What is the cause and appropriate treatment for pain under the right tongue and slight swelling on the right side of the cheek?

Evaluation and Management of Pain Under Right Tongue with Slight Cheek Swelling

The most likely diagnosis for pain under the right tongue with slight cheek swelling is burning mouth syndrome or glossopharyngeal neuralgia, requiring thorough oral examination and appropriate imaging to rule out more serious conditions.

Initial Assessment

Key Diagnostic Considerations:

• Burning Mouth Syndrome (BMS): Characterized by burning sensation primarily affecting the tongue, lips, and buccal mucosa with normal-appearing oral mucosa 1
• Glossopharyngeal Neuralgia: Presents as severe pain in the oropharyngeal region, sometimes triggered by swallowing 2
• Tongue Abscess: Though rare, can present with tongue swelling, pain, and difficulty swallowing 3
• Oral Candidiasis: May present with white annular lesions and pain 4
• Malignancy: Should be considered especially in patients with risk factors 5

Physical Examination Focus:

• Examine the oral cavity thoroughly, including:
  • Tongue mobility (limited mobility may indicate muscle or nerve invasion) 2
  • Presence of ulcers, masses, or abnormal coloration 2
  • Palpation of the floor of the mouth and tongue 2
  • Assessment of the oropharynx using bright light and tongue depressor 2

Diagnostic Approach

Step 1: Rule Out Serious Conditions

• Malignancy: Older patients with history of tobacco/alcohol use or younger patients with HPV infection require careful evaluation 2
• Abscess: Check for fluctuance, erythema, and signs of infection (fever) 3
• Referred Pain: Assess for TMJ syndrome, dental pathologies, or upper aerodigestive tract cancer 2

Step 2: Imaging Considerations

• MRI of face and neck: Recommended for persistent unexplained pain to evaluate the course of cranial nerves, particularly glossopharyngeal nerve (CN IX) 2
• CT neck: Complementary to MRI in assessing isolated CN IX palsy, can identify deep space neck masses 2

Step 3: Laboratory Testing

• Consider complete blood count if infection is suspected
• Evaluate for nutritional deficiencies if atrophic glossitis is present 6

Treatment Algorithm

For Burning Mouth Syndrome:

1. Patient education and reassurance about the chronic nature of the condition 1
2. Topical treatments:
   • Topical clonazepam for symptom relief
   • High-potency topical corticosteroid gel for temporary relief 1
3. Systemic medications:
   • Gabapentin starting at 300 mg daily with gradual titration 1
   • Alpha-lipoic acid has shown effectiveness in controlled trials 6
4. Cognitive behavioral therapy for patients with psychological factors 1
5. Salivary stimulants if dry mouth is present 1

For Glossopharyngeal Neuralgia:

1. First-line medication: Carbamazepine remains the primary drug of choice 2
2. Alternative medications:
   • Oxcarbazepine (equally effective with fewer side effects)
   • Lamotrigine and baclofen have some evidence of efficacy 2
3. Surgical interventions if medications are ineffective or poorly tolerated 2

For Tongue Abscess:

1. Antibiotics covering gram-positive and gram-negative anaerobes 3
2. Incision and drainage under appropriate anesthesia 3
3. Pocket irrigation with normal saline 3

For Oral Candidiasis:

1. Topical antifungals for localized infections 2, 4
2. Systemic antifungals for more extensive infections 4

Important Caveats

1. Misdiagnosis Risk: Tongue lesions of unclear etiology may require biopsy or referral to an oral and maxillofacial surgeon 6

2. Atypical Presentations: Some tongue abscesses may present as slowly growing, moderately painful swellings mimicking malignancy 7

3. Referred Pain: Pain under the tongue may be referred from other structures, including TMJ or dental pathologies 2

4. Medication Side Effects: Consider if symptoms began after starting new medications 1

5. Follow-up: Regular follow-up is essential, especially if symptoms persist despite appropriate treatment 1

If symptoms persist despite initial management, referral to a specialist (otolaryngologist, oral surgeon, or neurologist) is warranted for further evaluation and management.