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Ear, Nose & Throat Center
Specialists of the Ear, Nose and Throat / Head and Neck Surgery / Facial Plastic Surgery
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Geographic Tongue ( Benign Migratory Glossitis )
Geographic tongue describes a map-like appearance of the tongue. This results from irregular, denuded patches on its surface. Geographic tongue is a psoriasis-like condition of the tongue resulting in the production of snaky white lines on the tops and sides, often with small parallel grooves adjacent to them. These lines "roam" around the tongue, changing locations or appearances on a weekly, sometimes daily, basis. Many times these lines slowly radiate from a central area of smooth red mucosa, i.e. the normal tongue papillae or "bumps" disappear temporarily. The latter appearance often imparts an appearance similar to that of a globe of the Earth, with irregular white lines representing outlines of continents, hence, the common name for this disease: geographic tongue. The pattern results from the loss of papillae (tiny finger-like projections on the surface of the tongue). This gives areas of the tongue flat spots, and thus a geographic appearance. These areas of papillae loss are said to be "denuded." Denuded areas may persist for more than a month. Occasional patients have no white lines but have instead smooth red patches, sometimes with small grooves at their edges.
Cause:
The etiology of benign migratory glossitis (geographic tongue) is unknown. This may represent an autoimmune response to toxins from a preceding bacterial infection; possibly a streptococcal toxin. It may represent a latent Epstien-Barr viral integration in the tongue with periodic immune response and tissue inflammation. In some patients an food or environmental allergy may be involved. Symptoms can be exacerbated by irritation from hot or spicy foods, alcohol, or tobacco. In some patients particular foods seem to be a trigger, especially cheese. No increased incidence has been noted with medication use. Geographic tongue may be a manefestation of psoriasis. It is found with increased frequency (10%) in persons with psoriasis of the skin. The great majority of those with oral involvement, however, lack psoriatic skin involvement. Approximately 1-2% of the population are affected, although most cases are so mild that they are never formally diagnosed. There are also associations with diabetes, anemia or atopy (asthma and/or eczema). Geographic tongue does seem to become more prominent during conditions of psychological stress. It may occur in any race, age or sex. However, it appears more commonly in females than males and more frequently in adults. Variation with the menstrual cycle suggests hormonal factors. Clustering within a family suggests genetic involvement. Although this is an inflammatory condition histologically, a polygenic mode of inheritance has been suggested because it is seen clustering in families. Associations with human leukocyte antigen DR5 (HLA-DR5), human leukocyte antigen DRW6 (HLA-DRW6), and human leukocyte antigen Cw6 (HLA-Cw6) have also been reported.
History:
Patients with geographic tongue may present with a burning sensation or an irritation of the tongue noted with hot or spicy foods. Migratory glossitis is usually without symptoms. Often the burning or tingling sensation is exacerbated by an opportunistic secondary fungus or bacterial infection. Patients may report that the discomfort waxes and wanes over time, and they routinely describe that the lesions affect different areas of the tongue at different times. Patients can be concerned about the diagnosis of oral cancer, which prompts them to be evaluated, despite reporting that they have noted these lesions over many years.
Physical:
The tongue exhibits a well-demarcated area of erythema, primarily affecting the dorsum, and often extending to involve the lateral borders of the tongue. Within the area of erythema, the normal tongue architecture is effaced, with loss of the filiform papillae and atrophy of the overlying mucosa. Surrounding this area of erythema is a well-defined, hyperkeratotic, yellow-white border with an irregular serpiginous outline. Similar lesions may be present concurrently on other aspects of the tongue or other mucosal sites.
Microscopic examination:
Microscopic examination typically shows a thickened layer of keratin infiltrated with neutrophils ( a type of white blood cells), as are lower portions of the tongue layers to a lesser extent. These inflammatory cells often produce small microabscesses, called Monro's abscesses, in the keratin and spinous layers. Rete ridges (the superficial covering of the tongue cells) are typically thin and considerably elongated, with only a thin layer of epithelium overlying connective tissue papillae. When rete ridges are not elongated, the physician should consider Reiter's syndrome as a diagnostic possibility.
Treatment:
There is no malignant potentialto this process. Frequently, no treatment is normally needed, but antifungal and antibacterial medications may be used to control symptoms. Topical or systemic cortisone or prednisone may also be effective. The “Standford mouthwash” is a solution composed of tetracycline, hydrocortisone, nystatin, and chlorpheramine which has emprically been shown to give symptomatic improvement. Unfortunately, the process frequently reoccurs requiring repeated treatments of the mouthwash. Some patients have found over the counter Vitamin supplements helpful. Traditional antiviral medications are generally not helpful. Antifungals such as nystatin or diflucan can give symptomatic improvement by preventing yeast (candida) overgrowth. Avoidance of food, tobacco or alcohol irritants is recommended.
WHAT IS OTOLARYNGOLOGY-HEAD AND NECK SURGERY ?
Otolaryngology-Head and neck surgery is a specialty concerned with the medical and surgical treatment of the ears, nose, throat and related structures of the head and neck. The specialty encompasses cosmetic facial reconstruction, surgery of benign and malignant tumors of the head and neck, management of patients with loss of hearing and balance, endoscopic examination of air and food passages, and treatment of allergic, sinus, laryngeal, thyroid and esophageal disorders. To qualify for the American Board of Otolaryngology certification examination, a physician must complete five or more years of post-M.D. specialty training. Dr. Culberson was certified as a Fellow of the American Board of Otolaryngology in 1990.
American Academy of Otolaryngology-Head and Neck Surgery, Inc. This leaflet is published as a public service. The material may be freely used for noncommercial purposes so long as attributation is given to the American Academy of Otolaryngology-Head and Neck Surgery, Inc. One Prince Street, Alexandria, VA 22314-3357
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