 

Prenat. Diagn. 18: 577–580 (1998)

TRANSVAGINAL SONOGRAPHIC
MEASUREMENT OF FETAL LINGUAL WIDTH
IN EARLY PREGNANCY
 ,  . ,  ,  ,   
 *
Departments of Obstetrics and Gynecology, and Neonatology, Rambam Medical Center, Faculty of Medicine,
Technion—Israel Institute of Technology, Haifa, Israel

Received 19 May 1997

Revised 13 August 1997
Accepted 21 September 1997

SUMMARY
Our objective was to construct a nomogram of the fetal lingual size in early pregnancy and to assess the size of the
tongue in abnormal fetuses. The lingual width was measured by using transvaginal ultrasonography in 80 normal
fetuses at 13 and 18 weeks’ gestation. In addition the tongue was measured in 22 fetuses at these gestational ages who
had an abnormal karyotype or oro-facial malformations. A linear relationship was found between the lingual width
and gestational age in normal fetuses. The lingual size was within the normal range in cases of trisomy 13, trisomy
21 and Turner syndrome. A small tongue was observed in fetuses with micrognathia. Correlation between lingual
width and gestational age was observed in early pregnancy. The relationship between the size of the tongue and
oro-facial malformations needs further evaluation.  1998 John Wiley & Sons, Ltd.
 : lingual width; transvaginal sonography; fetus; malformations; early pregnancy

INTRODUCTION To date there is only one study on fetal tongue

Ultrasonographic assessment of the fetal tongue
is of importance, since abnormal lingual size
can be associated with more than 25 syndromes
and diseases (Gupta, 1971; Rice and Stephens,
1985; Reynoso et al., 1986; Petersen et al., 1987;
Jones, 1988). A large tongue is frequently found
in Beckwith–Wiedeman syndrome, gangliosidosis,
athyrotic hypothyroidism sequence, trisomy 4p
and autosomal dominant macroglossia. It may be
seen occasionally in conditions such as trisomy 21,
Hurler syndrome, Robinow syndrome, Scheie syn-
drome and others. A small tongue may be noted
frequently in the oromandibular-limb hypogenesis
spectrum and in the hypoglossia-hypodactyly syn-
drome, and may be found occasionally in other
syndromes (Table I).
circumference in the first half of pregnancy
(Achiron et al., 1997). However, since the proxi-
mal lingual edge has no well-defined border, an
accurate measurement of the length of the tongue
is difficult or even impossible.
In the present study we used a vaginal ultra-
sound transducer to measure the maximal lingual
width of fetuses at 13–18 weeks’ gestation, thus
attempting to establish a nomogram for lingual
width at these gestational ages. In addition, we
assessed lingual width in fetuses with pathological
findings, such as chromosomal aberrations, facial
clefts and other oro-facial dysmorphism.
MATERIALS AND METHODS

*Correspondence to: Shraga Blazer, Department of Neo-

Fetal tongue width measurements were obtained
natology, Rambam Medical Center, POB 9602, Haifa 31096, prospectively in 80 consecutive normal single-
Israel. ton pregnancies at 13–18 weeks’ gestation. The

CCC 0197–3851/98/060577–04 $17.50

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578 .   .
Table I—Syndromes and diseases associated with abnormalities of the tongue size

Macroglossia:
Frequent in:
Athyrotic hypothyroidism sequence
Beckwith–Wiedemann syndrome
Generalized gangliosidosis syndrome type I
Trisomy 4p syndrome
Trisomy 22 syndrome (Petersen et al., 1987)
Autosomal dominant macroglossia (Reynoso et al., 1986)
Occasional in:
Trisomy 21 syndrome
Hurler syndrome
Killian/Teschler–Nicola syndrome
Maroteaux–Lamy mucopolysaccharidosis syndrome
Robinow syndrome
Scheie syndrome
Schinzel–Giedion syndrome
Triploidy syndrome
Lingual thyroid (Rice and Stephen, 1985)
Lymphangioma (Rice and Stephen, 1985)
Neurofibromatosis (Rice and Stephen, 1985)
Lingual hemangioma (Gupta, 1971)

Microglossia:
Frequent in:
Oromandibular-limb hypogenesis spectrum
Occasional in:
Arthrogryposis syndrome type II
Freeman–Sheldon syndrome
Lenz–Majewski hyperostosis syndrome
Moebius sequence
Pallister–Hall syndrome
Short rib–Polydactyly, Majewski type

The unreferenced disorders refer to Jones (1988).

measurements were done during routine ultra-
sound examinations at the Rambam Medical
Center, Haifa, Israel. Each patient was studied
only once during gestation, and all the measure-
ments were done by a single observer. In order to
assess the intra-observer variability, five repeated
measurements were done in 20 patients. In the
study group three repeated measurements were
performed in each patient, and the largest measure-
ment was obtained for statistical analysis for the
nomogram. Ultrasonography was performed using
6·5 and 7·5 MHz transvaginal transducers (ESI
1000 and ESI 3000; Elscint Ltd, Haifa, Israel).
In each case gestational age was confirmed
based on the last menstrual period, vaginal
examination and/or ultrasound examination in the
first trimester. All patients underwent a complete
ultrasonic survey for fetal anomalies as well
as biometric measurements. Lingual width was
defined as the maximal width achieved on a
tangential coronal view of the fetal face (Fig. 1).
Paediatric examination after delivery confirmed
that all these 80 fetuses were normal.
In addition to the normal fetuses, measurements
of lingual width were performed in 22 fetuses at
13–18 weeks’ gestation who had chromosomal
aberrations or oro-facial malformations. Both
groups of patients represent consecutive normal
and abnormal fetuses. Obviously, the abnor-
mal fetuses were scanned at different and longer
times because of the low incidence of fetal
anomalies.

 1998 John Wiley & Sons, Ltd. Prenat. Diagn., 18: 577–580 (1998)
        579
STATISTICS

The maximal width of the tongue measurements

Fig. 1—Maximal width of the tongue as measured trans-
vaginally on a tangential coronal view of a fetus at 15 weeks’
gestation
were examined for dependency on gestational age
at a given period. A least square regression
line was fitted through the measurements scatter
diagram. The 95 per cent confidence intervals
for the calculated values were also plotted. The
normality assumption of the linear regression was
graphically verified by normal probability paper.
Residuals were analysed for trends as described by
Draper and Smith (1981).
The results of the regression analysis are shown
in Table II. The high value of the multiple
R-square indicates that a straight line with ‘a’ and
‘b’ as in Table II is an adequate fit to actual lingual
width measurements. In other words, the linear
model represents quite faithfully the actual growth
of a tongue during the observation period.

Table II—Summary of results for maximal lingual width RESULTS

measurements
Nomograms were established for fetal tongue
Number of Value of Slope Intercept Standard width at 13–18 weeks in 80 normal fetuses. The
observations multiple R2 ‘a’ ‘b’ error
growth of the lingual width diameter was found to
be linear at these gestational ages (Fig. 2). The
80 0·83 0·15
1·4 0·0079 coefficient of correlation for intraobserver vari-
ability was 0·95. In six fetuses lingual measurement

Fig. 2—Lingual width as a function of gestational age at 13–18 weeks. The continuous line
represents the predicted mean by regression analysis and the dotted lines represent the upper
and lower 95 per cent confidence limits. Circles represent individual data

 1998 John Wiley & Sons, Ltd. Prenat. Diagn., 18: 577–580 (1998)
580 .   .
was not technically possible in the initial examina-
tion because of fetal head position. However, on
repeated scan an hour later, measurements were
possible due to the change of fetal position.
Lingual width was also measured in 22
abnormal fetuses. 15 fetuses with chromosomal
aberrations were studied: five with trisomy 21
(14–18 weeks), four with trisomy 13 (13–18 weeks),
three with trisomy 18 (14–17 weeks) and three with
Turner syndrome (15–18 weeks). In all these cases
the width of tongue was within the range observed
in the normal fetuses. The lingual width of all four
fetuses with cleft palate (three of them with
additional cleft lip; 13–15 weeks), was also in the
normal range. Three cases with micrognathia were
studied: two had Pierre Robin syndrome and one
had Meckel–Gruber syndrome. Lingual width
could not be exactly defined in one additional fetus
with Pierre Robin syndrome due to technical dif-
ficulties. In the three fetuses with micrognathia, the
lingual width was clearly below the normal range,
4 mm at 17 weeks and 4·7 mm at 18 weeks in the
two Pierre Robin cases, and 4·8 mm at 16 weeks in
the Meckel–Gruber fetus.
DISCUSSION
The present prospective study established a
nomogram for sonographic measurements of
lingual width in normal fetuses at 13 to 18 weeks’
gestation. A linear relationship between lingual
width and gestational age was demonstrated. Very
recently Achiron et al. (1997) found a linear rela-
tionship between lingual circumference and
gestational age. However, because the proximal
border of the tongue cannot accurately be deter-
mined we believe measurements of the lingual
width are more reliable compared with measure-
ments of the lingual length or circumference. In the
study of Achiron et al. (1997) two abnormal
fetuses were evaluated at 24 weeks’ gestation. One
fetus with trisomy 21 had macroglossia, and the
second with partial trisomy 1 had microglossia. In
 1998 John Wiley & Sons, Ltd.
our study we performed lingual measurements in
22 abnormal fetuses, and except for the three
fetuses with micrognathia, all other fetuses had
normal lingual size.
Measurements in abnormal fetuses showed a
normal lingual width in fetuses with chromosomal
aberrations and cleft palate at 13–18 weeks of
gestation. The width of tongue in the five fetuses
with trisomy 21 was also normal. This may indi-
cate that the increase in the size of the tongue
observed in Down syndrome probably occurs later
on in pregnancy. On the other hand, our finding of
a small lingual width in the Pierre Robin and
Meckel–Gruber syndromes suggests that this
measurement might serve as an indicator of micro-
gnathia. Further studies are needed in order to
elucidate the value of sonographic measurement of
lingual width as a tool for the early prenatal
diagnosis of oro-mandibulo-facial anomalies.
REFERENCES
Achiron, R., Ben Arie, A., Gabbay, U., Mashiach, S.,
Rotstein, Z., Lipitz, S. (1997). Development of the
fetal tongue between 14 and 26 weeks of gestation:
in utero ultrasonographic measurements, Ultrasound
Obstet. Gynecol., 9, 39–41.
Draper, N.R., Smith, H. (1981). Applied Regression
Analysis, New York: John Wiley & Sons, 7–55.
Gupta, O.P. (1971). Congenital macroglossia, Arch.
Otolaryngol., 93, 378–383.
Jones, K.L. (1988). Pattern of malformation differential
diagnosis by anomalies. In: Jones, K.L. (Ed.). Smith’s
Recognizable Patterns of Human Malformation, 4th
ed., Philadelphia: W. B. Saunders Co., 707–763.
Petersen, M.B., Hansen, M., Djernes, B.W. (1987). Full
trisomy 22 in a newborn infant, Ann. Genet., 30,
101–104.
Reynoso, M.C., Hernandez, A., Soto, F., Garcia-Cruz,
O., Martinez, Y., Martinez, R., Cantu, J.M. (1986).
Autosomal dominant macroglossia in two unrelated
families, Hum. Genet., 74, 200–205.
Rice, J.P., Stephen, H.C. (1985). A case report of lingual
lymphangioma presenting as recurrent massive tongue
enlargement, Clin. Pediatr., 24, 47–50.
Prenat. Diagn., 18: 577–580 (1998)