Macroglossia - Clinical Features, Complications, Diagnosis and Treatment

What Is the Average Size of the Tongue?

A tongue is a muscular organ seated on the floor of the oral cavity. It has taste buds and serves as a primary organ responsible for the taste sensation. It aids in speech, mastication, swallowing, and natural teeth cleaning processes.

Tongue length is measured from the tongue tip in the front to the epiglottis, a cartilaginous flap present behind the tongue. According to studies, the average length of the tongue is about 3.3 inches in males and 3.1 inches in females. However, there can be slight variations in the length from one individual to another.

What Is Macroglossia?

Macroglossia is a condition characterized by enlargement of the tongue, which is above normal. In the case of macroglossia, the tongue is seen protruding outside the oral cavity or crossing the teeth or alveolar ridges on the sides. A slight increase from the average tongue size is not considered abnormal.

Macroglossia can occur as one single disorder, or in some cases, it can be present along with other medical disorders. It can be due to congenital conditions or acquired causes.

Since the tongue plays a vital role in mastication, speech, etc., having an oversized tongue can bring about difficulties in speech and digestion. The tongue can also block the respiratory pathway when it is abnormally big, leading to breathing difficulties.

What Are the Types of Macroglossia?

Macroglossia is divided into two types, namely

• True Macroglossia:

As the name suggests, it is an actual tongue enlargement. That is, the tongue appears more prominent in size despite the average size of the mouth.

• Relative Macroglossia:

In the case of relative macroglossia, the tongue is of the normal size; however, the relatively reduced size of the oral cavity makes the tongue appear larger. This condition is also known as pseudo macroglossia.

What Causes macroglossia?

A number of conditions can cause macroglossia, which is categorized below:

A. True Macroglossia:

True macroglossia can occur due to congenital or acquired causes.

Congenital Macroglossia -

Below are the congenital abnormalities that cause macroglossia:

• Beckwith-Heidmann syndrome.

• Maroteux-Lamy syndrome.

• Down syndrome.

• Hunter syndrome.

• Apert syndrome.

• Robinow syndrome.

• Hurler syndrome.

• Crouzon syndrome.

• Vascular and lymphatic malformations.

• Multiple endocrine neoplasia type 2B.

• Becker or Duchenne muscular dystrophy.

• Idiopathic muscular hemihypertrophy or hypertrophy.

• Neurofibromatosis type 1.

• Infantile hemangioma (non-cancerous blood vessel tumor).

Acquired Macroglossia -

Certain inflammatory and metabolic conditions cause macroglossia, which includes the following:

• Acromegaly (a condition characterized by increased production of growth hormones).

• Systemic amyloidosis (accumulation of an abnormal protein called amyloid).

• Radiation therapy.

• Hypothyroidism (a condition that occurs due to inadequate thyroid hormone production).

• Amyotrophic lateral sclerosis.

• Trauma or injury to the tongue.

• Surgeries involving the cervical spine, posterior fossa, and craniofacial area.

• Polymyositis.

• Tuberculosis.

• Glossitis.

• Syphilis.

B. Relative Macroglossia:

Below are the most common causes of relative macroglossia:

• Down syndrome.

• A low palatal vault that has reduced the volume of the oral cavity.

• The tongue has been pushed forward in position due to either tonsillar hypertrophy or any tumor.

How Is Macroglossia Manifested?

The following are the symptoms associated with macroglossia:

• The tongue protrudes out of the oral cavity.

• The tongue extends wider than the teeth or alveolar ridge on the lateral aspect.

• Drooling of saliva.

• High-pitched breathing sounds are produced, called stridor.

• Large-sized tongues produce speech difficulties.

• Problems with swallowing and mastication.

• Breathing difficulties may occur.

• Frequent tongue injuries.

• Snoring.

• In some patients, the tip of the tongue can be extended to the nose or chin.

In addition to the above common symptoms, some disease-specific symptoms can also occur with macroglossia. These include,

• Hemihypertrophy:

In hemihypertrophy of the tongue, there is unilateral or one-sided tongue enlargement.

• Tumors of the Tongue:

There is a focal enlargement of the tongue in the case of tongue tumors.

• Lymphatic Malformation:

A lymphatic disorder also produces a focal enlargement; however, in this type, the tongue has a pebbly appearance with numerous vesicle formations.

• Other Conditions:

In hypothyroidism, Beckwith-Weidmann syndrome, and acromegaly, the tongue has a smooth appearance, with the enlargement being more generalized. While in the case of conditions like neurofibromatosis, amyloidosis, and multiple endocrine neoplasias, there is also generalized enlargement, but the surface appears nodular.

How Is Macroglossia Diagnosed?

The following are the diagnostic modalities employed in identifying macroglossia:

• Medical History:

A complete medical history of the patient is taken, which helps determine the causes for the tongue enlargement.

• Physical Examination:

The size of the tongue is measured in relation to the oral cavity. Also, any lesions, discoloration, irregularity in surface, and swelling are identified with the physical examination.

• Blood Picture:

Blood examinations like thyroid function tests are done to detect the cause of tongue enlargement, such as hypothyroidism.

• Imaging Tests:

In the fetal stage, an ultrasound examination of the abdomen can help diagnose macroglossia. Other imaging tests like computerized tomography (CT) scan and magnetic resonance imaging (MRI) are employed to detect abnormalities in the surrounding structures.

• Other Tests:

Biopsy, gene analysis, and fine-needle aspiration cytology (FNAC) are diagnostic tests that help identify any underlying condition present.

How Is Macroglossia Treated?

Treatment for macroglossia is aimed at treating the underlying condition that causes it. In addition, managing the symptoms of macroglossia is needed.

The following are the treatment modalities involved in the treatment for macroglossia:

Medications:

In cases where the underlying conditions causing macroglossia can be treated with medicines, drugs are usually prescribed by the healthcare professional.

The following are some of the conditions that can be treated with drugs:

1. Acromegaly.

2. Hypothyroidism.

3. Tuberculosis.

Speech Therapy:

In patients with speech difficulties, speech therapies may be advised; however, it helps only in cases of mild macroglossia. In this therapy, the patient is trained to improve speech by controlling the tongue's position.

Surgical Approach:

Around one-tenth of the population with macroglossia might need surgery. It involves removing a part of the tongue, and this procedure is called glossectomy. With the help of surgery, drooling of saliva and difficulties in speech and mastication can be corrected. After surgery, orthodontic treatment may be needed to correct the spacing between teeth in some patients.

What Are the Complications of Macroglossia?

Below are the complications that can arise with macroglossia:

• Spacing between teeth can bring about esthetic and periodontal concerns.

• Open bite or inability to close the mouth.

• Lateral borders of the tongue may develop ulcerations.

• Tongue protrusion can result in frequent infections.

• Obstructive sleep apnea.

• Problems with speech.

• Swallowing and chewing difficulties.

• Protrusion of the mandible.

• Stridor or noisy breathing.

Conclusion:

Big tongue or macroglossia can cause a lot of discomfort and difficulty in an individual. Performing dental procedures is also complex in patients with larger tongues. Such patients might require appropriate methods to protect the tongue from iatrogenic damage. Also, using general anesthesia in patients with macroglossia can cause the tongue to fall back, thus obstructing the airway leading to breathing difficulties.