Median Rhomboid Glossitis

Background

Median rhomboid glossitis occurs in the posterior midline of the dorsum of the tongue. They are commonly associated with candida infection and these latter cases are more erythematous. The lesions are usually less than 2 cm and have smooth flat surface. The lesion is benign but should not be overdiagnosed as cancer. A kissing lesion occurs with the midline soft palate comes in contact with the tounge, forming an area of erythema.

OUTLINE

Epidemiology

Disease Associations

Pathogenesis

Histopathological Features and Variants

Prognosis

Treatment

Commonly Used Terms

Internet Links

EPIDEMIOLOGY CHARACTERIZATION

AGE 30-50 years

SEX M:F 3:1

DISEASE ASSOCIATIONS CHARACTERIZATION

ACTINOMYCES

Median rhomboid glossitis: secondary to colonisation of the tongue by Actinomyces (a case report).

Deshpande RB, Bharucha MA.

Department of Pathology, P. D. Hinduja National Hospital and Medical Research Centre, Veer Savarakar Marg, Mahim, Bombay, Maharashtra.
J Postgrad Med 1991 Oct;37(4):238-40 Abstract quote
Median rhomboid glossitis is an inflammatory lesion of the tongue, now believed to be secondary to candidiasis. We document a case of median rhomboid glossitis with heavy colonisation by Actinomyces in a 60-year-old male.

We propose that Actinomyces, like Candida, induces pseudoepitheliomatous hyperplasia of the mucosa of the tongue and florid inflammatory hyperplasia of the underlying connective tissue, resulting in the characteristic elevated lesion.

Actinomyces has not earlier been implicated as a cause of median rhomboid glossitis.

HIV INFECTION

Median rhomboid glossitis. An oral manifestation in patients infected with HIV.

Kolokotronis A, Kioses V, Antoniades D, Mandraveli K, Doutsos I, Papanayotou P.

School of Dentistry, Aristotle University of Thessaloniki, Specific Infectious Diseases Unit, Greece.
Oral Surg Oral Med Oral Pathol 1994 Jul;78(1):36-40 Abstract quote
A follow-up study included the oral examination of 39 persons known to be infected with the human immunodeficiency virus. In addition to the other human immunodeficiency virus-associated oral lesions, lesions clinically similar to the smooth form of median rhomboid glossitis, which is now believed to be erythematous candidiasis located in the dorsum of the tongue, were found in seven patients (18%).

Patients with median rhomboid glossitis were classified in different stages of the Centers for Disease Control 1986 classification system and showed an average of CD+4 cell counts 397.5/mm3. Also the presence or the absence of anti-p24 antibodies in the serum and stimulated whole saliva of the patients with median rhomboid glossitis did not correlate with the stage of the disease or with low levels of CD+4 cell counts as in other forms of oral candidiasis.

Therefore our results suggest that median rhomboid glossitis should be included as a distinct form of oral candidiasis in the classification of the oral manifestations of infection with the human immunodeficiency virus.

PATHOGENESIS CHARACTERIZATION

GENERAL

Tobacco smoking and denture wearing as local aetiological factors in median rhomboid glossitis.

Arendorf TM, Walker DM.
Int J Oral Surg 1984 Oct;13(5):411-5 Abstract quote
The importance of tobacco smoking and denture wearing in the aetiology of median rhomboid glossitis (MRG) has been evaluated in 39 patients. Significantly more of the MRG patients (85%) smoked tobacco compared with the corresponding proportion (41%) of the 39 healthy age-and sex-matched control subjects. Their tobacco consumption was also heavier. A significantly greater proportion of the MRG patients wore their dentures continuously compared with the controls.

The number of MRG patients who were both tobacco smokers and denture wearers was significantly increased above that of the control group, as was the number who both smoked and wore dentures continuously. Only 1 patient neither smoked nor wore dentures and she was taking an antidepressant (imipramine hydrochloride) with a reported association with oral candidosis.

It is suggested that these local factors may play a part in the development of MRG by favouring the local proliferation of Candida albicans on the dorsum of the tongue. Although conservative or surgical treatment may provide relief, management should also include attention to possible predisposing local factors.

CANDIDA

Candida albicans in median rhomboid glossitis. A postmortem study.

van der Wal N, van der Waal I.
Int J Oral Maxillofac Surg 1986 Jun;15(3):322-5 Abstract quote
To investigate the possible role of Candida in median rhomboid glossitis, the presence of Candida was looked for both in the foramen cecum area and the lateral borders of 100 human cadaver tongues. Almost equal %s were found in both locations.

Although extrapolation of findings from postmortem material to normal subjects is somewhat hazardous, the results seem to question the importance of Candida in the etiology of median rhomboid glossitis.

Median rhomboid glossitis caused by Candida?

van der Waal I, Beemster G, van der Kwast WA.
Oral Surg Oral Med Oral Pathol 1979 Jan;47(1):31-5 Abstract quote
The etiology and pathogenesis of median rhomboid glossitis have been subjects of controversial discussions for a long time.

In recent years, the possible role of Candida albicans has been stressed.

The findings in 18 patients with median rhomboid glossitis only support partly the hypothesis of Candida albicans being an important etiologic factor.

HISTOLOGICAL TYPES CHARACTERIZATION

GENERAL

Median rhomboid glossitis: not a misnomer. Review of the literature and histologic study of twenty-eight cases.

Wright BA.
Oral Surg Oral Med Oral Pathol 1978 Dec;46(6):806-14 Abstract quote
A series of twenty-eight cases of median rhomboid glossitis were studied histologically. Of these twenty-eight cases, 85 percent showed fungal hyphae in the parakeratin layer.

The literature is reviewed, and additional evidence is presented to support the theory the median rhomboid glossitis is not a developmental condition but the clinical expression of a localized chronic fungal infection.

VARIANTS

AMYLOIDOSIS

Median rhomboid glossitis associated with amyloid deposition.

Yamoka Y, Suzuki A, Hatakeyama S, Noda M, Hiraga M, Sekiyama S.
Acta Pathol Jpn 1978 Mar;28(2):319-23 Abstract quote
There are some controversies over the pathogenesis and clinical features of median rhomboid glossitis.

A case of median rhomboid glossitis associated with amyloid deposition was presented. Clinically there was no organ involved in amyloid other than the tongue.

It was suspected that median rhomboid glossitis occurred first and that amyloid was induced later.

PROGNOSIS CHARACTERIZATION

GENERAL Benign

TREATMENT CHARACTERIZATION

GENERAL Antifungal therapy will reduce clinical erythema and inflammation due to candida infection

Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.
Rosai J. Ackerman's Surgical Pathology. Eight Edition. Mosby 1996.
Sternberg S. Diagnostic Surgical Pathology. Third Edition. Lipincott Williams and Wilkins 1999.
Robbins Pathologic Basis of Disease. Sixth Edition. WB Saunders 1999.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 5th Edition. McGraw-Hill. 1999.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.

Commonly Used Terms

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Internet Links

Last Updated 5/5/2003

PATHOGENESIS	CHARACTERIZATION
GENERAL
Tobacco smoking and denture wearing as local aetiological factors in median rhomboid glossitis. Arendorf TM, Walker DM.	Int J Oral Surg 1984 Oct;13(5):411-5 Abstract quote The importance of tobacco smoking and denture wearing in the aetiology of median rhomboid glossitis (MRG) has been evaluated in 39 patients. Significantly more of the MRG patients (85%) smoked tobacco compared with the corresponding proportion (41%) of the 39 healthy age-and sex-matched control subjects. Their tobacco consumption was also heavier. A significantly greater proportion of the MRG patients wore their dentures continuously compared with the controls. The number of MRG patients who were both tobacco smokers and denture wearers was significantly increased above that of the control group, as was the number who both smoked and wore dentures continuously. Only 1 patient neither smoked nor wore dentures and she was taking an antidepressant (imipramine hydrochloride) with a reported association with oral candidosis. It is suggested that these local factors may play a part in the development of MRG by favouring the local proliferation of Candida albicans on the dorsum of the tongue. Although conservative or surgical treatment may provide relief, management should also include attention to possible predisposing local factors.
CANDIDA
Candida albicans in median rhomboid glossitis. A postmortem study. van der Wal N, van der Waal I.	Int J Oral Maxillofac Surg 1986 Jun;15(3):322-5 Abstract quote To investigate the possible role of Candida in median rhomboid glossitis, the presence of Candida was looked for both in the foramen cecum area and the lateral borders of 100 human cadaver tongues. Almost equal %s were found in both locations. Although extrapolation of findings from postmortem material to normal subjects is somewhat hazardous, the results seem to question the importance of Candida in the etiology of median rhomboid glossitis.
Median rhomboid glossitis caused by Candida? van der Waal I, Beemster G, van der Kwast WA.	Oral Surg Oral Med Oral Pathol 1979 Jan;47(1):31-5 Abstract quote The etiology and pathogenesis of median rhomboid glossitis have been subjects of controversial discussions for a long time. In recent years, the possible role of Candida albicans has been stressed. The findings in 18 patients with median rhomboid glossitis only support partly the hypothesis of Candida albicans being an important etiologic factor.

Epidemiology
Disease Associations
Pathogenesis
Histopathological Features and Variants
Prognosis
Treatment
Commonly Used Terms
Internet Links

EPIDEMIOLOGY	CHARACTERIZATION
AGE	30-50 years
SEX	M:F 3:1

DISEASE ASSOCIATIONS	CHARACTERIZATION
ACTINOMYCES
Median rhomboid glossitis: secondary to colonisation of the tongue by Actinomyces (a case report). Deshpande RB, Bharucha MA. Department of Pathology, P. D. Hinduja National Hospital and Medical Research Centre, Veer Savarakar Marg, Mahim, Bombay, Maharashtra.	J Postgrad Med 1991 Oct;37(4):238-40 Abstract quote Median rhomboid glossitis is an inflammatory lesion of the tongue, now believed to be secondary to candidiasis. We document a case of median rhomboid glossitis with heavy colonisation by Actinomyces in a 60-year-old male. We propose that Actinomyces, like Candida, induces pseudoepitheliomatous hyperplasia of the mucosa of the tongue and florid inflammatory hyperplasia of the underlying connective tissue, resulting in the characteristic elevated lesion. Actinomyces has not earlier been implicated as a cause of median rhomboid glossitis.
HIV INFECTION
Median rhomboid glossitis. An oral manifestation in patients infected with HIV. Kolokotronis A, Kioses V, Antoniades D, Mandraveli K, Doutsos I, Papanayotou P. School of Dentistry, Aristotle University of Thessaloniki, Specific Infectious Diseases Unit, Greece.	Oral Surg Oral Med Oral Pathol 1994 Jul;78(1):36-40 Abstract quote A follow-up study included the oral examination of 39 persons known to be infected with the human immunodeficiency virus. In addition to the other human immunodeficiency virus-associated oral lesions, lesions clinically similar to the smooth form of median rhomboid glossitis, which is now believed to be erythematous candidiasis located in the dorsum of the tongue, were found in seven patients (18%). Patients with median rhomboid glossitis were classified in different stages of the Centers for Disease Control 1986 classification system and showed an average of CD+4 cell counts 397.5/mm3. Also the presence or the absence of anti-p24 antibodies in the serum and stimulated whole saliva of the patients with median rhomboid glossitis did not correlate with the stage of the disease or with low levels of CD+4 cell counts as in other forms of oral candidiasis. Therefore our results suggest that median rhomboid glossitis should be included as a distinct form of oral candidiasis in the classification of the oral manifestations of infection with the human immunodeficiency virus.

HISTOLOGICAL TYPES	CHARACTERIZATION
GENERAL
Median rhomboid glossitis: not a misnomer. Review of the literature and histologic study of twenty-eight cases. Wright BA.	Oral Surg Oral Med Oral Pathol 1978 Dec;46(6):806-14 Abstract quote A series of twenty-eight cases of median rhomboid glossitis were studied histologically. Of these twenty-eight cases, 85 percent showed fungal hyphae in the parakeratin layer. The literature is reviewed, and additional evidence is presented to support the theory the median rhomboid glossitis is not a developmental condition but the clinical expression of a localized chronic fungal infection.
VARIANTS
AMYLOIDOSIS
Median rhomboid glossitis associated with amyloid deposition. Yamoka Y, Suzuki A, Hatakeyama S, Noda M, Hiraga M, Sekiyama S.	Acta Pathol Jpn 1978 Mar;28(2):319-23 Abstract quote There are some controversies over the pathogenesis and clinical features of median rhomboid glossitis. A case of median rhomboid glossitis associated with amyloid deposition was presented. Clinically there was no organ involved in amyloid other than the tongue. It was suspected that median rhomboid glossitis occurred first and that amyloid was induced later.