A healthy 4-year-old girl presented to the emergency department (ED) with suspected inflicted burns on the tongue. Initially, the patient had complained of a burning mouth to school staff. On direct questioning by the principal, the child said her mother had burned her tongue with a cigarette. School staff noted the lesions depicted here. The child was taken to the local ED where she was evaluated. The diagnosis was cigarette burns, which caused the regular and sharp margins of the lesions and the burning sensation.
The Child Protective Services (CPS) staff referred the patient to an abuse specialist for a second opinion. The mother reported the child's oral lesions had been present for quite some time. Only their location and severity had changed. At the time of the evaluation, the patient was able to eat and drink normally. Physical examination results were normal except for a red plaque on the tongue with a well-demarcated irregular white border. The lesion was nontender. There were no other indications of abuse. Specifically, the skin was free of bruises, scars, burns, or other suspicious findings.
Is this lesion an inflicted cigarette burn, or is there another answer?
(Answer and discussion on next page.)
Answer: Geographic tongue (benign migratory glossitis)
Geographic tongue, or benign migratory glossitis, was first described in 1831 by Rayer.1 This recurring inflammatory disorder is characterized by loss of filiform papillae on the tongue. On examination, the lesions appear as erythematous plaques surrounded by an irregular white border. They are commonly found on the dorsum and lateral borders of the anterior two thirds of the tongue. However, geographic tongue can also be seen in unusual sites, such as the palatal mucosa, labial mucosa, and floor of the mouth.2
Red Patches on a 10-Year-Old’s Tongue
The cause of geographic tongue is unknown. This condition seems to run in families, which suggests some genetic predisposition. There are several reports showing an association with conditions such as psoriasis, Down syndrome, allergies, juvenile diabetes mellitus, and stress.Diagnostic Considerations
Most patients with geographic tongue are asymptomatic. Occasionally, children may present with difficulty in eating and sleeping because of a burning sensation in the mouth. They may also be sensitive to hot or spicy foods.
The onset and movement of lesions in geographic tongue can be rapid. Lesions may last a few weeks to a few months. No diagnostic test is available, and none is needed for the diagnosis, which is usually made on clinical grounds. Reassurance is the only necessary treatment.3
Several factors were present in our patient's case that allowed differentiation between a cigarette burn and geographic tongue. First, the patient's mother had similar lesions (Figure), which supported a diagnosis of geographic tongue. In addition, the characteristic migration of the lesions and longer-term presence helps distinguish geographic tongue from the nonmigratory lesions caused by cigarette burns. Finally, burn components, such as eschar and signs of tissue coagulation would not be present in a child with geographic tongue.
A couple of items should be considered. First, any history of alleged abuse, even if odd, should not be automatically discounted. Keep in mind that abuse and the medical condition could coexist. Second, a follow-up examination--perhaps in several weeks--can allow verification of the condition (including its migratory nature) and strengthen the confidence you have that the child is safe.
In this child's case, CPS did not substantiate abuse after a thorough investigation. Perhaps the most important point to be raised here is the care that must be used in questioning children about potential abuse.
It is not entirely clear why this child implicated her mother. However, if (like the principal in this case) one asks a young child a direct question along the lines of "Did mommy burn your tongue?"--false answers can be given. Young children generally believe that the adult questioner knows the answers and is only asking to see whether the child is telling the truth. Young children are usually brought up to tell the truth, and they may answer "yes" even though the answer is not necessarily true. This is why direct and leading questions are fraught with difficulty in young children. When possible, open-ended questions are best: direct questions should be avoided. When a direct question is needed, follow-up answers should be open-ended and invite a free narrative. *