What is the appropriate evaluation and treatment for a patient presenting with lumps on the tongue, considering potential causes such as trauma, infection, or oral cancer?

Evaluation and Management of Tongue Lumps

Any tongue lump that persists beyond 2-3 weeks, particularly on the lateral or ventral tongue in patients over 40 years old, must be referred to an ENT specialist within 2 weeks for urgent evaluation and biopsy to exclude oral squamous cell carcinoma. 1, 2

Immediate Risk Stratification

High-risk features requiring urgent ENT referral within 2 weeks include: 1, 2

• Location: Lateral tongue, ventral tongue, or floor of mouth (highest malignancy risk sites) 2
• Patient age >40 years 1, 2
• Non-homogeneous appearance or ulceration 1, 2
• Induration or firmness on palpation 1, 2
• Persistence >2-3 weeks 3, 2, 4
• Associated cervical lymphadenopathy (firm, fixed nodes >1.5 cm) 1
• Tobacco and/or alcohol use (synergistic risk factors) 3, 1, 2
• Immunosuppression (HIV, transplant, chemotherapy) 2

Red flag symptoms that mandate urgent evaluation: 1

• Ipsilateral ear pain with normal ear examination (referred pain from pharyngeal malignancy) 1
• Odynophagia or dysphagia 1
• Unexplained weight loss 1
• Blood in saliva 1

Initial Clinical Assessment

Attempt to characterize the lesion by clinical appearance: 4, 5

If white, removable plaques are present:

• Scrape with tongue depressor - if easily removable, suspect oropharyngeal candidiasis 4
• Obtain KOH preparation to demonstrate yeast forms 4
• Treat with topical clotrimazole troches or systemic fluconazole 3, 4
• If lesion persists beyond 2 weeks despite antifungal treatment, refer for biopsy to exclude malignancy 4

If black discoloration is present:

• Refer to ENT within 2 weeks for biopsy, as lateral tongue is high-risk for melanoma or carcinoma 2
• Attempt gentle scraping - if removable, may be black hairy tongue (benign) 2, 5
• Document tobacco/alcohol use and immunosuppression status 2

If firm mass, nodule, or non-removable lesion:

• Do not prescribe antibiotics without tissue diagnosis - this is the most common cause of delayed cancer diagnosis 1
• Refer to ENT within 2 weeks for flexible fiberoptic endoscopy and biopsy 1, 2

Pre-Referral Laboratory Testing

Obtain before ENT consultation: 3, 2

• Full blood count (rule out leukemia, anemia) 3
• Coagulation studies (assess surgical risk) 3, 2
• Fasting blood glucose (rule out diabetes; risk factor for fungal infection) 3, 2
• HIV antibody and syphilis serology if risk factors present 3

Imaging Requirements

Contrast-enhanced CT or MRI of the neck is mandatory for suspected malignancy to assess tumor extent and regional lymph nodes 1

The American College of Radiology states both CT and MRI are equally effective, but IV contrast is essential for detecting nodal necrosis 1

Critical Management Pitfalls to Avoid

Never prescribe multiple courses of antibiotics without definitive diagnosis - the American Academy of Otolaryngology-Head and Neck Surgery identifies this as the most common cause of delayed cancer diagnosis and worse outcomes 1, 4

Never assume a cystic or fluctuant tongue mass is benign in adults >40 years - up to 80% malignancy rate in this population 1

Never delay biopsy for persistent lesions - any oral abnormality lasting >2-3 weeks requires tissue diagnosis 3, 4

Benign Conditions That May Present as Tongue Lumps

While urgent referral is appropriate for high-risk features, some benign conditions include: 5

• Geographic tongue (benign, no treatment needed) 5
• Traumatic fibroma (requires biopsy to differentiate from malignancy) 5
• Squamous cell papilloma (requires biopsy) 5
• Pyogenic granuloma (vascular lesion, requires evaluation) 6
• Mucocele (salivary gland obstruction) 6
• Foreign body granuloma (rare, may mimic cancer on imaging) 7
• Tongue abscess (presents with pain, fever, fluctuance; requires incision and drainage) 8

However, biopsy is mandatory to differentiate benign lesions from leukoplakia and squamous cell carcinoma 5

Specific Algorithm for Decision-Making

1. If removable white plaques: Treat for candidiasis; if no resolution in 2 weeks → ENT referral 4
2. If age >40 AND lateral/ventral tongue location: Immediate ENT referral within 2 weeks 1, 2
3. If ulceration, induration, or firmness: Immediate ENT referral within 2 weeks 1, 2
4. If persistence >2-3 weeks regardless of appearance: ENT referral for biopsy 3, 4
5. If tobacco/alcohol use AND any tongue abnormality: Lower threshold for ENT referral 3, 1, 2