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A Man With a Midline Lesion Within the Oral Tongue

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A man in his 30s with a medical history of asthma, social history of smoking, and allergy to shellfish presented to the emergency department with tongue swelling. The patient reported a history of a local burn from hot food but denied any history of trauma, foreign body, or piercing. He was evaluated, given a presumptive diagnosis of sialadenitis, and discharged home with ibuprofen and clindamycin. He returned several days later with worsening tongue swelling, voice change, and subjective fever. Postcontrast axial computed tomography (CT) demonstrated a midline lesion within the oral tongue that was predominantly hypodense and demonstrated rim enhancement. No calcifications were seen within the lesion (Figure, A). The lesion was predominantly isointense to muscle on axial T1-weighted images without intravenous (IV) contrast (Figure, B). Axial T2-weighted images with fat saturation showed predominantly hyperintense signal relative to muscle as well as punctate internal foci of T2 hypointensity (not shown). The lesion was hyperintense on diffusion-weighted imaging (Figure, C) and hypointense on the apparent diffusion coefficient map (not shown). Sagittal T1-weighted magnetic resonance imaging (MRI) with IV contrast and fat suppression demonstrated signal hypointense to muscle centrally with peripheral enhancement (Figure, D).

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C. Abscess

Approximately 50 cases of glossal abscess have been reported in the English literature during the past 40 years.1 The diagnosis of glossal abscess can be reached clinically. The patient may have tongue swelling, fever, and pain radiating toward the ears. However, in one study, more than 50% of the patients had no clinical or laboratory findings to suggest glossal abscess.2

The typical imaging features of glossal abscess are similar to those of abscesses found in other parts of the body: restricted diffusion, central fluid signal (T1 hypointensity, T2 hyperintensity), peripherally enhancing wall, and perilesional edema.3 However, when small, they can present with uniform hypointensity on T1-weighted images that enhance diffusely after the administration of intravenous contrast. Most tongue abscesses are located within the oral tongue.2

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Article Information

Corresponding Author: Alex Levitt, MD, Department of Neuroradiology, Montefiore Medical Center, 303 W 66th St, Apt 5HE, New York, NY 10023 (alevitt@montefiore.org).

Published Online: May 24, 2018. doi:10.1001/jamaoto.2018.0873

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Antoniades  K, Hadjipetrou  L, Antoniades  V, Antoniades  D.  Acute tongue abscess: report of three cases.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97(5):570-573.PubMedGoogle Scholar
2.
Ozturk  M, Mavili  E, Erdogan  N, Cagli  S, Guney  E.  Tongue abscesses: MR imaging findings.  AJNR Am J Neuroradiol. 2006;27(6):1300-1303.PubMedGoogle Scholar
3.
Desprechins  B, Stadnik  T, Koerts  G, Shabana  W, Breucq  C, Osteaux  M.  Use of diffusion-weighted MR imaging in differential diagnosis between intracerebral necrotic tumors and cerebral abscesses.  AJNR Am J Neuroradiol. 1999;20(7):1252-1257.PubMedGoogle Scholar
4.
Fang  WS, Wiggins  RH  III, Illner  A,  et al.  Primary lesions of the root of the tongue.  Radiographics. 2011;31(7):1907-1922.PubMedGoogle Scholar
5.
Yonetsu  K, Nakayama  E, Miwa  K,  et al.  Magnetic resonance imaging of oral and maxillofacial angiomas.  Oral Surg Oral Med Oral Pathol. 1993;76(6):783-789.PubMedGoogle Scholar
6.
Tshering Vogel  DW, Zbaeren  P, Thoeny  HC.  Cancer of the oral cavity and oropharynx.  Cancer Imaging. 2010;10(1):62-72.PubMedGoogle Scholar
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