Reasoning GP · Algorithm · 1-page summary
Tongue problems
For: adults with a tongue ulcer, patch, colour change, swelling, burning, numbness or abnormal movement. Not for: mouth ulcers or a sore mouth elsewhere (mouth ulcers and sore mouth and tongue algorithms) or dental problems (own dentist).
Core rule: retract the tongue with gauze and look at the lateral and ventral borders, then feel for induration and neck nodes. Unexplained oral ulceration over 3 weeks, at any site → NICE NG12 says consider a suspected cancer pathway referral; local safety policy is to refer by default.
0Stop — call 999 now — airway first
- Tongue swelling with stridor, drooling or airway compromise (anaphylaxis or ACE inhibitor angioedema) → 999, ABCDE, anaesthetics/ENT early. Do not examine the back of the tongue.
- IM adrenaline (1 mg/mL, thigh) if airway, breathing or circulation problems: adult and child >12 y 500 µg; 6–12 y 300 µg; 6 months–6 y 150 µg. Repeat after 5 minutes if no improvement.
- ACE inhibitor angioedema (no urticaria; can start years into treatment): antihistamines and steroids do not work; icatibant or C1-inhibitor by hospital protocol only. Stop the ACE inhibitor for good and record it as an allergy.
- SJS/TEN, neutropenic sepsis or deep-neck infection → Immediate hospital
1Triage by lesion — the 3-week rule (NG12)
| Finding | Action |
|---|---|
| Ulcer >3 wk | Unexplained, any site: NG12 “consider”; local default → Suspected cancer pathway |
| Red patch, lump | Red or red-white patch, lip or oral lump: consider → Dental / oral ≤2 wk at first presentation |
| Hard or fixed | Induration, restricted movement, tongue base mass, tonsil asymmetry, earache with a normal ear → Urgent OMFS / ENT |
| White, fixed | Non-wipeable white patch → dental / oral medicine; urgency by red areas, induration, nodes, risk. |
| Ulcer <3 wk | Document and review before 3 weeks; no empirical treatment beyond 3 weeks. |
2Screen — one row is enough
- New unexplained CN XII palsy (wasting, fasciculation, deviates to the weak side) → Urgent neurology + imaging; neck pain, Horner's or other signs → Same-day emergency
- Macroglossia progressing fast, with dysphagia or sleep obstruction → Urgent airway assessment
- Iron deficiency + dysphagia + glossitis (Plummer-Vinson) → Urgent upper-GI pathway + haematology
- Numbness after dental treatment: complete loss, severe dysaesthesia, transection, progressing → Urgent dental / OMFS
- Hairy leukoplakia → offer an HIV test (indicator condition) ≤7 days
- Macroglossia + periorbital purpura or carpal tunnel → electrophoresis, free light chains → haematology
3Assess — whole tongue, floor of mouth, neck
☐ Protrusion and side-to-side movement ☐ Gauze retraction: lateral and ventral borders ☐ Bimanual palpation ☐ Neck nodes ☐ Smoking, alcohol, ACE inhibitor, antibiotics, recent dental work
Targeted tests only: FBC, ferritin, B12, folate; tTG IgA + total IgA; TSH; HbA1c; IGF-1 if acromegaly features. Do not biopsy in primary care or test typical geographic or fissured tongue.
4Classify — only once blocks 0–2 are clear
- Geographic — migrating smooth red patches, white borders; benign → reassure.
- Fissured — deep dorsal grooves; normal variant → gentle tongue brushing.
- Black hairy — antibiotics, smoking, coffee, poor hygiene → remove cause, brush.
- Glossitis — smooth, beefy-red, sore → iron, B12, folate; find the cause.
- Burning mouth — no visible lesion, eases with eating → exclude candida, deficiency, dry mouth, diabetes, thyroid first.
- Uncertain — lump or induration without a clear cause → Urgent OMFS / ENT
5Treat today — doses: NICE/SPC, BNF, local formulary
- Deficiency: treat the confirmed deficiency and its cause; no folic acid until B12 deficiency considered; zinc only if deficient.
- Possible candida under “burning mouth”: fluconazole 50 mg daily for 7 days, or nystatin until 48 hours after resolution.
- Burning mouth: reassure, explain, CBT (NHS Talking Therapies). Clonazepam, tricyclics, gabapentinoids: specialist only.
- Hypothyroid macroglossia: levothyroxine (NG145); TSH every 3 months until stable. Stop smoking; alcohol ≤14 units a week.
6Refer routinely
- Burning mouth not settling (candida and deficiency excluded); recurrent major aphthae → oral medicine.
- Raised IGF-1 with macroglossia or acral change → endocrinology. Macroglossia affecting swallowing or speech → OMFS.
7Never reassure by
- Asking the patient to stick out their tongue: the lateral borders are unseen without gauze.
- A painless ulcer: tongue cancer is often painless at first.
- Repeated topical steroid for an ulcer over 3 weeks.
- Tongue deviation put down to a benign cause: urgent neurology.
- A normal ear in persistent one-sided earache: examine the tongue and oropharynx.
- A red patch seen only recently: refer at first presentation.
8Safety-net — say it, then document it
999 “Call 999 if your tongue swells and you have difficulty breathing or swallowing.” Within a few days: “Contact us — do not wait for it to settle — for a red or white patch that won't rub off, a lump, a hard area, or a tongue that does not move normally.” Give a date: “Come back if any ulcer or changing area has not settled within 3 weeks.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 feature
Lateral and ventral tongue, floor of mouth and neck examined
Size, site, duration recorded; referral made if >3 weeks
Drugs and risks reviewed (ACE inhibitor, smoking, alcohol)
Safety-net given with a 3-week date
Summary of the full Reasoning GP tongue problems algorithm, which holds the detail, examination, causes and evidence. Sources: NICE NG12 (updated April 2026); Resuscitation Council UK anaphylaxis (2021); NICE NG145; BSG iron deficiency anaemia (2021); BHIVA HIV testing. Clinical reference — follow local referral pathways and check doses: NICE/SPC, BNF.