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Black Hairy Tongue - The American Journal of Medicine

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The American Journal of Medicine


Volume 124, Issue 9, Pages 816817, September 2011

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Black Hairy Tongue

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Llus Nisa, MD
, Roland Giger, MD
Department of Otolaryngology, Hpital de Sion, Sion, Switzerland

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DOI: http://dx.doi.org/10.1016/j.amjmed.2011.01.029

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A 62-year-old man, known for alcohol and tobacco abuse, was diagnosed with laryngeal squamous cell carcinoma in
2008. He underwent curative radiotherapy (70 Gy), delivered to the laryngeal and oropharyngeal area as well as the neck.
Follow-up 4 months after this treatment showed recurrence, for which we performed total laryngectomy and bilateral neck
dissection.
Eight months after surgery he was doing well and presented no recurrence, but physical examination showed thick black
hairy lesions on the back of his tongue (Figure). These lesions had appeared and quickly evolved 4 weeks before the
consultation, with no associated symptoms such as pain, dysphagia, or dysgeusia. The patient had not received
antibiotics in the last months. Bacterial and fungal cultures of tongue swab were negative. Basic blood tests showed no
particularity. Thus, we diagnosed the patient with black hairy tongue.

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Figure
Black hairy tongue, poor oral hygiene.

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He was sent to the dentist to improve his oral hygiene, and we recommended brushing the tongue with a toothbrush
several times a day. He continued consuming excessive amounts of red wine, and even though there was some
improvement, the lesions were not completely resolved after 6 months.
This case illustrates black hairy tongue, a condition due to the accumulation of keratin on the filiform papillae of the
tongue, in a patient presenting several predisposing factors: alcohol abuse, a history of smoking, poor oral hygiene, and
status after radiation therapy. Other predisposing factors for this condition are poor feeding, oral infections, and drugs such
as bismuth, tetracycline, linezolid, and olanzapine.1, 2
Black hairy tongue, or lingua villosa nigra, presents as a black coating on the tongue's dorsum, anterior to the
circumvallate papillae. Usually it does not affect the tip or the sides of the tongue, and it represents a particular form of a
wider condition called hairy tongue, for which other colorations have been described (brown, yellow, and green). Most
often asymptomatic, its principal associated problem is of aesthetic order. The main differential diagnosis of hairy tongue
consists of some forms of acanthosis nigricans (which usually involves the lips), hairy oral leukoplakia (white lesions), and
black staining over a normal tongue (bismuth, food colorings).3
Hairy tongue represents a common benign disorder. Its estimated prevalence in a large series of Turkish dental
outpatients is as high as 23.7% (17.8% in men, 5.9% in women).4 Geographic location seems to play an important role in
the global prevalence of tongue lesions, and thus of hairy tongue. As an example, hairy tongue was found as being a very
rare condition in a group of American schoolchildren,5 while it was relatively common in a young population from Finland
(8.4%).6 The reason behind these differences is not clearly elucidated, but oral hygiene habits and variations in the oral
flora seem to be key etiologic factors.
Adult patients are most often concerned, and although black hairy tongue is rare in children, it has been described in
7

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10/31/2014

Black Hairy Tongue - The American Journal of Medicine

pediatric patients as young as 2 months

old.7

Related Articles

Because hairy tongue is a benign and self-limiting disorder, the first therapeutic action consists of eradicating
predisposing factors. Mechanical removal of the lesions, by brushing or scraping, can be very effective. Finally, some
medications such as retinoids, urea solutions, and keratolytic agents can be efficiently used to treat hairy tongue.3, 7

References

Linezolid-Induced Lingua
Villosa Nigra
Marwan Refaat, Emily Hyle,
Rajeev Malhotra, Dominika
Seidman, Bimalangshu Dey
The American Journal of
Medicine, Vol. 121, Issue 6

1. Van-Galvn, S. and Jan, P. Black hairy tongue. Cleve Clin J Med. 2008; 75: 847848
View in Article | CrossRef | PubMed | Scopus (5)

2. Refaat, M., Hyle, E., Malhorta, R. et al. Linezolid-induced lingua villosa nigra. Am J Med. 2008; 121: e1
View in Article | PubMed | Scopus (11)

3. McGrath, E.E., Bardsley, P., and Basran, G. Black hairy tongue: what is your call?. CMAJ. 2008; 178: 11371138
View in Article | PubMed

4. Avcu, N. and Kanli, A. The prevalence of tongue lesions in 5150 Turkish dental outpatients. Oral Dis. 2003; 9: 188
195
View in Article | CrossRef | PubMed | Scopus (32)

5. Redman, R.S. Prevalence of geographic tongue, fissured tongue, median rhomboid glossitis, and hairy tongue
among 3,611 Minnesota schoolchildren. Oral Surg Oral Med Oral Pathol. 1970; 30: 390395
View in Article | PubMed

6. Kullaa-Mikkonen, A., Mikkonen, M., and Kotilainen, R. Prevalence of different morphologic forms of the human
tongue in young Finns. Oral Surg Oral Med Oral Pathol. 1982; 53: 152156
View in Article | PubMed

7. Poulopoulos, A.K., Antoniades, D.Z., Epivatianos, A. et al. Black hairy tongue in a 2-month-old infant. J Paediatr
Child Helath. 2008; 44: 377379
View in Article | CrossRef | PubMed | Scopus (9)

Thomas J. Marrie, MD, Section Editor


Funding: None.
Conflict of Interest: None.
Authorship: Both authors had access to all data and participated in the production of this work.
2011 The Association of Professors of Medicine. Published by Elsevier Inc. All rights reserved.

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