may remain for months unchanged, or may approach the surface, soften, and break down, leaving a deep, ragged ulcer.

_Syphilitic ulcers and fissures_ are nearly always due to the softening and breaking down of gummas. The ulcers have seldom the typically rounded or serpiginous outline of gummatous ulcers on other parts of the body. The base is ragged and unhealthy, and on it a yellowish-grey slough resembling wash-leather may be seen. The edges are steep, ragged, and often undermined, and the surrounding parts thickened and indurated. The neighbouring glands are not usually enlarged. The ulcer is extremely painful when irritated by food, hot fluids, or spirits. If untreated, the sore may remain indolent and for months show no sign either of spreading or healing, but at any time it may become the seat of cancer.

Syphilitic fissures are met with as long, narrow, deep clefts, or as stellate or sinous cracks in the substance of the tongue. After the healing of these ulcers and fissures permanent furrows and depressed scars remain.

_Treatment._--The tertiary manifestations of syphilis in the tongue are treated on the same lines as other tertiary lesions. Locally, the use of mouth-washes, such as chlorate of potash or black wash diluted with lime-water, the insufflation of powdered iodoform and borax with a small quant.i.ty of morphin, or the application of mercurial ointment is useful. The sore must be thoroughly cleansed before these remedies are applied.

NEW GROWTHS

#Carcinoma# is by far the most common form of new growth met with in the tongue, and it is almost invariably a squamous epithelioma.

Epithelioma generally occurs between the ages of forty and sixty, and attacks males oftener than females, in the proportion of about six to one. Its development is favoured by any long-continued irritation, such as the rubbing of the tongue against a carious tooth, an ill-fitting tooth-plate, or the rough end of a short clay pipe, particularly when such irritation leads to the formation of an ulcer.

Chronic superficial glossitis a.s.sociated with leucoplakia, and syphilitic fissures, ulcers, or scars, also act as predisposing factors. The repeated application of strong caustics to chronic inflammatory conditions is, according to Butlin, a determining cause of cancer. The degree of malignancy appears to vary in different cases, and is probably lowest when the disease originates in a patch of leucoplakia or other pre-cancerous lesion.

The disease is usually situated in the anterior half of the tongue, and more commonly on the edge than on the dorsum. It may begin as an excoriation, ulcer, or fissure, or as a warty growth, particularly in a.s.sociation with a patch of leucoplakia. In all cases ulceration begins early, and the base of the ulcer and the surrounding parts become indurated. The lymph glands are, as a rule, early infected.

_Clinical Features._--The clinical appearances vary widely. Sometimes the surface presents a warty growth; sometimes it is excavated, forming a deep ulcer with raised nodular edges; in other cases the ulcer is smooth, and its edges even and rounded. Extreme hardness of the edges and base of the ulcer is always a characteristic feature.

The tongue tends to become fixed, especially when the disease spreads to the floor of the mouth, so that it cannot be protruded, and the restriction of its movement produces a characteristic interference with articulation, certain words being slurred, and when the fixation is extreme it may interfere with mastication and swallowing. The patient complains of a constant gnawing pain in the tongue, and of severe pain shooting along the branches of the trigeminal nerve, and especially towards the ear. In the advanced stages there is salivation and ftor of the breath.

When the disease is situated on the edge of the tongue it tends to spread to the floor of the mouth and the muco-periosteum of the mandible. If situated far back on the dorsum, it spreads on to the epiglottis, the pillars of the fauces, and the tonsil.

The neighbouring lymph glands--particularly those under the jaw and along the line of the carotid vessels--soon become infected and are palpable. The submaxillary and sublingual salivary glands are also liable to be affected. The enlarged cervical glands later undergo softening, or suppurate and burst on the skin surface, forming fungating ulcers. Metastasis to the liver, lungs, and other viscera is exceptional. If the disease is allowed to run its course, the patient usually dies in from twelve to eighteen months from repeated small haemorrhages, toxin absorption, or septic broncho-pneumonia.

_Differential Diagnosis._--Cancer of the tongue has to be diagnosed from syphilitic and tuberculous affections, from papilloma, and from simple ulcer and fissure. It is to be borne in mind that any of these conditions may take on malignant characters and develop into epithelioma. The microscopic examination of a portion of the growth removed under local anaesthesia from the base of the ulcer at some distance from its epithelial core is often the only certain means of establishing the diagnosis, and should be had recourse to as early as possible. When there is still doubt as to the nature of the growth, it should be treated as if it were cancerous.

An unbroken gumma is liable to be confused only with the uncommon form of epithelioma which begins as a nodule under the mucous membrane.

Gumma, however, are often multiple, and the tongue shows old scars or other evidence of syphilis.

Gummatous ulcers are usually situated on the dorsum, are frequently multiple, and have sloughy, undermined edges; the surrounding parts, although indurated, are not so densely hard as in cancer; there is not necessarily any involvement of lymph glands. The cancerous ulcer is usually single and situated on the margin of the tongue; its edges are hard, raised, and nodular; and the glands are usually enlarged and hard. Little reliance is to be placed on the therapeutic effects of anti-syphilitic drugs in the differential diagnosis, as they are often inconclusive, and their use results in loss of time.

Tuberculous ulcers usually occur in a.s.sociation with other and unmistakable evidences of tuberculosis. A papilloma, when sessile, may simulate cancer; these tumours show a marked tendency to become malignant. Simple ulcers and fissures are usually recognised by the history of the condition, the absence of induration and of glandular involvement, and by the fact that they heal quickly on removal of the cause.

_Treatment._--The only treatment that offers any hope of cure is free removal of the disease, and experience has proved that unless this is done early the prospect of the cure being a radical one is remote. Not only must the segment of the tongue on which the growth is situated be widely excised, but all the lymphatic connections must also be removed whether the glands are palpably enlarged or not.

The chief risk after operation is pneumonia resulting from the inhaling of blood and products of infection: hence the importance of rendering the mouth as dry and as sweet as possible before operation, special attention being paid to the teeth, and precautions being taken at the operation to prevent the pa.s.sage of blood down the trachea. The patient is usually able to be out of bed on the second or third day, and is well in a fortnight or three weeks. The operation, even when followed by recurrence, usually prolongs life by six or eight months, and renders the patient more comfortable by removing the foul ulcer from the mouth. The speech, although impaired by the removal of one-half or even more of the tongue, is distinct enough for ordinary purposes. When recurrence takes place it is usually in the glands, and may be attended with great suffering.

_Treatment of Inoperable Cases._--The mouth must be kept as sweet as possible. The pain may be relieved to some extent by cocain or orthoform, but as a rule the free administration of morphin is called for. Pain shooting up to the ear may be relieved by resection of the lingual nerve, or the injection of alcohol into its substance. If haemorrhage takes place from the ulcerated surface and cannot be controlled by adrenalin, or other local styptics, it may be necessary to ligate the lingual, or even the external carotid artery.

Interference with respiration may necessitate tracheotomy. When the patient has difficulty in taking food, recourse should be had to the use of the stomach-tube or to gastrostomy. The use of radium or of the X-rays appears to have a restraining influence on the disease in the glands, but has not proved curative.

#Sarcoma# of the tongue is rare, and is sometimes met with in children. The round-cell type is the most common; it grows rapidly, and tends to ulcerate and fungate, pain becoming severe when the growth has broken down. The diagnosis is always difficult, and is seldom made until a portion of the growth has been removed and examined microscopically. The more slowly growing forms, if removed before ulceration has taken place, show little tendency to recur, but those which grow rapidly and break down, not only recur locally, but are liable to give rise to metastases. The treatment is the same as for cancer; the use of radium is more likely to be beneficial than in epithelioma.

#Innocent Tumour and Cysts.#--_Lipoma_, _fibroma_, and various forms of _angioma_ (Fig. 258) are occasionally met with. They are all of slow growth, and give rise to inconvenience chiefly by their bulk, and should be removed.

[Ill.u.s.tration: FIG. 258.--Papillomatous Angioma of left side of tongue in a woman aged 26.]

_Papilloma_ may occur on any part of the tongue, and at any age. It may be single or multiple, pedunculated or sessile, and is liable to become malignant, especially when a.s.sociated with leucoplakia. It should be freely removed by excising a wedge-shaped portion of the tongue.

_Dermoid_ cyst is met with beneath the tongue, lying in the middle line, between the genio-glossi (genio-hyoglossi), and on the upper surface of the mylo-hyoid muscles. It may be noticed soon after birth, or may only attract attention during adult life. The cyst usually projects under the chin, forming a soft swelling of putty-like consistence, which varies in size from a pigeon's to a turkey's egg (Fig. 259). When it bulges towards the mouth it is liable to be mistaken for a retention cyst of one of the salivary glands. It is distinguished by its medial position, its yellow colour, and its opacity, the retention cyst being to one side of the middle line, purplish in colour, translucent and fluctuating. The cyst should be dissected out, either from the mouth or from under the chin, according to circ.u.mstances.

[Ill.u.s.tration: FIG. 259.--Dermoid Cyst in middle line of neck.

(Mr. J. W. Struthers' case.)]

A _sebaceous cyst_ may reach such dimensions as to simulate a dermoid or thyreo-glossal cyst.

_Hydatid and cysticercus cysts_ have also been met with in the tongue.

#Thyreo-glossal Tumours and Cysts.#--Tumours may develop in the embryonic tract which pa.s.ses from the isthmus of the thyreoid gland to the foramen caec.u.m at the base of the tongue--the thyreo-glossal tract of His. They have the same structure as the thyreoid gland, and occupy the dorsum of the tongue, extending from the foramen caec.u.m backwards towards the epiglottis, in some cases attaining considerable size. They are of a bluish-brown or dark red colour, and are liable to repeated attacks of haemorrhage. These tumours sometimes become cystic, the cysts being lined with ciliated epithelium and containing colloid material. Bleeding may take place into a cyst, causing it to become suddenly enlarged, or the cyst may burst and the blood escape into the mouth. These variations in size and repeated attacks of bleeding help to distinguish thyreo-glossal cysts from other swellings of the tongue. Treatment is only called for when the swelling causes interference with speech or swallowing; it consists in removing the tumour by dissection.

When the lower end of the tract becomes cystic it forms a swelling in the neck (p. 583).

#Malformations.#--Complete or partial _absence_ of the tongue is exceedingly rare.

Occasionally the fore part of the tongue is _bifid_. The function of the organ is not interfered with, and the operation of paring and suturing the two halves is only called for on account of the disfigurement.

_Congenital tongue-tie_ is a condition in which the tip of the tongue is bound down to the floor of the mouth by an abnormally short and narrow frenum, or by folds of mucous membrane on each side of the frenum, so that the tongue cannot be protruded. Although this deformity is rare, it is common for parents to blame an imaginary tongue-tie when a child is slow in learning to speak, or when he speaks indistinctly or stammers, and the doctor is frequently requested to divide the frenum under such circ.u.mstances. In the vast majority of cases nothing is found to be wrong with the frenum. In the rare cases of true tongue-tie the edges of the shortened bands should be snipped with scissors close behind the incisor teeth, and then torn with the finger-nail.

_Excessive length_ of the frenum is occasionally met with, and in children may allow of the tongue falling back into the throat and causing sudden suffocative attacks, one of which may prove fatal. In some cases the patient is able voluntarily to fold the tongue back behind the soft palate.

_Macroglossia_ is the term applied to a variety of conditions in which the tongue becomes unduly large, so that it tends to be protruded from the mouth, and to become scored by the teeth. The typical form--lymphangiomatous macroglossia--is due to a dilatation of the lymph s.p.a.ces of the tongue. It is often congenital, and may affect the whole or only a part of the tongue. The enlargement may be progressive from the first, or may remain stationary for years, and then begin to develop somewhat suddenly, sometimes after an injury or as a result of some infective condition. The treatment consists in removing a wedge-shaped portion of the tongue.

In certain cases of macroglossia in children, the lesion has been found to be a fibromatosis of the nerves of the tongue, a.n.a.logous to the plexiform neuroma.

_Atrophy_ of the tongue is rare as a congenital condition.

Hemi-atrophy occurs in various diseases of the central nervous system, as well as after injuries and diseases implicating the hypoglossal nerve.

#Nervous Affections of the Tongue.#--_Neuralgia_ confined to the distribution of the lingual nerve is comparatively rare. It usually yields to medical treatment, but in inveterate cases it is sometimes necessary to resect the nerve.

It is more common to meet with a condition in which the patient complains of severe burning or aching pain in the region of the foliate papilla, which is situated on the edge of the tongue just in front of the anterior pillar of the fauces. The patient is usually a middle-aged, neurotic woman, and often with a gouty or rheumatic tendency. The pain, for which it is seldom possible to discover any cause, is usually worst at night, and may last for months, or even years. The practical importance of the condition is that, as the foliate papilla is prominent and red, it is liable to be mistaken on superficial examination for a commencing epithelioma. An inspection of the opposite side of the tongue, however, will reveal an exactly similar condition, which is not painful. The first and most important step in treatment is to a.s.sure the patient that the condition is not cancerous. Caustics and other irritating applications are to be avoided.

_Spasm_ of the tongue sometimes occurs after injuries of the head implicating either the centre or the trunk of the hypoglossal nerve.

It may also appear as a reflex condition in infective affections of the teeth and gums, or as a manifestation of some general disease of the central nervous system.

_Paralysis_ of the tongue--unilateral or bilateral--may be due to injury or disease of the nerve centres of the hypoglossal nerve, more frequently to injury of or pressure on the nerve-trunk. The nerve may be bruised or divided in operations for the removal of tuberculous glands or other tumours in the neck. When the tongue is protruded it deviates towards the paralysed side, being pushed over by the active muscles of the opposite side (Fig. 260), and speech and mastication may be interfered with. The paralysed half of the tongue subsequently undergoes atrophy, but the functional disability largely disappears.

[Ill.u.s.tration: FIG. 260.--Temporary Unilateral Paralysis of Tongue, from bruising of hypoglossal nerve during operation for tuberculous cervical glands.]