What is the treatment for a tongue infection?

Treatment of Tongue Infection

For bacterial tongue infections (tongue abscess), immediate incision and drainage under general anesthesia combined with broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria is the definitive treatment; for fungal tongue infections (median rhomboid glossitis with candidiasis), topical or systemic antifungal therapy is first-line.

Bacterial Tongue Infections (Tongue Abscess)

Immediate Management

• Tongue abscess requires urgent surgical intervention with incision and drainage under general anesthesia to prevent life-threatening airway compromise 1, 2
• Needle aspiration can provide diagnostic confirmation and temporary symptom relief, but definitive drainage is necessary 1
• The abscess pocket should be thoroughly irrigated with normal saline and 2% hydrogen peroxide after drainage 2

Antibiotic Coverage

• Empiric antibiotic therapy must cover gram-positive, gram-negative, and anaerobic organisms given the polymicrobial nature of oral infections 2
• Continue antibiotics for 7-14 days post-drainage with clinical monitoring 2
• The tongue's rich vascular supply and lymphatic drainage typically prevent abscess formation, so when present, aggressive treatment is warranted 2

Critical Warning Signs

• Acute tongue swelling with throbbing pain, fever, difficulty swallowing, drooling, and respiratory difficulty indicate potential abscess requiring immediate evaluation 1, 2
• Any acute tongue swelling in immunocompromised patients should raise high suspicion for abscess formation 1
• Airway compromise and disseminated infection to deep neck spaces are life-threatening complications requiring emergency intervention 1

Fungal Tongue Infections

Candidal Infections (Median Rhomboid Glossitis)

• For symptomatic candidal tongue infections, fluconazole 100-200 mg daily for 7-14 days is first-line systemic therapy 3, 4
• Topical antifungals (clotrimazole troches 10 mg 5 times daily or nystatin suspension 100,000 U/mL, 4-6 mL four times daily) are appropriate for mild cases 3
• Median rhomboid glossitis often improves with antifungal treatment when symptomatic 4

Treatment Duration and Monitoring

• Continue treatment for the full 7-14 day course even if symptoms resolve earlier 3
• For fluconazole-refractory cases, itraconazole solution (>200 mg/day orally) is effective in approximately two-thirds of cases 3
• Intravenous amphotericin B (0.3-0.7 mg/kg/day) is reserved for otherwise refractory disease 3

Special Considerations for Immunocompromised Patients

• HIV-infected or severely immunocompromised patients require more aggressive initial therapy and may need suppressive therapy with fluconazole 100-200 mg three times weekly for recurrent infections 3
• Antiretroviral therapy reduces recurrent fungal infections in HIV-infected patients 3

Common Clinical Pitfalls to Avoid

Diagnostic Errors

• Do not delay surgical drainage of suspected tongue abscess—clinical diagnosis is sufficient in acute cases 1
• Fungal cultures of the tongue are of little benefit as many individuals have asymptomatic colonization 3
• Distinguish between infectious glossitis requiring antimicrobial therapy and benign conditions (geographic tongue, fissured tongue, black hairy tongue) that require no treatment 4

Treatment Mistakes

• Never use systemic antifungals for uncomplicated superficial fungal infections—reserve for invasive or refractory disease 5
• Azole-refractory fungal infections are more common in patients with prior azole use and severely immunocompromised states 3
• For bacterial infections, inadequate antibiotic coverage of anaerobes is a common cause of treatment failure 2

Monitoring Failures

• If no improvement occurs within 48-72 hours of antifungal therapy, reassess the diagnosis and consider alternative causes 5
• Post-drainage tongue abscess patients should be monitored for at least 48 hours before discharge 2