Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4440_Библиотеки_им_академика_М_И_Перельмана.pdf
260
approximately 250 buds each, for an average of 3000 total buds. Cranial nerve IX
innervates these, along with the entire posterior one-third of the tongue.
Foliate papillae—Reside in folds and
clefts at the lateral borders of the tongue,
with approximately 1280 buds. Cranial
nerve IX innervates these buds.
Filiform papillae—Have no taste buds.
Other locations of taste buds include the
following:
• Soft palate—Innervated by CN VII via
the greater supercial petrosal nerve
• Epiglottis and larynx—Supplied by the
superior laryngeal branch of CN X
• Pharynx—Supplied by branches from
CN IX and CN X
How to Examine
The tongue is examined using both direct
and indirect vision (use the mirror to examine the postero-lateral borders and posterior part of the tongue). To observe the
lateral border, the examiner grasps the tip
of the tongue with a gauze square and rolls
the tongue over on one side to observe the
lateral border and then repeats for the other
side. Ask the patient to touch the tip of the
tongue to the roof of the mouth to inspect
the ventral surface. Ask the patient to protrude the tongue straight out and inspect for
deviation, colour, texture and masses. The
movements are noted in all directions.
1. Inspection of Tongue
General appearance—The tongue tissues
should appear pink in colour with a rough surface texture on the dorsal surface and a
smoother surface texture on the ventral surface. The tongue should be symmetrical in
shape and in function.
(a) Gross appearance of the tongue
6 History andExamination ofLip andOral Cavity
• Fissured tongue—A ssured tongue is
marked by a deep, prominent groove
in the middle. There may also be small
furrows or ssures across the surface,
causing the tongue to have a wrinkled
appearance. It affects the dorsal surface of the tongue.
• Hairy tongue—It is an abnormal coating
on the top (dorsal) surface of the tongue.
• Geographical tongue—It appeared as
smooth, red patches of varying shapes
and sizes. It is the loss of papillae over
the dorsum of the tongue.
• Smooth tongue—It appears bald and
thin due to the loss of papillae. The
tongue is tender and sensitive to
touch—a classic smooth, beefy red
tongue from vitamin B12 deciency.
• Coated tongue (Fig.6.5)
– Thick yellow coating—It is discol-
ouration of the tongue caused by
poor hygiene, tobacco chewing and
drugs
– White-coated tongue—Improper
oral hygiene, antibiotics, alcohol,
oral thrush (candidiasis), trauma to
tongue, xerostomia, leukoplakia
– Black-coated tongue—Hairy leu-
koplakia, vitamin niacin deciency
– Red-coated tongue—Folic acid
deciency, vitamin B12 deciency
(b) Type of tongue
• Hairy tongue
• Oral hairy leukoplakia—It is dened
as a patched side or dorsum of the
tongue that gives a hairy appearance. It
is caused by the EBV and is present in
an HIV-positive individual.
• A black, hairy tongue—It gives a dark
and furry appearance caused by
tobacco use, Aspergillus overgrowth
and poor oral hygiene.
• Furrowing/ssured tongue—It is a
benign condition affecting the dorsum
of the tongue. They can be either small
or deep. The tongue with a furrow
called a ssured tongue gives a wrinkled appearance.
kR
6.3 Examination ofSpecic Sites inOral Cavity Proper
Fig. 6.5 Shows coating
of the tongue
261
Fig. 6.6 Shows shapes of tongue
(c) Size of tongue
• Normal—It should t comfortably in
the mouth, tip against lower incisors
• Hypertrophied tongue (macroglossia)—It is dened as the enlargement
of tongue tissue due to muscular
hypertrophy, glandular hypertrophy or
tissue inltration. The causes are
Down’s syndrome, Beckwith—
Wiedemann’s syndrome, lymphangioma, haemangioma, neurobroma,
acromegaly, myxedema, amyloidosis,
acromegaly, lingual thyroid nodule,
haemangioma, lymphangioma,
abscess, inammatory, angio oedema,
haematoma, cysts, tumours.
WhiteYellow
• Atrophied tongue (macroglossia,
Hunter glossitis, Moeller glossitis)—It
is dened as a small tongue caused by
either loss of papillae or loss of muscle
tissue. In this condition, the tongue
appears smooth, glossy and red. The
causes are starvation, atrophic glossitis, motor neuron disease, pseudobulbar palsy, cerebral diplegia and
vitamin deciency.
• Aglossia (absence of tongue)—It is a
rare congenital disorder due to failure
of development of the tongue.
(d) Shape of tongue (Fig.6.6)
Blac
ed
262
6 History andExamination ofLip andOral Cavity
• Rectangular tongue—It is long, but
equally wide at the root, body and tip.
• Round tongue—Look round
• Hammer tongue—It is wider at the tip
than at the root while.
• Triangular tongue—It is wider at the
root than the tip. It may be either acute
or obtuse triangular.
• Ellipse tongue—It is wider at the base,
but the tip is round.
• Square tongue—The tongue size is the
same at the base and tip.
(e) Movement of the tongue (Fig.6.7)—The
patient is asked to move the tongue in all
directions, i.e. touching the upper lip,
protrusion, lateral movement.
• Normal movement—Tongue can move
in all directions without any deviation,
superior, lateral, protrusion, etc.
• Reduced movement—Tongue tie, carcinoma, unilateral deviation (hypoglossal nerve palsy).
• No movement (ankyloglossia)—
Tongue tie, carcinoma, ankylosis of
tongue.
(f) Colour of tongue (Fig.6.8)
• Pink—Normal
• White—Leukoplakia, candidiasis,
lichen planus
• Blue—Cyanosis, eczema
• Red—Vit. B deciency, scarlet fever,
glossitis, Kawasaki’s disease
• Black—Poor oral hygiene, tobacco
use, dark liquid, diabetes
• Grey—Geographical tongue
• Yellow—Jaundice, bacterial growth
• Orange—Dry mouth, certain food and
antibiotic
(g) Surfaces and borders of the tongue
• Dorsal surface—Papillae (liform,
fungiform, circumvallate), median sulcus, sulcus terminalis. It consists of
irregular areas of loss of epithelial
papillae on the dorsum and lateral
margins of the tongue.
• Lateral borders—Foliate papillae
• Ventral surface—Lingual veins, plica
mbriata, lingual frenum
tongue should feel soft and resilient with no
palpable indurations or masses. The clinician
should identify the normal anatomy of the
tongue as well as atypical ndings on the dorsal surface.
(a) General palpation of tongue with gloved
hands, the examiner holds the tongue
with gauze in one hand while palpating
Fig. 6.7 Shows
movements of the
tongue
6.3 Examination ofSpecic Sites inOral Cavity Proper
263
White
Black
Fig. 6.8 Shows colour of the tongue
Fig. 6.9 Shows area of
taste on tongue
Purple
Yellow
Red
Orange
Sour Bitter Sweet Salty
the tongue between the thumb and index
nger of the other, noting masses and
areas of tenderness.
(b) General sensation over the tongue—
Touch, pressure, pain and temperature—
carried by the lingual nerve to the
mandibular nerve, then the trigeminal
nerve to the trigeminal ganglion to the
sensory root to the thalamus and cerebral
cortex.
(c) Taste function tests—Lingual papillae
have the following four forms, each occupying different areas of the tongue
(Fig.6.9).
Gray
Green
Clinical Measurement of Taste
Pink
Blue
It involves the measurement of detection or
recognition thresholds. No comparable
approach to odour identication tests is
available because only ve basic taste sensations exist, and only four of these (sweet,
salty, bitter and sour) are tested. Testing of
the taste thresholds alone does not provide
a full picture of the level of gustatory function or dysfunction.
(continued)
264
6 History andExamination ofLip andOral Cavity
Odour Identication Test
• Threshold detection test—Taste Strips
(Burghart, Messtechnik, Germany) are
strips of paper that can be purchased and
are already impregnated with four taste
qualities: sweet, sour, salty and bitter,
each of these containing four different
concentrations, resulting in 16 strips in
total. Specically, these are sweet (0.4,
0.2, 0.1, 0.05g/mL sucrose), sour (0.3,
0.165, 0.09, 0.05g/mL citric acid), salty
(0.25, 0.1, 0.04, 0.016 g/mL sodium
chloride) and bitter (0.006, 0.0024,
0.0009, 0.0004 g/mL quinine hydrochloride). Normative values for these
strips are available.
• Magnitude matching—Suprathreshold testing involves the assessment of
the patient’s perceptions of taste intensities at levels above the threshold. One
method of measuring this quality is
with a psychophysical procedure known
as magnitude matching. Several concentrations of sodium chloride, sucrose,
citric acid and quinine hydrochloric
acid, along with several loudness levels
of a 1000-Hz tone, are provided for the
magnitude matching task. The patient
sips each solution and expectorates, and
the tones are presented via headphones.
The patient provides estimates of the
perceived magnitude of each stimulus.
The results are scaled in relation to
loudness functions to reveal abnormalities of taste as depressed psychophysical functions. In other words, patients
with hypogeusia associate stronger
taste concentrations with weaker tones
than normal patients. The major limitations of this testing modality are its
dependence on normal hearing and its
complicated design, which takes a signicant amount of time to administer
and analyse.
• Spatial test—Taste function in the vari-
ous areas of the tongue and oral cavity
can be measured using a spatial test.
Because the gustatory system is multiply innervated, damage to one of the
three major nerves (i.e. the chorda tympani branch of the facial nerve, the glossopharyngeal nerve and the vagus nerve)
or their ganglia may cause a disturbance
of taste that can be evaluated only by
testing the anatomic areas supplied by
those nerves. To test these areas, four
standardized sizes of lter paper are
soaked with strong concentrations of the
four basic tastes. The papers are randomly placed on the four quadrants of
the tongue and on both sides of the soft
palate. Patients then identify the quality
of the taste and rate its intensity using
the same scale as in the whole mouth
assessment.
6.3 Examination ofSpecic Sites inOral Cavity Proper
Classication of Benign Tumour of Oral
Cavity (Table6.35)
Table 6.35 Shows the classication of benign tumours of the oral cavity
Benign tumour Description
1. Odontogenic tumour
(epithelial, mesenchymal and
mixed)
Epithelial tumour
Ameloblastoma (solid, cystic or
peripheral)
Calcifying epithelial odontogenic
tumour
Adenomatoid odontogenic
tumour
Squamous odontogenic tumour Rare, occur in both the maxilla and mandible
Mesenchymal tumour
Odontogenic broma It is an extremely rare benign tumour. It is presented as an asymptomatic
Cementoblastoma It is rare, found in the second and third decades of life, in the lower molar
Odontogenic myxoma Second most common tumour, 20–40years,
Cementifying broma It is a benign, osseous tumour, which arises from the periodontal ligament as a
Mixed tumour
Odontoma It is a benign tumour linked to an unerupted tooth usually present as incidental
Ameloblastic broma It is an extremely rare true mixed benign tumour that can occur either in the
Ameloblastic bro-odontoma It is a quite rare, mixed odontogenic tumour generally seen in the early stages
2. Non-odontogenic tumour
Fibro-osseous tumour
Ossifying broma Painless, slowly growing, third and fourth decades of life, F>M
Fibrous dysplasia Monostotic or polyostotic (McCune-Albright syndrome), second and third
Cemento-osseous dysplasia Periapical occurs most commonly in the mandibular anterior teeth, while focal
Langerhans cell disease
(haematopoieticreticuloendothelial)
Ameloblastoma (solid)—It is found in the mandible angle or ramus in the fth
decade of life, slow growing.
Cystic—It is the less aggressive, younger, posterior part of the mandible and
anterior maxilla
Peripheral—Sessile growth rm, exophytic
Common site—Mandibular premolar area
Slow growing also called Pindborg tumour
Occur only in jaw, common in females, 5–30years of age
expansion of the cortical plate of the mandible or maxilla. Peripheral at the
anterior gingival margin and central posterior to rst molar in the mandible
and anterior to rst molar in the maxilla.
region and presents as low-grade pain
large swelling in the upper back tooth region, which is round-to-oval in shape
with overlying smooth mucosa, soft to rm in consistency, well-dened
margin.
ndings on X-ray.
mandible or maxilla. It is frequently found in the posterior region of the
mandible, often associated with an unerupted tooth. It usually occurs in the
rst two decades of life with a slight female predilection.
of life. It presents in the maxilla as swelling with an irregular surface.
Mandible is common; juvenile ossifying broma occurs in children involving
craniofacial complex.
decades, F, maxilla more affected.
appears predominantly in the mandibular posterior teeth and orid in both
maxilla and mandible in multiple quadrants.
(continued)
265
266
Table 6.35 (continued)
Benign tumour Description
Chronic localized (eosinophilic
granuloma)
Chronic disseminated (HandSchuller- Christian disease)
Acute disseminated (LettererSiwe disease)
Giant cell lesion
Central giant cell granuloma It is a solitary lesion of the jaw, usually affecting the younger age group
Giant cell tumour It is a benign tumour of the jaw arising from bone marrow present as swelling
Aneurysmal bone cyst It is a rapidly growing, pseudo-cystic lesions which destroy bone. Normal
Cherubism It is a rare genetic disorder characterized by abnormal bone tissue in the jaw.
Neurogenic tumour
Schwannoma It is a benign encapsulated, slow growing, solitary tumour rarely present in the
Neurobroma It is an uncommon benign tumour of the oral cavity presented as a discrete,
Osteoid osteoma and
osteoblastoma
Osteoma It is a benign tumour of bony origin that grows on other bone and is known as
Desmoplastic broma It is a rare tumour of connective tissue present in the metaphyseal region of
It is a benign tumour of bone, self-limiting disease that can present as isolated
or in association with hand- Schuller- Christian disease and letterer-Siwe
disease.
It is a chronic, disseminated form of bone and visceral lesions.
It is a fatal form that occurs in young children.
<30years and anterior to rst molar, presenting radiologically as multilocular
radiolucency with scalloped margins and honeycomb or soap bubble
appearance, mandible > maxilla.
of the jaw, multiloculated radiolucency lesion present usually at ramus.
bone is replaced by bro-osseous tissue containing blood-lled sinusoidal or
cavernous space.
Both the mandible and maxilla can be affected.
oral cavity, and the tongue is the most common site.
nontender submucosal mass. The tongue and buccal mucosa are the
commonest sites, and the posterior mandible is a common intraosseous
location.
homoplastic osteoma, and it grows on other tissue, it is known as heteroplastic
osteoma.
long bones. In the head and neck, it is more common in the ramus—The angle
region of the mandible—Followed by the maxilla. It presents with the bony
expansile region, which expands to surrounding tissue. Radiographically, the
desmoplastic broma may be unilocular or multilocular.
6 History andExamination ofLip andOral Cavity
6.3 Examination ofSpecic Sites inOral Cavity Proper
mm to cm
mm to cm
Red/pink/
purple
purple
Pedunculated or
sessile
Sessile Red/pink/
Pedunculated/sessile Pink <1.5cm
Soft to
rm
Soft to
rm
rm
Pedunculated/sessile Red to pink <2cm
hard
>2cm
Pedunculated Pink 1cm to huge
rm
Firm Sessile/pedunculated Reddish Small to large
267
Sessile/pedunculated Red to pink Small to large
rm
lobulated
lobulated
10–19years F Gingivae Smooth Firm to
Smooth Firm Sessile/pedunculated Bluish purple <2cm to
gingivae
F Edentulous ridge and
Decade
ulcerative
Deciduous teeth Smooth Soft to
adult
Name Age Sex Site Surface Consistency Type of base Colour Size
Pyogenic granuloma Children/young F Gingiva Smooth/
Pregnancy tumour Pregnancy F Gingivae Smooth/
Irritation granuloma 4th–6th decade F Buccal mucosa Smooth Soft to
Peripheral ossifying
broma
Epulis granulomatosum >40years F Dental socket Smooth Soft to
Giant cell granuloma 5th–6th
Leaf-like broma Palate Smooth Firm Sessile/pedunculated Pink Small to large
Epulis ssuratum Upper alveolar ridge Smooth/
Pulp polyp Child/young
Differential Diagnosis of Smooth Lesions of the Oral Cavity (Table6.36)
Table 6.36 Shows differential diagnosis of smooth lesions of the oral cavity
Giant cell broma 3rd decade F Gingivae Rough Firm Sessile/pedunculated Pink Small to large
268
6 History andExamination ofLip andOral Cavity
Differential Diagnosis of Clinically Benign
Mass of Upper Lip (Table6.37)
Differential Diagnosis of Erythematous
Lesions (Table6.39)
Differential Diagnosis of Oral Mass in
Children (Table6.38)
Table 6.37 Shows Differential diagnosis of benign nasal mass of upper lip
Salivary gland
tumours Mesenchymal tumours Infection Others
Pleomorphic
adenoma
Canalicular
adenoma
Table 6.38 Shows differential diagnosis of oral mass in children
Congenital Acquired
Vascular—Congenital haemangioma, infantile
haemangioma, oral vascular malformation (AV
malformation, mixed vascular malformation)
Non-vascular—Epulis, epulis, oral duplicate cyst, oral
hamartoma, hairy polyp
Lipoma, leiomyoma, granular cell tumour,
neurobroma, oral focal mucinosis,
schwannoma
Benign—Ranula, oral neurobroma
Oral epithelial lesions—(papilloma, broepithelioma,
calcifying epithelioma)
Odontogenic (odontoma, ameloblastoma)
Malignant lesions—Oral rhabdomyosarcoma, oral
lymphoma, oral myoblastoma
Tuberculosis, periapical
abscess, syphilitic Gumma
Furunculosis
Haemangioma
Lymphangioma
Table 6.39 Show differential diagnosis of erythematous oral lesions
Mucosal lesions Vascular lesions Reactive lesions
Erythroplakia
Candidiasis, geographical tongue,
Allergy (contact dermatitis, plasma
cell gingivitis)
Vitamin deciency
Haematological deciency
Dermatological lesion (pityriasis
rosea, psoriasis)
Haemangioma
Kaposi sarcoma
AV malformation
Genodermatosis (Osler-weberRendu disease, mucoepithelial
dysplasia syndrome)
Pyogenic granuloma
Peripheral giant cell granuloma
6.4 Colour Atlas ofLip andOral Cavity Diseases
269
6.4 Colour Atlas ofLip andOral
Cavity Diseases
6.4.1 Colour Atlas ofCommon
Diseases ofLip (Fig.6.10)
a b c
d e f
g h
Fig. 6.10 Common diseases of lip. (a) Furunculosis, (b) Aphthous ulceration, (c) Retention cyst, (d) Sarcoidosis, (e)
Pemphigus vulgaris, (f) Paraneoplastic pemphigus, (g) Steven-Johnson’s syndrome, (h) Lichen planus