International Journal of Pediatric Otorhinolaryngology Extra
Volume 1, Issue 1 , Pages 12-14, March 2006

Lingual abscess in two children

  • A. Faruk Kiroglu

      Affiliations

    • Corresponding Author InformationCorresponding author at. Yüzüncü Yıl Üniversitesi Tıp Fakültesi, Araştırma Hastanesi KBB Anabilim Dalı, 65200 Van, Turkey. Tel.: +90 4322144415; fax: +90 4322168352.
    • ,
  • Hakan Cankaya
    • ,
  • Muzaffer Kiris

Yüzüncü Yıl University, School of Medicine, Department of Otolaryngology, Van, Turkey

Received 13 August 2005; received in revised form 7 November 2005; accepted 17 November 2005.

Article Outline

Summary 

Acute lingual abscess is a rare condition despite exposure to frequent trauma. Because of possible airway management and spread of the infection to adjacent structures, it may be life-threatening. The diagnosis can be reached clinically. Also, aspiration of the pus by needle is a useful method both for diagnosis and treatment. The management of lingual abscess includes ensuring adequate airway, drainage of the abscess and antimicrobial therapy.

In this paper two rare pediatric acute lingual abscess cases are presented and differential diagnosis and treatment options are discussed.

Keywords: Lingual abscess, Tongue, Abscess, Pediatric

 

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1. Introduction 

Lingual abscess is a rare entity with its 40 reported cases in the English literature over the past 30 years. When the literature is reviewed, it can be seen that the most common etiologies are trauma and spread of local infection from adjacent structures, respectively [1], [2], [3]. However, etiology may be unknown in some cases. Generally, the etiologic factors differ according to the location of the abscess. In the anterior part of the tongue local traumas and in the posterior part spreading of an infection from adjacent structures are the most common causes. Lingual tonsils, infected remnants of a thyroglossal duct cyst and the first or second molars may be the source of spreading infection [4]. Despite exposure to frequent trauma, the tongue is resistant to infection.

Lingual abscess usually shows itself as a tender, rapidly growing swelling in the tongue and differential diagnosis should include other etiologic factors causing acute lingual swelling such as, allergic edema, cysts, lingual artery aneurysms, arterioveneous malformations and infarction [5], [6], [7], [8].

In this report two cases of pediatric lingual abscess are presented.

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2. Case 1 

A 7-year-old boy was admitted to our clinic with the complaints of progressive dysphagia, inability to close the mouth, fever and drooling for six days. ENT examination revealed hard, reddish and painful swelling of the whole tongue. In addition, the patient could not close the mouth because of the swollen tongue and lifted floor of the mouth by edematous sublingual tissue. His temperature was 38.5°C. He was not in respiratory distress that no immediate airway management was needed. There was no history of trauma. A mild dehydration was noticeable. Bilateral tender and palpable submandibular lymph node enlargements were present. The white blood cell (WBC) count was 14.200/mm3 with shift to left. Computed tomography (CT) scan with contrast revealed a hypodense area with irregular borders consisted with lingual abscess. (Fig. 1, Fig. 2) The patient had the diagnosis of acute lingual abscess and following the administration of intra-venous fluids, cefazolin sodium, ceftriaxone and metronidazole, multiple needle aspirations were performed under general anaesthesia. Almost 10mL of pus was collected by needle aspirations. On the first postoperative day the size of the tongue reduced dramatically. Culture of the aspirates revealed Staphylococcus epidermidis. The patient was discharged on day three given oral antibiotics.

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3. Case 2 

A 14-year girl was admitted with a 3-day history of odynophagia, dysphagia and otalgia. A history of oral trauma by a fishbone was present seven days before the admission.

She had received oral amoxycillin-clavulanic acid from her primary care physician. Physical examination revealed a tender swelling on the posterior third of the tongue. The patient was afebrile. Laboratory analysis resulted a WBC of 10.500/mm3 with a shift to left. She had a tender and enlarged submandibular lymph node on the right side. CT scan with contrast demonstrated a hypodens area located at the base of the tongue consisted with abscess. (Fig. 3) The same triple antibiotic therapy was initiated and under general anaesthesia immediate needle aspiration of the abscess was performed. However, the culture of the pus did not reveal any bacteria. The patient responded to the antibiotics and was externed on the fifth day given oral antibiotic therapy.

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4. Discussion 

Lingual abscesses are very rare and most of the cases in the literature are adults. The rarity of this condition results in the lack of knowledge in clinical textbooks and lack of experience in diagnosis and management of this entity. The rich blood supply, strong lingual muscles, thickness of the covering mucosa and cleansing action of saliva causes the resistance of tongue against infection during considerable trauma [9].

Lingual abscess is more common on the anterior part and the cause is generally direct trauma. Abscess originating from the posterior third of the tongue is usually due to lingual tonsillar infection, infected tyroglossal cyst or dental origin [3]. In our second case the etiology was direct trauma by a fishbone. However, as in our first case sometimes the etiology may be unknown.

In lingual abscess the most common isolated organisms are Staphylococcus aureus, alpha hemolytic streptococci, Haemophilus spp., Bacteroides spp., and anaerobic cocci [10]. Empric antimicrobial therapy should be effective to aerobic and anaerobic bacteria colonized in oropharynx. Once culture results are available, specific anti-microbial therapy should be administered. We administrated triple antibiotic therapy against gram (+), gram (−) and anaerobic microorganisms for both cases.

Swelling of the tongue, dysphagia, odynophagia, referred otalgia, dyspnea and voluntary fixation of the tongue due to pain are the possible symptoms in lingual abscess [11], [12], [13]. Dyspnea is the most important symptom which should alert the surgeon about airway maintenance. Our patients were not in respiratory stress that airway management was not needed.

Though the diagnosis of lingual abscess can be reached clinically, because of the rarity of the condition in neglected cases the diagnosis can be difficult. Laboratory tests and imaging techniques including CT, ultrasonography, and magnetic resonance imaging can be useful in differential diagnosis [3].

Allergic edema, cysts, lingual artery aneurysms, hemorrhage, arterioveneous malformations and infarction are the other etiologic factors causing acute lingual swelling and they should be considered in differential diagnosis [5], [6], [7], [8].

The management of lingual abscess includes ensuring adequate airway, drainage of the abscess and anti-microbial therapy. Since most of the lingual abscesses are localized in the anterior part of the tongue, they can be managed by medical treatment and drainage. However, abscesses that are involving the posterior third of tongue may cause difficulty in breathing and they may be life threatening. In that cases airway management should be added to the treatment.

The drainage of the abscess may be performed by surgical incisions or needle aspirations. However, incisions have the disadvantages of increased edema and possible airway compromise that needle aspirations seem to be more conservative treatment options [1]. We also preferred needle aspiration in the treatment of our cases and no tongue base edema requiring airway management was seen.

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5. Conclusion 

Lingual abscess is rarely seen because of local resistance factors and it should be kept in mind especially in exposure to oral trauma.

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References 

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PII: S1871-4048(05)00005-5

doi:10.1016/j.pedex.2005.11.001

International Journal of Pediatric Otorhinolaryngology Extra
Volume 1, Issue 1 , Pages 12-14, March 2006

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