Tongue cancer differential diagnosis: Difference between revisions

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{{CMG}}{{AE}}{{Simrat}}
{{CMG}}{{AE}}{{Simrat}}
==Overview==
==Overview==
Tongue cancer must be differentiated from other diseases that cause malignant lesions of the oral cavity and from few non-neoplastic lesions of the oral cavity, such as [[lymphoma]], [[adenoid cystic carcinoma]], [[adenocarcinoma]], [[mucoepidermoid carcinoma]], [[rhabdomyosarcoma]], [[liposarcoma]], infections at the floor of mouth and mandible, and normal adenoid tissue for lesions at base of tongue.<ref name="radio">Squamous cell carcinoma of the tongue. Radiopedia(2015) http://radiopaedia.org/articles/squamous-cell-carcinoma-of-the-tongue Accessed on November 16, 2015</ref>
Tongue cancer must be differentiated from other diseases that cause malignant lesions of the oral cavity and from few non-neoplastic lesions of the oral cavity, such as [[lymphoma]], [[adenoid cystic carcinoma]], [[adenocarcinoma]], [[mucoepidermoid carcinoma]], [[rhabdomyosarcoma]], [[liposarcoma]], infections at the floor of mouth and mandible, and normal adenoid tissue for lesions at base of tongue.
==Differential Diagnosis==
==Differential Diagnosis==
The differential diagnosis for a [[squamous cell carcinoma]] of the tongue is essentially that of other malignant lesions of the oral cavity as well as a few non-neoplastic lesions. It includes the following:<ref name="radio">Squamous cell carcinoma of the tongue. Radiopedia(2015) http://radiopaedia.org/articles/squamous-cell-carcinoma-of-the-tongue Accessed on November 16, 2015</ref>
The differential diagnosis for a [[squamous cell carcinoma]] of the tongue is essentially that of other malignant lesions of the oral cavity as well as a few non-neoplastic lesions. It includes the following:
*Other malignancy
*Other malignancy
**[[Lymphoma]]
**[[Lymphoma]]
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|-
|-
| rowspan="3" |[[Infections]]
| rowspan="3" |[[Infections]]
|'''[[Tuberculosis]]'''
|'''[[Tuberculosis]]'''<ref name="pmid17051875">{{cite journal| author=Ajay GN, Laxmikanth C, Prashanth SK| title=Tuberculous ulcer of tongue with oral complications of oral antituberculosis therapy. | journal=Indian J Dent Res | year= 2006 | volume= 17 | issue= 2 | pages= 87-90 | pmid=17051875 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17051875  }}</ref>
|Dorsum
|Dorsum
|
|
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|
|
|-
|-
|'''[[Scarlet fever]]'''
|'''[[Scarlet fever]]'''<ref name="pmid24429462">{{cite journal| author=Kutsuna S, Hayakawa K, Ohmagari N| title=Scarlet fever in an adult. | journal=Intern Med | year= 2014 | volume= 53 | issue= 2 | pages= 167-8 | pmid=24429462 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24429462  }}</ref>
|Dorsum
|Dorsum
|
|
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|Mainly in children due to [[group A streptococcal infection]]
|Mainly in children due to [[group A streptococcal infection]]
|-
|-
|'''[[Syphilis]]'''
|'''[[Syphilis]]'''<ref name="pmid5036799">{{cite journal| author=Abdullaev AKh| title=[Characteristics of the clinical picture of syphilis in recent years]. | journal=Vestn Dermatol Venerol | year= 1972 | volume= 46 | issue= 2 | pages= 61-5 | pmid=5036799 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5036799  }}</ref>
|Dorsum
|Dorsum
|
|
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|
|
|-
|-
|[[Lipoma]]
|[[Lipoma]]<ref name="pmid23362064">{{cite journal| author=Agarwal R, Kumar V, Kaushal A, Singh RK| title=Intraoral lipoma: a rare clinical entity. | journal=BMJ Case Rep | year= 2013 | volume= 2013 | issue=  | pages=  | pmid=23362064 | doi=10.1136/bcr-2012-007889 | pmc=3604517 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23362064  }}</ref>
|Dorsum and lateral borders
|Dorsum and lateral borders
|
|
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|
|
|-
|-
|'''[[Leiomyoma]]'''
|'''[[Leiomyoma]]'''<ref name="pmid9135966">{{cite journal| author=Baden E, Doyle JL, Lederman DA| title=Leiomyoma of the oral cavity: a light microscopic and immunohistochemical study with review of the literature from 1884 to 1992. | journal=Eur J Cancer B Oral Oncol | year= 1994 | volume= 30B | issue= 1 | pages= 1-7 | pmid=9135966 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9135966  }}</ref>
|Dorsum
|Dorsum
|
|
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|
|
|-
|-
|'''[[Schwannoma]]'''
|'''[[Schwannoma]]'''<ref name="pmid28203620">{{cite journal| author=Abreu I, Roriz D, Rodrigues P, Moreira Â, Marques C, Alves FC| title=Schwannoma of the tongue-A common tumour in a rare location: A case report. | journal=Eur J Radiol Open | year= 2017 | volume= 4 | issue=  | pages= 1-3 | pmid=28203620 | doi=10.1016/j.ejro.2017.01.002 | pmc=5292651 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28203620  }}</ref>
|Dorsum and lateral borders
|Dorsum and lateral borders
|
|
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|
|
|-
|-
|'''[[Neurofibroma]]'''
|'''[[Neurofibroma]]'''<ref name="pmid2100491">{{cite journal| author=Acampa O, Frojo M, Palomba F, Rullo R| title=[A case of solitary neurofibroma of the tongue]. | journal=Arch Stomatol (Napoli) | year= 1990 | volume= 31 | issue= 4 | pages= 821-5 | pmid=2100491 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2100491  }}</ref>
|Dorsum and lateral borders
|Dorsum and lateral borders
|
|
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* Computed tomography
* Computed tomography
|-
|-
|'''Malignant [[Salivary gland tumor|salivary gland tumors]]'''
|'''Malignant [[Salivary gland tumor|salivary gland tumors]]'''<ref name="pmid27466575">{{cite journal| author=| title=Salivary Gland Neoplasms. | journal=Anticancer Res | year= 2016 | volume= 36 | issue= 8 | pages= 4372 | pmid=27466575 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27466575  }}</ref>
|Ventral and dorsum
|Ventral and dorsum
|
|
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* Adenocarcinomas
* Adenocarcinomas
|-
|-
|'''[[Sarcoma]]'''
|'''[[Sarcoma]]'''<ref name="pmid21934227">{{cite journal| author=Anbarasi K, Sathasivasubramanian S, Kuruvilla S, Susruthan| title=Alveolar soft-part sarcoma of tongue. | journal=Indian J Pathol Microbiol | year= 2011 | volume= 54 | issue= 3 | pages= 581-3 | pmid=21934227 | doi=10.4103/0377-4929.85099 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21934227  }}</ref>
|Palate and tongue  
|Palate and tongue  
|
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|-
|-
| rowspan="2" |[[Idiopathic]]
| rowspan="2" |[[Idiopathic]]
|'''[[Migratory glossitis|Benign migratory glossitis]]'''
|'''[[Migratory glossitis|Benign migratory glossitis]]'''<ref name="pmid10612869">{{cite journal| author=Abensour M, Grosshans E| title=[Geographic tongue or benign migratory glossitis]. | journal=Ann Dermatol Venereol | year= 1999 | volume= 126 | issue= 11 | pages= 849-52 | pmid=10612869 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10612869  }}</ref>
|Dorsum
|Dorsum
|
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|
|
|-
|-
|'''Hairy tongue'''
|'''Hairy tongue'''<ref name="pmid13211220">{{cite journal| author=| title=HAIRY tongue. | journal=J Am Med Assoc | year= 1954 | volume= 156 | issue= 12 | pages= 1175 | pmid=13211220 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13211220  }}</ref>
|
|
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|
|
|-
|-
|'''[[Acromegaly]]'''
|'''[[Acromegaly]]'''<ref name="pmid28904697">{{cite journal| author=Anoun N, El Ouahabi H| title=[Acromegaly features in the aging population]. | journal=Pan Afr Med J | year= 2017 | volume= 27 | issue=  | pages= 169 | pmid=28904697 | doi=10.11604/pamj.2017.27.169.11518 | pmc=5579428 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28904697  }}</ref>
|Generalized
|Generalized
|
|
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|
|
|-
|-
|'''[[Vitamin B deficiency]]'''
|'''[[Vitamin B deficiency]]'''<ref name="pmid1264303">{{cite journal| author=Spatz R, Thimm R, Heinze HG, Ross A, König M| title=[Changes in the clinical picture of vitamin B-12 deficiency diseases]. | journal=Nervenarzt | year= 1976 | volume= 47 | issue= 3 | pages= 169-72 | pmid=1264303 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1264303  }}</ref>
|Dorsum
|Dorsum
|
|
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|
|
|-
|-
|'''[[Amyloidosis]]'''
|'''[[Amyloidosis]]'''<ref name="pmid1056992">{{cite journal| author=Akin RK, Baron K, Walters PJ| title=Amyloidosis, macroglossia, and carpal tunnel syndrome associated with myeloma. | journal=J Oral Surg | year= 1975 | volume= 33 | issue= 9 | pages= 690-2 | pmid=1056992 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1056992  }}</ref>
|Lateral borders
|Lateral borders
|
|
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|-
|-
| rowspan="3" |[[Immunological|Immunologic disorders]]
| rowspan="3" |[[Immunological|Immunologic disorders]]
|'''[[Mucous membrane pemphigoid|Benign mucous membrane pemphigoid]]'''
|'''[[Mucous membrane pemphigoid|Benign mucous membrane pemphigoid]]'''<ref name="pmid12063752">{{cite journal| author=| title=[Diagnosis and therapy of mucous membrane pemphigoid. Results of the 1st International Consensus Conference]. | journal=Hautarzt | year= 2002 | volume= 53 | issue= 5 | pages= 371-2 | pmid=12063752 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12063752  }}</ref>
|Generalized
|Generalized
|
|
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|
|
|-
|-
|'''[[Erythema multiforme]] '''
|'''[[Erythema multiforme]]'''<ref name="pmid7722922">{{cite journal| author=Farthing PM, Maragou P, Coates M, Tatnall F, Leigh IM, Williams DM| title=Characteristics of the oral lesions in patients with cutaneous recurrent erythema multiforme. | journal=J Oral Pathol Med | year= 1995 | volume= 24 | issue= 1 | pages= 9-13 | pmid=7722922 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7722922  }}</ref>
|Generalized  
|Generalized  
|
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|
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|-
|-
|'''[[Pemphigus]] '''
|'''[[Pemphigus]]'''<ref name="pmid23414160">{{cite journal| author=Apalla Z, Sotiriou E, Lazaridou E, Manousari A, Trigoni A, Papagarifallou I et al.| title=Pemphigus vegetans of the tongue: a diagnostic and therapeutic challenge. | journal=Int J Dermatol | year= 2013 | volume= 52 | issue= 3 | pages= 350-1 | pmid=23414160 | doi=10.1111/j.1365-4632.2011.05277.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23414160  }}</ref>
|Generalized
|Generalized
|
|

Revision as of 18:07, 5 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

Overview

Tongue cancer must be differentiated from other diseases that cause malignant lesions of the oral cavity and from few non-neoplastic lesions of the oral cavity, such as lymphoma, adenoid cystic carcinoma, adenocarcinoma, mucoepidermoid carcinoma, rhabdomyosarcoma, liposarcoma, infections at the floor of mouth and mandible, and normal adenoid tissue for lesions at base of tongue.

Differential Diagnosis

The differential diagnosis for a squamous cell carcinoma of the tongue is essentially that of other malignant lesions of the oral cavity as well as a few non-neoplastic lesions. It includes the following:

Site Clinical presentation Investigations Others
Symptoms Signs
Infections Tuberculosis[1] Dorsum
  • History of contact with TB patients
  • Primary TB symptoms: night fever, sweating, bloody cough, and loss of weight
  • Painful tongue ulcers
  • Ulcer: irregular outline, undulated borders, and covered with a yellowish-gray, and fibrinous layer 
  • Chest x-ray for primary infection
  • Tubercelin skin test
Scarlet fever[2] Dorsum
  • Fever, malaise, headache, pharyngitis Red skin rash
  • Swelling of tongue, white and red coating
  • Heavy gray-white coating
  • Enlargement of the fungiform papillae, which appear as multiple red dots
  • Dots disappear after that
  • Throat swab and culture
  • Rapid streptococcal antigen tests 
 Mainly in children due to group A streptococcal infection
Syphilis[3] Dorsum
  • Single or multiple painless masses or ulcers according to the stage
  • White patches of leukoplakia
  • Symptoms of generalized syphilis in secondary and tertiary stages especially generalized lymphadenopathy

The primary stage

  • The lingual chancre is a solitary, painless, slightly raised, well-demarcated ulcer
  • Enlarged, painless, regional lymph nodes

The secondary stage:

  • The mucous patches are slightly raised, grayish-white, and usually surrounded by a red halo.
  • If the lesion is scraped, it leaves a raw, bleeding surface.

The third stage:

  • The gumma appears as a painless, elastic mass that subsequently undergoes central necrosis and ulceration.
  • Atrophy of the papillae
  • Frequently associated with leukoplakia, which has a tendency to undergo malignant transformation
Benign neoplasms Papilloma Dorsum and lateral borders
  • Painless slowly growing mass
  • Warty surface or consist of hyperkeratotic finger-like projections
  • Sessile or pedunculated, pink to white color
  • Biopsy
Lipoma[4] Dorsum and lateral borders
  • Painless slowly growing mass
  • Soft, sessile, and yellowish
  • Biopsy
Leiomyoma[5] Dorsum
  • Painless slowly growing mass
  • Small, single

or multiple, circumscribed mass

  • Biopsy
Schwannoma[6] Dorsum and lateral borders
  • Painless slowly growing lesions, may be painful
  • Firm, submucosal mass
  • Biopsy
Neurofibroma[7] Dorsum and lateral borders
  • Slowly growing multiple nodules
  • Unilateral macroglossia
  • Tongue may show multiple nodules or there may be a more diffuse involvement causing unilateral macroglossia
  • Biopsy
Granular cell tumor Dorsum
  • Painless, firm, slwoly growing nodules
  • Submucosal nodules with a yellowish or pinkish color 
  • Biopsy
Malignant neoplasms Squamous cell carcinoma Lateral borders
  • Painless ulcer or exophytic mass.
  • History of heavy use of alcohol and tobacco
  • The lesion has an ulcerated appearance with rolled borders around a necrotic center.
  • It frequently resembles a traumatic ulcer.
  • Biopsy
  • Computed tomography
Malignant salivary gland tumors[8] Ventral and dorsum
  • Slow-growing, painless mass
  • Submueosal masses
  • May ulcerate in the later stages
Metastatic tumor Base of tongue
  • Painful mass
  • Dysphagia
  • Symptoms of primary tumor

[null Insert paragraph]

  • Mass in tongue base
  • Cachexia and loss of appetite
  • Signs of primary tumor
  • Mass in tongue base
  • Cachexia and loss of appetite
  • Signs of primary tumor
 Subtypes:
  • Mucoepidemoid tumors
  • Acinic cell tumors
  • Adenocarcinomas
Sarcoma[9] Palate and tongue
  • Painless slowly growing mass
  • Dysphagia and weight loss
  • Reddish or bluisb macules that then coalesce to form purplish nodules and may get ulcerated
  • Biopsy
 Subtypes:
  •  Fibrosarcoma
  • Alveolar soft-part sarcoma
  • Rbabdomyosarcoma
  • Leiomyosarcoma
  • Synovial sarcoma
  • Chondrosarcoma
  • Neurogenic sarcoma
  • Kaposi's sarcoma
Idiopathic Benign migratory glossitis[10] Dorsum

Painless redish ulcerative lesions

The lesions appear as one or more irregularly shaped, reddish areas of depapillation surrounded by a narrow, whitish zone of regenerating papillae
Hairy tongue[11]
  • Tongue color change
  • Hypertrophy of the filiform papillae
  • Tongue color will vary from yellowish-white to brown or black
 Risk factors:
  • Tobacco
  • Radiation therapy
Metabolic Diabetes mellitus Dorsum
  • Burning and dryness
  • White plaques on the dorsum of tongue due to Candidal infection in uncontrolled cases
  • Lingual papillary atrophy
  • Throat swab
  • Blood glucose level
  • HB A1C
Hypothyroidism
  • Dry mouth
  • Difficulties in eating and speaking
  • Tongue swelling
  • Tongue protrusion
  • Macroglossia
  • TSH level
  • T3 and T4 levels
Acromegaly[12] Generalized
  • Swollen tongue
  • Lingual indentations
  • Hyperplasia of the epithelium and connective tissue
  • Macroglossia
  • Spacing and labial tilting of the teeth
  • Serum IGF-1 concentration
  • Oral glucose tolerance test 
Vitamin B deficiency[13] Dorsum
  • Redness in the tip and margins of the tongue
  • Swelling of the tongue
  • Indentations of the teeth
  • Associated neurological symptoms due to niacin and B12 deficiency
  • Atrophy of both the filliform and fungiform papillae
  • Serum vitamin B12 and folate levels
  • CBC and blood smear 
Amyloidosis[14] Lateral borders
  • Enlarged tongue
  • Decrease in lingual mobility
  • Difficulty in chewing, swallowing and speaking
  • Generalized induration
  • Yellowish nodules
  • Tongue biopsy
  • Abdominal fat pad biopsy 
  • Monoclonal pattern on serum protein electrophoresis (SPEP)
Immunologic disorders Benign mucous membrane pemphigoid[15] Generalized
  • Women over the age of 50
  • Painful bullae or ulcerations
  • Yellow or hemorrhagic bullae on an erythematous background.
  • Bullae rupture leaving a fibrin-covered ulceration. 
  • Biopsy
  • Indirect immunofluorescence
  • Autoantibodies against BP180, BP230, laminin 332 
Erythema multiforme[16] Generalized
  • It occurs primarily in young men
  • Small, erythematous plaque that then becomes a vesicle, quickly rupture and become confluent, shallow erosions covered by a pseudomembrane of necrotic tissue
 The cause of this disorder is an infectious disease such as Hepes simplex, Coxsackie virus, or drug therapy
Pemphigus[17] Generalized
  • Bullae rupture soon after formation to produce ulcers (pemphigus vulgaris)
  • Fungoid vegetations develop on the base of these ulcers (pemphigus vegetans)
  • ELISA for antibodies to the BP180 NC16A
  • Biopsy

References

  1. ↑ Ajay GN, Laxmikanth C, Prashanth SK (2006). "Tuberculous ulcer of tongue with oral complications of oral antituberculosis therapy". Indian J Dent Res. 17 (2): 87–90. PMID 17051875.
  2. ↑ Kutsuna S, Hayakawa K, Ohmagari N (2014). "Scarlet fever in an adult". Intern Med. 53 (2): 167–8. PMID 24429462.
  3. ↑ Abdullaev AKh (1972). "[Characteristics of the clinical picture of syphilis in recent years]". Vestn Dermatol Venerol. 46 (2): 61–5. PMID 5036799.
  4. ↑ Agarwal R, Kumar V, Kaushal A, Singh RK (2013). "Intraoral lipoma: a rare clinical entity". BMJ Case Rep. 2013. doi:10.1136/bcr-2012-007889. PMC 3604517. PMID 23362064.
  5. ↑ Baden E, Doyle JL, Lederman DA (1994). "Leiomyoma of the oral cavity: a light microscopic and immunohistochemical study with review of the literature from 1884 to 1992". Eur J Cancer B Oral Oncol. 30B (1): 1–7. PMID 9135966.
  6. ↑ Abreu I, Roriz D, Rodrigues P, Moreira Â, Marques C, Alves FC (2017). "Schwannoma of the tongue-A common tumour in a rare location: A case report". Eur J Radiol Open. 4: 1–3. doi:10.1016/j.ejro.2017.01.002. PMC 5292651. PMID 28203620.
  7. ↑ Acampa O, Frojo M, Palomba F, Rullo R (1990). "[A case of solitary neurofibroma of the tongue]". Arch Stomatol (Napoli). 31 (4): 821–5. PMID 2100491.
  8. ↑ "Salivary Gland Neoplasms". Anticancer Res. 36 (8): 4372. 2016. PMID 27466575.
  9. ↑ Anbarasi K, Sathasivasubramanian S, Kuruvilla S, Susruthan (2011). "Alveolar soft-part sarcoma of tongue". Indian J Pathol Microbiol. 54 (3): 581–3. doi:10.4103/0377-4929.85099. PMID 21934227.
  10. ↑ Abensour M, Grosshans E (1999). "[Geographic tongue or benign migratory glossitis]". Ann Dermatol Venereol. 126 (11): 849–52. PMID 10612869.
  11. ↑ "HAIRY tongue". J Am Med Assoc. 156 (12): 1175. 1954. PMID 13211220.
  12. ↑ Anoun N, El Ouahabi H (2017). "[Acromegaly features in the aging population]". Pan Afr Med J. 27: 169. doi:10.11604/pamj.2017.27.169.11518. PMC 5579428. PMID 28904697.
  13. ↑ Spatz R, Thimm R, Heinze HG, Ross A, König M (1976). "[Changes in the clinical picture of vitamin B-12 deficiency diseases]". Nervenarzt. 47 (3): 169–72. PMID 1264303.
  14. ↑ Akin RK, Baron K, Walters PJ (1975). "Amyloidosis, macroglossia, and carpal tunnel syndrome associated with myeloma". J Oral Surg. 33 (9): 690–2. PMID 1056992.
  15. ↑ "[Diagnosis and therapy of mucous membrane pemphigoid. Results of the 1st International Consensus Conference]". Hautarzt. 53 (5): 371–2. 2002. PMID 12063752.
  16. ↑ Farthing PM, Maragou P, Coates M, Tatnall F, Leigh IM, Williams DM (1995). "Characteristics of the oral lesions in patients with cutaneous recurrent erythema multiforme". J Oral Pathol Med. 24 (1): 9–13. PMID 7722922.
  17. ↑ Apalla Z, Sotiriou E, Lazaridou E, Manousari A, Trigoni A, Papagarifallou I; et al. (2013). "Pemphigus vegetans of the tongue: a diagnostic and therapeutic challenge". Int J Dermatol. 52 (3): 350–1. doi:10.1111/j.1365-4632.2011.05277.x. PMID 23414160.


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