What is the treatment for bilateral enlarged bumps on the back of the tongue?

Bilateral Enlarged Bumps on Back of Tongue

Most Likely Diagnosis: Normal Lingual Tonsils

The bilateral enlarged bumps on the back of the tongue are most likely normal lingual tonsils, which require no treatment unless symptomatic or associated with concerning features such as asymmetry, ulceration, rapid growth, or systemic symptoms. 1

Initial Assessment

The key to management is distinguishing normal anatomic structures from pathologic lesions through focused history and examination:

Critical History Elements to Obtain:

• Duration and progression: Sudden onset versus longstanding 2
• Associated symptoms: Pain, dysphagia, odynophagia, otalgia, weight loss, hemoptysis, or hoarseness suggest malignancy 2
• Risk factors for malignancy: Age >40 years, tobacco use, alcohol abuse, immunocompromised status, multiple sexual partners, or history of HPV exposure 2
• Infectious symptoms: Fever, night sweats, recent upper respiratory infection 2
• Systemic conditions: Immunosuppression, diabetes, recent antibiotic use 2

Physical Examination Findings to Document:

• Symmetry: Bilateral symmetric enlargement of lingual tonsils is typically benign, while asymmetry raises concern for malignancy 2
• Surface characteristics: Smooth versus ulcerated, color (normal pink versus erythematous or white), presence of exudate 2, 1
• Consistency: Soft versus firm or hard masses 2
• Mobility: Limited tongue mobility suggests muscle or nerve invasion from tumor 2
• Cervical lymphadenopathy: Nontender neck masses are more suspicious for malignancy than tender masses 2

Management Algorithm

If Bilateral, Symmetric, Non-Tender, Without Red Flags:

Reassurance and observation are appropriate. 1 Lingual tonsils are normal lymphoid tissue located at the base of the tongue and commonly appear as bilateral bumps. 2

If Associated with White Coating or Plaques:

• Consider candidiasis: Scrape lesion and examine with KOH preparation 3
• Treatment: Topical antifungals if candidiasis confirmed 1

If Red Flags Present (Requires Further Workup):

Red flags include: 2

• Unilateral or asymmetric enlargement
• Ulceration or irregular surface
• Firm or fixed consistency
• Associated symptoms (dysphagia, odynophagia, otalgia, weight loss)
• Tobacco/alcohol use with age >40 years
• Persistent symptoms >2-3 weeks

Action: Refer to otolaryngology for flexible laryngoscopy and possible biopsy 2

If Symptomatic (Dysphagia, Airway Obstruction):

• Enlarged lingual tonsils can cause obstructive symptoms, particularly in sleep apnea patients 2
• Surgical options include lingual tonsillectomy or tongue base reduction procedures, though these carry significant risks including postoperative edema requiring temporary tracheotomy 2
• Refer to otolaryngology for evaluation 2

Common Pitfalls to Avoid

• Do not dismiss asymmetric lesions: Tonsil asymmetry or unilateral masses require specialist evaluation to exclude malignancy 2
• Do not overlook malignancy risk factors: In patients >40 years with tobacco/alcohol use, maintain high suspicion even for seemingly benign lesions 2
• Do not assume all bilateral lesions are benign: While bilateral symmetric lingual tonsils are typically normal, bilateral pathology can occur (e.g., lymphoma, bilateral infections) 2
• Do not delay referral for persistent unexplained lesions: Lesions that persist beyond 2-3 weeks without clear benign etiology warrant specialist evaluation 2

When to Biopsy

Biopsy is indicated for: 2

• Any unilateral or asymmetric tongue base mass
• Ulcerated lesions without clear infectious etiology
• Firm or fixed masses
• Lesions in high-risk patients (age >40, tobacco/alcohol use)
• Lesions persisting >2-3 weeks despite appropriate treatment
• Any lesion with concerning features on flexible laryngoscopy