(P02) Tongue Tied: Glossitis as a Cause of Dysphagia

Introduction: Dysphagia is a common complaint in the post-acute long- term care (PALTC) setting and can be secondary to a variety of etiology. Broad differential diagnosis and thorough physical exam is necessary for evaluation of dysphagia. Oral examination in older adults is routinely performed less than 20% of the time by physicians. Glossitis as etiology of dysphagia is rare, but oral examination could identify this condition. Treatment is directed at the underlying cause, which could be nutritional deficiency, medication side effect, infection or systemic disease. Thereby, it behooves the PALTC provider to be cognizant of various causes of dysphagia, to be comfortable in, and routinely perform intraoral examination, and to conduct comprehensive evaluation for underlying etiology.

Case Description : We present a case of an 84-year-old female recently discharged to skilled nursing facility (SNF) for rehabilitation following hospitalization for debility, dehydration, and diarrhea secondary to Clostridioides difficile infection complicated by pancolitis and proctitis.  She had been treated with oral vancomycin, IV metronidazole, IV fluids, and required brief medical ICU stay due to fulminant colitis.

During her hospitalization, she developed glossitis, burning pain in her mouth and dysphagia. Physical exam revealed significant edema and erythema of her tongue consistent with glossitis. She developed desquamation of the infero-lateral aspect of her tongue. Evaluation for vitamin deficiencies returned unremarkable. Metronidazole was discontinued and she remained on oral vancomycin on discharge. She continued to have symptoms upon discharge to SNF with notable improvement in her dysarthria and dysphagia associated with glossitis over time.

Discussion: Glossitis is characterized by atrophy of the filiform papillae of the tongue, resulting in a smooth, shiny and erythematous appearance. Symptoms typically include burning sensation, increased sensitivity with acidic or salty foods, or dysphagia in cases where there is extensive edema. Causes of atrophic glossitis include nutritional deficiencies, malnutrition, underlying Celiac disease, candida or lichen planus, and more rarely, drug side effect.

Drug-induced tongue disorders are reported in up to 7% of drugs. Metronidazole is an antimicrobial that has been widely used in the treatment of variety of infections for decades. It has been shown to have affiliation with metallic dysgeusia, headache and dry mouth, but also has been associated with symptoms of glossitis.

It is important for PALTC providers to be familiar with oral examinations of their residents and be able to recognize and diagnose glossitis along with other potential causes of dysphagia. It is important to recognize medications can cause adverse effects of the oral cavity. In particular, metronidazole has been associated with glossitis, although rare.