CASE STUDY Clinical Differential Diagnosis: Solitary Tongue Mass

by Glen Houston, DDS, MSD

History

A 67-year-old Caucasian man presents to his internist concerned about a “knot” involving his tongue. The patient notes the area of concern is “not painful” and has been present for “several days”. In review of his health history, the patient received a renal transplant approximately 10 years ago, has a lengthy history of uncontrolled hypertension, Type II non-insulin dependent diabetes mellitus (NIDDM) or adult onset diabetes, and a significant history of tobacco and alcohol abuse.

QUESTION #1

Terminology to describe this lesion clinically involving the ventral tongue would include which of the following: a. Circumscribed area of erythroplakia b. Asymptomatic ulcerated umbilicated mass c. Convoluted papillary lesion d. Asymptomatic pigmented macule e. None of the above

ANSWER #1

The correct answer is an asymptomatic ulcerated umbilicated mass (b). Because a circumscribed area of erythroplakia (a) represents a clinical term describing a red patch that cannot be clinically or pathologically diagnosed as any other condition, this answer is not a consideration in the clinical description.

Additionally, a convoluted papillary lesion (c) and an asymptomatic pigmented macule (d) would not accurately describe this asymptomatic ulcerated umbilicated mass from a clinical standpoint. The last choice, none of the above (e), does not apply in this case.

QUESTION #2

An appropriate clinical differential diagnosis for this asymptomatic ulcerated umbilicated mass involving the ventral tongue would include: a. Traumatic ulcer b. Keratoacanthoma c. Squamous cell carcinoma d. Histoplasmosis e. Basal cell carcinoma

ANSWER #2

All of these lesions (a-e) may present clinically as an asymptomatic ulcerated umbilicated mass. However, the keratoacanthoma (b) and basal cell carcinoma (e) typically arise in actinically damaged skin. Both of these lesions have been reported intraorally, but further review and analysis indicate that the cases described as keratoacanthoma actually represent well differentiated squamous cell carcinoma. The cases of basal cell carcinoma were observed arising from the gingiva and actually represented the extra osseous or peripheral variant of the odontogenic neoplasm, ameloblastoma.

Cases of traumatic ulcer (a) are usually unintentional and arise from a variety of causes. These lesions are usually observed involving the tongue, lips, and buccal mucosa injured by the dentition. Lesions of the gingiva, palate, and mucobuccal fold may occur from other sources of irritation. Thorough questioning of the patient will usually lead to the appropriate diagnosis. Once the irritating source of the injury has been identified and, if necessary, removed, rapid resolution is usually observed.

The tongue is the most common location intraorally for squamous cell carcinoma (c) and accounts for approximately 50% of all oral cancer cases. The majority of these cases present as an asymptomatic ulcerated umbilicated mass involving the posterior lateral border, followed by the anterior lateral or ventral surfaces. A very small percent involves the dorsal surface.

The most common systemic fungal infection in America is histoplasmosis (d) caused by the organism, Histoplasma capsulatum. It is primarily a respiratory disease but may manifest in the oral cavity (disseminated disease from the lungs) as an asymptomatic ulcerated umbilicated mass that is easily mistaken clinically for a chronic traumatic ulcer or squamous cell carcinoma.

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