CASE REPORT

Tongue abscess: a rare clinical entityShambulingappa Pallagatti1, Soheyl Sheikh1, Anupreet Kaur1, Nidhi Puri2, Ravinder Singh1 &Smriti Arya2

1 Department of Oral Medicine and Radiology, Maharishi Markandeshwar College of Dental Sciences and Research, Ambala, Haryana, India

2 Dashmesh Institute of Research and Dental Sciences, Faridkot, India

3 Maxillofacial Unit Modern Hospital, Hoshiarpur, Punjab, India

Introduction

Swellings of the tongue are rare. Inflammatory, metabolic,

neoplastic, and developmental processes should be con-

sidered in the differential diagnosis of tongue lesions.

Infectious etiology is always a likely possibility with intra-

oral swellings of recent onset. Tongue abscesses seem to

be very uncommon infections in so far as little mention

is made of them in most recent literature. Over the last

30 years, approximately only 50 cases of glossal abscesses

have been reported in the English literature.

Although the tongue is exposed to considerable bite

trauma, it appears to be comparatively resistant to infec-

tions.1 This could in part be explained by the tongue’s

high vascularity, its thick covering of the keratinized

squamous epithelium, and the lubricating, cleansing, and

immunological functions of saliva and salivary flow.

However, when host defense mechanisms are impaired,

tongue abscesses are more likely to occur. Breached sur-

face barriers, foreign bodies, and immunodeficiency states

predispose to tongue infections.

Nowadays, the older age group population has

increased in number. This population is of particular

concern because their host defense mechanisms are likely

to be impaired. The alarming spread of HIV infection has

also contributed to the increase in people with impaired

host defense mechanisms. Thus, tongue infections must

be recognized promptly and treated as an emergency,

especially when dyspnea and dysphagia occur. In particu-

lar, abscesses at the base of the tongue could be fatal if

they are not recognized and treated. Underlying medical

problems must also be assessed carefully and controlled.

In addition to medical evaluation, in the diagnosis of ton-

gue abscess, the assessment of a recent history of trauma

is essential.

In the present study, a case of tongue abscess is

reported, along with discussion of the presentation, path-

ophysiology, differential diagnosis, and management of

this entity.

Case report

A 60-year-old female patient reported to the Department

of Oral Medicine and Radiology (Maharishi Markandesh-

war College of Dental Sciences and Research, Haryana,

India) complaining of difficulty in eating food for the

past 4 days due to a swelling in the left half of the tongue

(Figure 1). The patient reported an increase in swelling

Keywords

abscess, culture, swelling, tongue, ultrasound.

Correspondence

Dr Anupreet Kaur, Department of Oral

Medicine and Radiology, M.M. College of

Dental Sciences and Research, Mullana,

Ambala, Haryana 133203, India.

Tel: +62-097-2817-4643

Email: anupreet.mds@gmail.com

Received 30 December 2010; accepted

31 May 2011.

doi: 10.1111/j.2041-1626.2011.00101.x

AbstractSwelling of the tongue is a rare clinical entity. It is a potentially life-threatening

condition, as it could result in airway compromise. The differential diagnosis

of acute tongue swelling includes hemorrhage, infarction, abscess, tumor, and

edema. A tongue abscess should be considered in all cases of acute tongue

swelling, especially when host defenses are severely impaired. Although the

diagnosis of lingual abscess can be reached clinically because of the rarity of

the condition, in neglected cases, the diagnosis can be difficult. Despite of the

rarity and complexity of this condition, its management strategy is relatively

simple. In the present study, we describe a case of a tongue abscess on the

anterior two-thirds of the tongue in a 60-year-old woman, and discuss the

pathophysiology, diagnosis, and treatment of this complex entity.

Journal of Investigative and Clinical Dentistry (2012), 3, 240–243

240 ª 2011 Blackwell Publishing Asia Pty Ltd

and pain for the past 2 days. The patient had no history

of any irritation or trauma to the tongue. The medical

history was irrelevant.

All the vital signs were within the normal range and

the patient was afebrile. The extraoral examination

revealed no abnormalities. Upon intraoral examination,

there was a solitary swelling in the anterior two-thirds

of the left side of the tongue on the dorsal surface. It

extended throughout the thickness of tongue musculature

involving some part of the ventral surface of the tongue.

The swelling was spherical in shape and measured

approximately 1.5 · 1.5 cm in size. The overlying tongue

mucosa was intact and of normal color. The swelling was

very tender and firm in consistency. There were no signs

of fluctuation, compressibility, and reducibility, with no

discharge at the time of examination. The patient was

partially edentulous, but with poor oral hygiene. The

lymph nodes were not palpable.

An intraoral periapical film was used and placed

beneath the tongue to rule out the possibility of any for-

eign body in the tongue (Figure 2). A complete hemo-

gram reported all values to be within normal range.

Ultrasonography revealed multiple linear channels that

were of low velocity flow (Figure 3). The ultrasono-

graphic diagnosis was given to be hemangioma. As the

patient was very apprehensive that day, she was coun-

seled and convinced to report the next day for further

investigations.

The patient reported after 2 days. On examination,

there was frank pus discharge on slight manipulation of

the tongue. The tongue surface was scrubbed with gauze

soaked in 0.2% chlorhexidine solution, and further rinsed

with normal saline to minimize the contamination with

normal oral flora. On aspiration, slight yellowish liquid

was obtained, which was sent for culture. The abscess

was aspirated using a sterile, air-tight syringe under all

aseptic conditions. The needle was plunged into a sterile

rubber cork to seal it and was sent immediately to the

laboratory. Examination of a Gram-stained smear was

useful, and long, slender rods that were wide at the centre

Figure 1. Pus discharge from the left half of the tongue.

Figure 2. Radiograph of the tongue (radiopaque shadow is of maxil-

lary tooth).

Figure 3. Ultrasonographic diagnosis: hemangioma (multiple linear

channels of low velocity flow).

S. Pallagatti et al. Tongue abscess: a rare clinical entity

ª 2011 Blackwell Publishing Asia Pty Ltd 241

and tapered towards the ends were observed. The speci-

mens were plated as rapidly as possible onto culture media

that had been prepared with freshly-prepared blood agar

with neomycin, yeast extract, hemin, and vitamin K. All

these plates were kept in a Gas Pak jar that provided

anaerobic conditions. The jar was then placed in an incu-

bator at 37�C. Parallel aerobic cultures were also set up.

Plates were examined after 24 and 48 h. The organisms

found included Fusobacterium nucleatum, prevotella, and

streptococci species. All organisms were sensitive to peni-

cillin, clindamycin, erythromycin, and vancomycin.

The patient was put on antibiotics, that is, a combina-

tion of 500 mg amoxicillin and cloxacillin, 400 mg of

anti-inflammatory ibuprofen, and 10 mg serratiopeptidase

three times per day for 5 days, along with warm saline

and hexidine rinses. The patient was followed up after

5 days.

After the fourth day of treatment, the swelling had

started to reduce, and within 1 week, the swelling had

regressed and the patient was able to eat comfortably. She

was advised to stop the medication, as the swelling had

subsided, but was advised to continue with the rinses.

The patient was also recommended full mouth rehabilita-

tion, including oral prophylaxis, selective grinding of the

sharp edges of teeth, and replacement of the missing

teeth.

Discussion

Tongue abscesses are surprisingly rare, but complex, con-

sidering the frequency with which the tongue is exposed

to trauma. This could in part be explained by the rich

vascularity of the tongue and its thick covering of kerati-

nized mucosa. By 2004, only 50 cases of glossal abscesses

had been reported in the English literature.

They occur more frequently in males than females,2

possibly because of poorer oral hygiene and higher rates

of tobacco smoking. They are more frequently found on

the anterior portion of the tongue and are usually unilat-

eral,3 being related to direct trauma. Abscesses in the pos-

terior part of the tongue usually have a different etiology.

In this case report, we present an unusual clinical presen-

tation in a female patient with no history of trauma, and

lesion duration of just 4 days.

The literature on the bacteriology of tongue abscess is

limited (Table 1). Case reports of tongue abscesses pub-

lished in past 15 years are briefly discussed. In 1996 in

the UK, Hehar et al. described a case of glossal abscess,

together with its diagnosis and management, highlighting

the role of ultrasound and the study of the microbiology.4

The microbiology showed a mixed growth of oral anero-

bic bacteroides and Hemophilus. In 1993 in the USA, and

in 2006 in Turkey, Sands et al.1 and Kiroglu et al.,5

respectively, found oral aerobic viridians streptococci,

anaerobic streptococci, Bacteriodes, and Staphylococcus

aureus to be the main etiologic agents.

In 1996 in Finland, Jungell et al. reported Fusobac-

terium nucleatum, prevotella, Hemophilus and Peptostrep-

tococcus to be the main etiologic agents,6 whereas in 2004

in Greece, Antoniades et al. said the main etiologic agent

of tongue abscess was Streptococcus fecalis.7 The conclu-

sions from these studies suggest that obligate anaerobes

(i.e. prevotella and streptococci) are the most common

etiologic agents for tongue abscess.

Table 1. Organisms identified in similar cases within the literature

Literature Organisms found

Hehar SS, Johnson M, Jones NS. Glossal abscess presenting as unilateral tongue swelling.

J Laryngol Otol 1996; 110: 389–90.

Oral aerobic viridians streptococci,

anaerobic streptococci, and bacteroides

species (Staphylococcus aureus) and

Haemophilus parainfluenzae

Osammor JY, Cherry JR, Dalziel M. Lingual abscess: the value of ultrasound in diagnosis.

J Laryngol Otol 1989; 103: 950–1.

Streptococcus sanguinis

Ozturk M, Durak AC, Ozcan N. Abscess of the tongue:findings on MR imaging.

AJR Am J Roentgenol 1998; 170: 797–8.

Anaerobic bacteria

Kiroglu A, Cankaya H, Kiris M. Lingual abscess in two children. Int J Pediatr Otorhinolaryngol

2006; 1: 12–4.

Staphylococcus epidermidis

Jungell P, Asikainen A, Malmstrom M. Acute tongue abscess: report of two cases. Int J Oral

Maxillofac Surg 1996; 25: 308–10.

Fusobacterium nucleatum,

prevotella/Porphyromonas species,

anaerobic bacteria

Antoniades K, Hadjipetrou L. Acute tongue abscess:report of three cases. Oral Surg Oral Med

Oral Pathol Oral Radiol Endod 2004; 97: 570–3.

Streptococcus fecalis

Sands M, Pepe J, Brown RB. Tongue abscess: case report and review. Clin Inf Dis 1993; 16:

133–5.

Aerobic viridians streptococci,

Peptostreptococci, and bacteroides

species

Tongue abscess: a rare clinical entity S. Pallagatti et al.

242 ª 2011 Blackwell Publishing Asia Pty Ltd

In the present case, the organisms found in abundance

were prevotella species, which are obligate Gram-negative

anaerobes. Very few reports have reported this particular

organism to be the cause of tongue abscess.

In the present study, the patient gave no history of

trauma, but we assume there could have been microtrau-

ma that went unnoticed by the patient and could have

been a causative factor. Anaerobes are normally found

within certain areas of the body, and have increased

numbers in oral conditions, such as periodontitis. They

result in serious infection when they have access to deep

tissue. It is assumed that the possible origin of the

organisms could be from the periodontally-affected tis-

sues, which were a result of the patient’s poor oral

hygiene.

The differential diagnosis of anterior lesions includes a

false lingual artery aneurysm,8 tuberculosis, syphilitic

gumma, actinomycosis, and inflammation around a carci-

noma.9 Computed tomography is said to be helpful in

posterior third tongue lesions.10

Although ultrasound is considered useful in the diagno-

sis of such soft tissue swellings,11 the diagnosis might be

misleading. In this case report, the ultrasound diagnosis

was given as hemangioma, which made aspiration a contra-

diction. It was only when the patient reported 2 days later

with frank pus discharge that a diagnosis of tongue abscess

was confirmed and aspiration could be safely considered.

Thus, a careful history is essential in establishing the diag-

nosis, and laboratory tests are of limited value in the pri-

mary examination of the swelling. The treatment of a

tongue abscess should aim at preventing deeper spread of

the infection. Therefore, aspiration, incision, and drainage

should be done without delay, and be followed by proper

antimicrobial treatment and careful follow up.

Tongue swellings caused by life-threatening conditions

are usually found to be various tumors, cysts, lymphangi-

oma, and hemangioma. It would be useful to keep in

mind that such a case of tongue abscess can be the cause

of a tongue swelling, which responded satisfactorily to

simple antibiotic therapy.

References

1 Sands M, Pepe J, Brown RB. Ton-

gue abscess: case report and review.

Clin Infect Dis 1993; 16: 133–5.

2 Huizinga E. Abscess of the tongue.

Acta Otolaryngol 1947; 35: 583–91.

3 Pal J, Prakash J. Lingual abscess. J

Indian Med Assoc 1976; 66: 57–60.

4 Hehar SS, Johnson IJM, Jones NS.

Glossal abscess presenting as unilat-

eral tongue swelling. J Laryngol Otol

1996; 110: 389–90.

5 Kiroglu AF, Cankaya H, Kiris M.

Lingual abscess in two children. Int

J Pediatr Otorhinolaryngol 2006; 1:

12–4.

6 Jungell P, Asikainen S, Kuikka A.

Acute tongue abscess: report of two

cases. Int J Oral Maxillofac Surg

1996; 25: 308–10.

7 Antoniades K, Hadjipetrou L,

Antoniades V. Acute tongue abscess:

report of three cases. Oral Surg Oral

Med Oral Pathol Oral Radiol Endod

2004; 97: 570–3.

8 DiStefano JF, Maimon W, Mandal

MA. False aneurysm of lingual artery.

J Oral Surg 1977; 35: 918–20.

9 Myers EN, Roberts JB. Lingual abscess.

J Laryngol Otol 1965; 79: 256–8.

10 Leggett JM. Use of ultrasound in the

management of acute lingual

swelling. J Laryngol Otol 1987; 101:

1312–4.

11 Osammor JY, Cherry JR, Dalziel M.

Lingual abscess: the value of ultra-

sound in diagnosis. J Laryngol Otol

1989; 103: 950–1.

S. Pallagatti et al. Tongue abscess: a rare clinical entity

ª 2011 Blackwell Publishing Asia Pty Ltd 243