Lingua villosa nigra (LVN), also called black hairy tongue, is a common benign condition with many known predisposing factors. When LVN shows no or modest improvement after conservative treatment, additional examinations should be performed to identify the underlying cause. Here we report a case in which therapy-resistant (LVN) was found to be related to a Zenker’s diverticulum associated with gastro-esophageal reflux disease (GERD). A 75-year-old woman presented with black discoloration of the tongue and halitosis, which had been present for years. Examination of the gastrointestinal tract revealed a Zenker’s diverticulum (ZD) in association with GERD. The resulting acidic oral mucosa, combined with regurgitation of food from the diverticulum, led to the LVN. After diverticulum treatment by a cricopharyngeal myotomy, the patient’s symptoms disappeared and there was no recurrence.
In a patient with a Zenker’s diverticulum, the combination of food regurgitation and an acidic oral mucosa can lead to lingua villosa nigra. The presently described case highlights the need for a thorough examination of the patient’s underlying conditions when conservative interventions for LVN are ineffective.
Lingua villosa nigra (LVN), also called black hairy tongue, is a benign disorder.
When conservative treatments for LVN are ineffective further examination is needed.
This article reports a rare association between LVN and a Zenker’s diverticulum.
Lingua villosa nigra (LVN), also called black hairy tongue, is a benign disorder that was first described by Amatus Lusitanus in 1557 [ ]. In LVN, the tongue appears hairy due to hypertrophy and elongation of the filiform papillae on the dorsum.
LVN is a common disorder that is usually asymptomatic and self-limiting. However, the condition can also be associated with symptoms, such as altered taste (metallic taste), a burning sensation on the tongue, halitosis, gagging, and nausea [ ]. Furthermore, the appearance of a hairy tongue is perceived as a barrier to oral intimacy. There are no reliable data concerning LVN prevalence, but estimates range from 0.06% in children to 11.3% [ ]. This wide range is due to a strong correlation between prevalence and geographic location, which influences the oral hygiene habits and the oral flora. The prevalence is higher among males, heavy smokers, and individuals who heavily consume coffee and tea [ ]. This condition is most common in elderly patients, with the higher prevalence of edentulism in this population being a contributing factor. However, in rare cases, it can occur in infants as young as 8 weeks [ , ].
The etiology of LVN has not been clearly defined. Many predisposing factors have been described, including poor oral hygiene, either by choice or due to limited self-sufficiency (e.g., in patients with amyotrophic lateral sclerosis) [ ]. Other factors include smoking, radiation, malignancy, emotional stress, Candida albicans , antiseptic oxidizing mouthwashes, oral surgery, abuse of alcohol or other drugs, trigeminal neuralgia [ ], xerostomia, acquired immunodeficiency syndrome, interferon therapy, oral antibiotics, and medicines that induce xerostomia (e.g., atypical antipsychotics, antidepressants, and anticholinergics) [ ]. This is the first case report to describe an association between lingua villosa nigra and a Zenker’s diverticulum.
A 75-year-old female patient presented at the Department of Oral and Maxillofacial Surgery with complaints of a black discoloration of the tongue and accompanying halitosis, which had been present for several years. The lesion on the tongue was not painful, but the patient was mainly concerned about the aesthetic consequences and related social problems.
The patient had a history of alcohol abuse (several years earlier). She did not have a history of smoking, was currently retired, and claimed to have no emotional stress. She occasionally drank coffee and tea. She was currently being treated by a psychiatrist for depression, for which she took the selective serotonin reuptake inhibitor (SSRI) citalopram. She also suffered from arterial hypertension and atrial fibrillation, for which she took propafenone (Rytmonorm), bisoprolol, and fenprocoumon (Marcoumar) daily. Other medications included pantoprazole (Pantomed) and lormetazepam, which had been prescribed many years ago. She was regularly seeing her general practitioner for these morbidities. She was not taking any antibiotics at the time of the consultation. Of these pharmaceutical agents, propafenone, pantoprazole, lormetazepam, and citalopram are all drugs that can have xerostomy as a side effect, which can be associated with drug-induced LVN [ ].
Intra-oral examination revealed black discoloration of the tongue with a hairy appears due to hypertrophy and elongation of the filiform papillae on the dorsum ( Fig. 1 ). The patient was also missing multiple teeth, and she wore a partial prosthesis. Her oral hygiene was moderate, with plaque accumulation and some tartar, but no other abnormalities were seen in the oral cavity. Halitosis was present. Due to the black discoloration and hairy appearance of the tongue, the lesion was diagnosed as LVN.