Lingual abscess is a rare disorder, and current knowledge regarding clinical manifestations and treatment modalities has not been well established. This study presented 6 cases of lingual abscess patients between January 2012 and December 2017. There were three men and three women. Median age was 54 years. Odynophagia and local pain were the common presenting symptoms. Local trauma was the main predisposing factor of anterior abscess, while lingual tonsillitis or infected thyroglossal cyst was the predisposing factor of posterior abscess. An impending airway obstruction was identified in two patients, requiring tracheostomy. All patients achieved an excellent outcome with a combination of surgical drainage and proper antibiotics as well as using proper investigation for detecting unusual areas of lingual abscess. According to the data from the study’s results and review of the relevant literature, an abscess located at the anterior two-thirds of the tongue is easy to diagnose while the posterior one-third of the tongue abscess is relative difficulty. Using contrast-enhanced computed tomography increases diagnostic accuracy, especially on the tongue base and deep space infection. The management strategies include (1) protecting the airway, (2) draining the abscess by needle aspiration or surgery, and (3) administering antibiotics early. Our series showed a superiority of surgical drainage when the patients present with marked tissue edema, deep loculated infection, and airway obstruction.
Lingual abscess is an infectious process within the tongue parenchyma [
The current study presents a series of six patients with lingual abscess who had a different degree of severity in clinical presentations with review and summarizes the previous literature relevant to our patients’ conditions in terms of possible pathophysiology, pathogens, predisposing factors, clinical manifestations, diagnosis, and proper management.
The retrospective medical chart review of patients with lingual abscess, who were admitted between January 2012 and December 2017, was performed at the otolaryngology unit. All demographic data, clinical presentations, abscess location, associated risk factors, investigations, surgical drainage, anaesthetic procedure, organism, and managements were studied. Furthermore, patients with airway obstruction and treatment intervention were also recorded. The inclusion criteria were patients admitted in the inpatient unit to receive abscess drainage and antibiotics administration. Some of the patients who presented with deep neck infection concomitant with tongue abscess were included. The exclusion criteria were patients who had underlying diseases of the tongue. The protocol of the investigation has been approved by the Institutional Review Board.
The relevant literature was identified by searching the following databases on March, 2018: Pubmed, Cochrane database of Clinical Trails, Science Direct, and Google Scholar. Lingual abscess or tongues abscess was used as a keyword. We searched for all types of studies about tongue abscess, and 85 articles were identified; however, 23 studies were excluded during the initial search as they were in non-English language. Five case series and 57 case reports met the criteria. All case series were summarized and compared to the result of this case series. In addition, some case reports which had different clinical course were reviewed by focusing on clinical manifestations, location of the abscess, concomitant deep space infection, presentation of airway obstruction, and management.
A 55-year-old Thai man presented with dyspnea for 1 day. The patient had a history of odynophagia and dysphagia for a week. He had a history of poor oral hygiene. On physical examination, he had low-grade fever (38°C), dyspnea, and marked swelling of the base of tongue (BOT) with partial occlusion of the oropharyngeal airway. Complete blood count (CBC) showed his white blood cell (WBC) count was 9300/mm3 with predominant neutrophil. Orobuccal computed tomography (CT) scan revealed the large abscess at the BOT. Tracheostomy and surgical drainage were performed.
A 52-year-old Thai man presented with a painful tongue and odynophagia for 7 days. The patient had a history of well-controlled diabetes mellitus (DM). He denied either trauma or infection at orobuccolingual regions. Also, the patient had poor oral hygiene. Physical examination showed the patient was afebrile (36.6°C). The antero-lateral aspect of the tongue was swollen and fluctuation. The airway was patent. CBC showed WBC was 4500/mm3 with neutrophilic predominance. Surgical drainage was performed under local anaesthesia. The pus culture did not show any organisms. Empirical antibiotics with amoxicillin-clavulanic acid 1.2 g 8 hourly and ceftriaxone 2 g once daily were administrated for 10 days, and the outcome was good.
A 52-year-old Thai woman reported having odynophagia and dysphagia for 1 week. She took amoxicillin for 5 days without signs of improvement. Her symptoms worsened, as did limitation of her tongue movement. She denied local trauma of orobuccolingual regions. Examination showed that her floor of mouth (FOM) and BOT were swollen without airway obstruction. She was afebrile (36.6°C), but her WBC was 14500/mm3. Contrast-enhanced CT scan demonstrated an abscess at the sublingual space and BOT. The pus was drained with the patient under general anaesthesia. The organism was identified as
A 46-year-old Thai woman with poorly controlled DM presented to the emergency department with dyspnea for 1 day. She had odynophagia and dysphagia for 4 days. She denied a history of trauma at orobuccolingual regions. On physical examination, her body temperature was 37.5°C. Limitation of tongue movement and swelling of the tongue and FOM were observed. The oropharyngeal airway was partially obstructed. Contrast-enhanced CT scan showed the abscess confined to the ventral aspect of the tongue with sublingual space cellulitis (Figure
Contrast-enhanced CT scan showed the abscess confined at the ventral aspect of the tongue with sublingual space cellulitis (thick arrow) and marked swelling of anterior floor of mouth was demonstrated (thin arrow).
A 58-year-old Thai male was admitted due to pain in the BOT with referred pain to the ear for 1 week. He had poor oral hygiene. He took amoxicillin for 5 days without clinical improvement. On physical examination, he was afebrile (37.3°C). Pain was detected at the left side of BOT just behind the circumvallate papillae with marked fluctuation. The other orobuccal regions were normal without evidence of airway obstruction. CBC showed WBC was 5500/mm3. Contrast-enhanced CT scan demonstrated an abscess at the left posterior tongue (Figure
Contrast-enhanced CT scan demonstrated an abscess at left posterior tongue (arrow).
Contrast-enhanced CT scan demonstrated an abscess at left posterior tongue with thyroglossal duct cyst (arrow) was also identified without feature of rim enhancement.
A 59-year-old Thai woman reported having mass within her tongue for 10 days. She had mild degree of pain and took amoxicillin-clavulanic acid for 7 days. Her tongue’s mass was still the same size while the pain was resolved. Her oral hygiene was good with no active dental and periodontal conditions. Physical examination showed the patient was afebrile (37°C). The firm mass within the antero-midline of the tongue of about 1.5
All patients’ demographic data are described in Table
Demographic data.
Patient 1 | Patient 2 | Patient 3 | Patient 4 | Patient 5 | Patient 6 | |
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Sex | Man | Man | Woman | Woman | Man | Woman |
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Age (year) | 55 | 52 | 52 | 46 | 58 | 59 |
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Underlying diseases | None | DM & HT | None | DM & HT | None | None |
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Clinical presentations | Odynophagia, Dysphagia, Dyspnea | Odynophagia, Localised pain | Odynophagia, Dysphagia, Limit tongue movement | Odynophagia, Dysphagia, Dyspnea | Localized pain, Refer pain to ear | Tongue mass, Localised pain |
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Duration of symptoms | 1 week | 1 week | 1 week | 4 days | 1 week | 10 days |
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Prior treatment | None | None | Amoxicillin | None | Amoxicillin | Amoxicillin-clavulanic acid |
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Physical examination | Marked swelling of BOT, partial occluded OP airway | Antero-lateral tongue swelling & fluctuation | Swelling of FOM & BOT | Swelling of FOM & ventral tongue, partial occluded OP airway | Swelling of BOT & fluctuation with marked tender | Antero-midline tongue mass |
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Body temperature (°C) | Low grade fever (38°C) | Afebrile (36.6°C) | Afebrile (36.6°C) | Afebrile (37.5°C) | Afebrile (37.3°C) | Afebrile (37°C) |
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Location of tongue abscess | Rt posterior 1/3 | Lt anterior 2/3 | Lt FOM & posterior 1/3 | Midline FOM & antero-ventral surface | Lt posterior 1/3 | Midline anterior 2/3 |
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Deep space of neck infection | None | None | Sublingual abscess | Sublingual cellulitis | None | None |
DM: diabetes mellitus, HT: hypertension, FOM: floor of mouth, BOT: base of tongue, OP: oropharynx.
Investigation, management, and clinical outcome.
Patient 1 | Patient 2 | Patient 3 | Patient 4 | Patient 5 | Patient 6 | |
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Imaging | CT w/ contrast | None | CT w/ contrast | CT w/ contrast | CT w/ contrast | None |
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WBC (cell/mm3) | 9300 | 4500 | 14500 | 12100 | 5500 | 5800 |
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Pathogen | | No growth | | | | No growth |
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Intravenous antibiotics | Amoxicillin-clavulanic acid + ceftriaxone | Amoxicillin-clavulanic acid + ceftriaxone | Clindamycin + ceftriaxone | Clindamycin + ceftriaxone | Amoxicillin-clavulanic acid + ceftriaxone | Amoxicillin-clavulanic acid |
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Duration for antibiotic (IV + oral form) | 2 weeks | 10 days | 2 weeks | 2 weeks | 2 weeks | 1 week |
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Anaesthesia | GA | LA | GA | GA | GA | GA |
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Drainage | Open surgical drainage | Open surgical drainage | Open surgical drainage | Open surgical drainage | Open surgical drainage | Open surgical drainage |
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Airway management | Tracheostomy | None | ETT | Tracheostomy | ETT | None |
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Complication | Impending upper airway obstruction | None | Sepsis | Sepsis, Impending upper airway obstruction | None | None |
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Outcome | Decannulation Day 6 | Good | Good | Decannulation Day 5 | Good | Good |
CT: computer tomographic scan, WBC: white blood count, IV: intravenous, GA: general anaesthesia, LA: local anaesthesia, ETT: endotracheal intubation.
There were 5 case series of 13 patients that correlated with this study (Table
Summary of the prior case series of lingual abscess.
Year | Authors | No. of cases | Case | Sex | Age (y) | Underlying disease | Source of infection | Clinical presentation (severity) | Abscess location | Sub-lingual infection | Anaesthesia | Drainage |
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1970 | Jain HK, et al | 2 | No. 1 | F | 26 | No | No | | Middle 1/3 | No | LA | Aspiration |
No. 2 | F | 4 | No | No | Pain & | Anterior 1/3 | No | LA | I & D | |||
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1996 | Jungell P, et al | 2 | No. 1 | M | 40 | No | No | Pain & | Middle 1/3 | No | LA | I & D |
No. 2 | M | 51 | No | No | Pain & | Middle 1/3 | No | LA | I & D | |||
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2004 | Antoniades K, et al | 3 | No. 1 | M | 55 | Thyroid cancer | Trauma | | Anterior 2/3 | Yes | LA | Aspiration+I&D |
No. 2 | M | 53 | Leukemia | Dental | | Anterior 2/3 | Yes | LA | Aspiration+I&D | |||
No. 3 | M | 49 | DM | Fish bone | | Anterior 2/3 | No | LA | I & D | |||
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2004 | Balatsouras DG, et al | 4 | No. 1 | F | 67 | DM | No | Pain & | Posterior 1/3 | No | LA | Aspiration |
No. 2 | M | 58 | No | No | | Middle +posterior 1/3 | No | LA | Aspiration | |||
No. 3 | M | 44 | No | No | Pain & | Middle 1/3 | No | LA | Aspiration | |||
No. 4 | M | 65 | DM | No | | Posterior 1/3 | No | LA | Aspiration | |||
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2006 | Kiroglu AF, et al | 2 | No. 1 | M | 7 | No | No | | BOT | No | GA | Aspiration |
No. 2 | F | 14 | No | Fish bone | | BOT | No | GA | Aspiration |
F: female, M: male,
The literature review also emphasized that drainage of the pus collection combined with board spectrum antibiotics was the effective management strategy for lingual abscess patients [
Clinical manifestation, location of abscess, and management of our case series and case series from literature review.
Variable | Our case series (n=6) | Literature review (n=13) | Total patient number (n=18) |
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Clinical presentation | |||
Pain + tongue swelling & no dyspnea | 4 | 11 | 14 |
Dyspnea & airway distress | 2 | 2 | 4 |
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Abscess location | |||
Anterior 2/3 (+ Middle 1/3) | 3 | 8 | 10 |
Posterior (base of tongue) | 3 | 5 | 8 |
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Sublingual space infection | |||
Present | 2 | 2 | 4 |
Absent | 4 | 11 | 14 |
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Anaesthesia | |||
LA | 1 | 11 | 12 |
GA | 5 | 2 | 6 |
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Drainage | |||
Needle aspiration | - | 7 | 7 |
I & D | 6 | 4 | 9 |
Aspiration + I & D | - | 2 | 2 |
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Tracheostomy | |||
Required | 2 | - | 2 |
Non-required | 4 | 13 | 16 |
LA: local anaesthesia, GA: general anaesthesia, I & D: incision & drainage.
According to the few cases, the incidence of lingual abscess has not been established. Much evidence has concluded this disorder affects males more often than females [
Pathophysiology of a lingual abscess may be explained by disruption or dysfunction of protective factors and invasion of a pathologic organism [
Many authors subdivided the location of the lingual abscess into oral and BOT [
According to this study, all patients presented with acute form of the lingual abscess which was similar to most of the previous literature. On the other hand, chronic form of lingual abscess can present as a clod abscess [
Careful history taking and physical examination, including orolingual palpation, help provide the exact diagnosis [
The keys to success in managing lingual abscess comprise three domains, including (1) maintaining airway, (2) draining the abscess, and (3) administering antibiotics [
Empirical antibiotics should be broad spectrum to cover the possible organisms originating from the oral cavity and oropharynx [
Clinical spectrum of lingual abscess can range from mild tongue pain to severe upper airway obstruction. Local trauma is the most common predisposing factor of anterior lingual abscess, while lingual tonsillitis or infected thyroglossal cyst are the main predisposing factors of infection of the tongue base. Diagnosis of an anterior lingual abscess is much easier than diagnosis in the posterior part. Contrast-enhanced CT helps diagnose a posterior lingual abscess. To minimize the morbidity and mortality rate, management strategies include (1) maintaining the airway, (2) draining the abscess by using needle aspiration or surgical drainage, and (3) administering antibiotics early, which is guided by bacterial culture. The authors suggested open surgical drainage when the patients present with marked tissue edema, deep space infection, and airway compromise. Conclusions are supported by the provided data. Treatment outcome was usually good. The mortality rates are less than 3% in the modern antibiotic era.
The authors declare that there are no conflicts of interest regarding the publication of this article.