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Oral cavity and Tongue

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CHAPTER 34
Oral Cavity and Tongue
Deepak Sarin, Indar K Dhawan, Minakshi Bhosle,
Sunil Chumber, Nitin Aggarwal

The oral cavity and the tongue are complex structures that The cheek mucosa covers the inside of the cheek, and
provide access to the twin inlets for digestion and respiration. is continuous with the upper and lower gingival mucosa.
Several congenital and inflammatory conditions are seen It would be thus appropriate to call this as gingivo-buccal
in the young. In India due to the habits of pan chewing and complex. The Stensen’s duct from the parotid opens into
smoking, cancer of oral cavity shows a high prevalence. the cheek mucosa opposite the upper second molar. The
Hence, the student must make all attempts to examine well cheek mucosa has a thin layer of fat and buccinator muscle
and make a correct diagnosis. separating it from the skin of the cheek. The buccinator
muscles facilitate passage of food towards the oropharynx.
Learning Objectives The muscles in the floor of the mouth are the mylohyoid,
yy Anatomy of oral cavity and tongue the anterior belly of the two digastrics and the geniohyoid
yy Inflammatory lesions muscles. On either side of the midline in the floor of mouth lie
yy Benign ulcers and cysts the sublingual salivary glands with several openings into the
yy Pigmentary disorders floor of mouth. The Wharton’s duct from the submandibular
yy Potentially malignant lesions glands runs in the floor of mouth to open near the frenum
yy Cancer of oral cavity of tongue. The floor of the mouth lies between the tongue
yy Diseases of tongue. and the lingual surface of the mandible. It extends into the
glossopalatine fold and the retromolar trigone. With the gums
it assists mastication in the process of eating.
Anatomy The tongue is a mobile muscular structure made up of a set
The anterior limit of the oral cavity is the vermilion border of of four intrinsic muscles. These are the superior and inferior
the upper and lower lips. The posterior limit of the oral cavity longitudinal muscles joined by the vertical and transverse
is the circumvallate papillae on the tongue, anterior tonsillar muscles. The extrinsic muscles which give it mobility are the
pillars, and the junction of the soft and hard palate. The hard hyoglossus muscle by which the tongue is connected to the
palate separates the oral and nasal cavities The contents of hyoid bone and the genioglossus muscles which connect
the oral cavity extending dorsally from the lips are the buccal it to the mandible. The styloglossus and palato­glossus are
mucosa, the upper and lower alveoli, the floor of mouth, the the other extrinsic muscles which attach the tongue to the
hard palate, the anterior two-thirds of tongue and retromolar base of the skull. The blood supply of the tongue is from
trigone. The oral cavity forms the entrance of the passage for the lingual artery, and the sensory nerve serving it is the
ingestion of food and liquids. The lips are a doorway to the lingual nerve. Specialized sensory organs for taste lie over
oral cavity that aid in the intake of food and liquid. the surface of the tongue. The mobile tongue participates in
 530 Head and Neck

the functions of speech and swallowing. It is responsible in factors include nutritional deficiency (iron and vitamin B),
assisting mastication and turning over the food in the mouth malabsorption syndromes, dental trauma and stress.
propelling it onward.
The retromolar trigone requires a special mention. It lies Clinical Features
behind and between the last molars on the upper and lower
jaws and at the junction of the oral cavity and oropharynx. It causes painful ulcers in the mouth which are shallow,
Two masticator muscles, namely the medial pterygoid and round or oval, and well punched out with discrete edges.
the masseter are attached to the medial and lateral surface There is a surrounding halo of erythema and the bed is
respectively of the ascending ramus of the mandible. The yellow or grayish. It is very tender but not indurated. The
retromolar trigone mucosa thus covers the mandible and the size is typically less than 5 mm. The ulcers commonly appear
masticator muscles and facilitates spread of tumors located over the lip mucosa, buccal mucosa, floor of mouth, ventral
in this area into the masticator fossa. tongue and soft palate. Dorsal tongue and hard palate are
The oropharynx contains the base of tongue, the tonsillar not generally involved. The ulcers heal in about one week.
SECTION

fossa, the soft palate and the pharyngeal walls up to the hyoid Generally they are single, but multiple ulcers may be seen
bone inferiorly. in the mouth at one time. It is important to distinguish these
8

The lining of the oral cavity consists of nonkeratinizing from aphthous-like ulcers which are similar in appearance but
squamous epithelium, with clumps of ectopic salivary tissue seen in immunologic conditions such as Behçet’s syndrome,
and mucus glands. The mucosa on the dorsum of tongue autoimmune diseases and HIV.
has filiform papillae, which give it the distinctive rough
appearance. Treatment
Treatment is directed towards correcting any predisposing
Oral Cavity factor and symptomatic treatment of the ulcers. Topical
corticosteroid gels and local anesthetic gels help in faster
healing and reducing pain but do not prevent future
INFLAMMATORY recurrences.
Several inflammatory, erosive and ulcerative conditions
affect the oral mucosa and are referred to by the common Herpes Simplex Infection
nomenclature of stomatitis. Gingivitis is inflammation of Herpes simplex results in stomatitis presents with vesicles
the gums. Since, they may be seen together, they are called that break-down to form ulcers with fever and lymph­adenitis.
gingivostomatitis. The mouth is an organ that is continuously Herpes labialis consists of a reactivating of the herpes virus
assaulted by organisms when performing its assigned duties. long past the original infection has resolved. Herpes febrilis
It is hence a residential area for innumerable organisms— presents as vesicles in infants and children during any febrile
most of them harmless under normal conditions. Constant illness.
washing of the mouth by salvia, the epithelium and local
lymphatic barriers are available to guard the body from attack
through this route. Sometimes facultative organisms take Pyogenic Granuloma
advantage of any weakness in the defenses of the oral mucosa A pyogenic granuloma present as a reddish nodular mass on
and result in infection. Oral ulcers are soon colonized by the gingiva, in the area between two teeth. It is painless but
these pathogens, e.g. streptococci and staphylococci. may bleed to touch. It may grow rapidly and cause alarm to
Nutritional deficiencies of iron, vitamin B­12, folic acid and the patient. Women are more affected than men. The term
severe protein deficiency lead to atrophy of the epithelium. itself is a misnomer as it is a mass of proliferating capillaries
In immunocompromised states due to chemotherapy, sometimes as a response to chronic irritation.
agranulocytosis, aplastic anemia and steroid intake and
reduced healing may lead to secondary infection.
Treatment
Recurrent Aphthous Stomatitis Treatment is by surgical excision.

Recurrent aphthous stomatitis (RAS) is a common condition

characterized by recurrent appearance of ulcers or sores in
Vincent’s Angina
the mouth. It result from a combined infection with Borrelia vincentii and
The pathophysiology is unknown but a positive family Bacteroides fusiformis, both anaerobic and gram-negative
history of similar ulcers is common. It is a condition that is organisms. It produces a deep ulcer covered with grayish
common in young adults and rare in the elderly. Predisposing necrotic slough that bleeds readily.
 Oral Cavity and Tongue 531

Clinical Features treated with topical antifungal preparations along with control
of underlying predisposing factors. Responses are generally
The patient presents with fever, dysphagia, salivation and rapid with disappearance of lesions within one week.
submandibular swelling.
Cheek Bite
Treatment
It is a very common reason for hospital visits as it raises
The treatment consists of intravenous penicillin and concern in the patient’s mind for a possible cancer. Due to
metronidazole. Repeated mouthwashes should be given with the buccal mucosa getting caught between the teeth, slightly
dilute povidone-iodine. raised white linear streaks develop along the lines of occlusion
on both sides. These are more prominent in the posterior
Oral Candidiasis (Thrush) aspect of the buccal mucosa.
Thrush is an oral infection due to Candida albicans, a

CHAPTER
fungus. Immunocompromised people are often affected and Treatment

34
presence of thrush should prompt a search for an underlying Grinding of any sharp teeth and reassurance to the patient is
immunocompromised state. It is generally seen in patients needed. A biopsy should be done if the area is ulcerated or
at extremes of ages (infants and elderly), diabetics, and indurated.
patients on immunosuppressive therapy (steroids) or on
chemotherapy.
Cancrum Oris
Clinical Features Cancrum oris (Noma in Africa) is a severe form of orofacial
disease that is commonly seen in poorly nourished children
The oral cavity shows multiple whitish spots or whitish
with poor oral hygiene often following other infections,
plaques. The white patches can be easily rubbed off (as against
particularly measles.
leukoplakia, which cannot be rubbed off) and leaves behind
bleeding erosions. The whitish lesions resemble milk-curd.
(Fig. 34.1). Diagnosis is clinical and the fungal hyphae can Clinical Features
be seen on a smear stained with potassium hydroxide. The During states of toxemia, severe dehydration results in
patients generally present with hypersensitivity to food in the thrombosis of the facial arteries or its branches and leads to
mouth. If dysphagia is present, then contiguous esophageal necrosis of the orofacial tissues. Ulceration starts from the
candidiasis should be suspected. gums (acute necrotizing gingivitis, ANG) and spreads into the
jaws, lips and cheeks producing extensive tissue loss.
Treatment
Treatment consists of painting the oral cavity and tongue with Treatment
1 percent aqueous gentian violet (mouth paint). It looks awful
Treatment should be started with systemic penicillin and
and leaves a bitter taste but is effective! Oral thrush can be
metronidazole. Local irrigation, and control of infection is
important. Children should be started on a high-protein
diet with vitamins—initially through a nasogastric tube. The
sequelae of the disease are awesome and repair of defects of
the lips and cheeks are required. This can be accomplished
with local nasolabial flaps or pedicle flaps (forehead flap,
deltopectoral flap) or micro­vascular flaps.

Angular Cheilitis
Angular cheilitis is seen in thumb-sucking infants. In the
elderly due to continuous drooling of saliva, moist cracks at
the angles of the mouth may be infected with Candida and
staphylococci.

Treatment
Treatment consists of addressing the primary cause which
Fig. 34.1: Bottle fed infant with thick oral thrush may be straightforward, yet difficult. Infection may be
 532 Head and Neck

controlled with application of gentian violet paint or nystatin Treatment

cream and povidone-iodine ointment.
Treatment consists of application of boroglycerine with a
swab of cotton. This will protect the surface from the irritants
ACQUIRED in the food. For relief of pain, xylocaine viscous should be
adminis­tered prior to meals.
Ulcers
Lichen Planus CYSTIC LESIONS
Oral lichen planus may be considered as a great mimic. Due Mucus Retention Cysts
to its variable physical presentation it is easy to confuse with These are commonly seen on the labial and buccal mucosa
premalignant lesions. and occur due to blockage of the duct of a minor salivary gland
In its most typical form, it presents as bilateral whitish
SECTION

resulting in salivary retention. The cysts are submucosal in

striae (Wickham striae) on the buccal mucosa and gingiva location, small, soft and translucent. A history of fluctuation
8

forming a reticular pattern. It may also appear as whitish in size is typical.

plaques, erythema or shallow erosions. In patients
predisposed to pigmentation, patchy brown melanin deposits
may be present. Lesions of lichen planus are also present in Treatment
the skin. Oral lichen planus persists for years with periods of Excision is curative and also helps rule out a minor salivary
exacerbation and quiescence. gland tumor.
If the diagnosis is not certain after clinical evaluation then
a biopsy should be performed to rule out premalignant or
malignant conditions.
Ranula
A ranula results from extravasation of secretions of the
Treatment sublingual gland into the submucosal tissues of the floor of
mouth. It presents as a translucent bluish cystic swelling in
Treatment is never curative. Topical steroid can be used to the floor of the mouth to one side of the midline. It can acquire
manage periods of exacerbations and reduce local symptoms a large size but is generally asymptomatic. It may extend into
like pain. Patients should be counseled for a small risk of the neck and is then known as a plunging ranula (Fig. 34.2).
developing oral cancer.
Treatment
Solitary Oral Ulcer
Treatment is surgical resection, which can be quite challeng-
A solitary oral ulcer is most often caused by a traumatic ing as the ranula has no true capsule. The sublingual gland
bite on the mucosa during meals. Ill-fitting dentures with should be excised as well. Recurrences are not uncommon as
malocclusion too, are responsible for recurrent traumatic excision may be incomplete. Marsupiali­zation of the cyst will
ulcers. These are very painful but, thankfully, heal within a also ensure the safety of the sub­mandibular duct.
few day.

Investigation
When an ulcer persists for more than two weeks and
no possible cause can be determined, a biopsy must be
performed to exclude a malignancy.

Treatment
Frequent mouthwashes should be employed for traumatic
ulcers. Xylocaine viscous should be used for rinsing the
mouth before meals. Ill-fitting dentures should be changed.

Dyspeptic Ulcers
Dyspeptic ulcers occur in the lips, tongue and cheek during
episodes of gastrointestinal upsets. These are small ulcers,
with surrounding erythema and are very painful. Fig. 34.2: Plunging ranula presenting as a swelling in the neck
 Oral Cavity and Tongue 533

Sublingual Dermoid Melanotic Macules

A sublingual dermoid presents as a midline swelling in the These may develop due to melanin deposition in the basal
floor of the mouth and the neck and results from inclusion layer of the epidermis. These are dark brown or black areas
of epithelial elements during fusion in the ventral midline of discoloration without any ulceration and affect any part
(seques­tration dermoid). This produces a whitish-opaque of the oral mucosa. Oral nevi are rare in the mouth. These
swelling. The cyst is lined by stratified squamous epithelium appear as brown or black elevated papules. Oral melanomas
and filled with paste-like material. are uncommon and similar to their cutaneous counterparts
in appearance (Fig. 34.3). Unlike cutaneous melanomas, sun
Treatment exposure is not a risk factor.

Careful excision of the cyst should be performed sparing

Treatment
adjacent structure like, the submandibular duct and nerves.

CHAPTER
The excision should be performed through an incision in the A biopsy or excision biopsy should be done if melanoma is
neck. suspected.

34
Fordyce’s Granules NEOPLASMS
Fordyce’s granules or spots are ectopic sebaceous glands
present below the oral mucosa. They are generally numerous Premalignant Lesions
and appear as yellowish white papules, 1–3 mm in diameter
with a slightly raised or cauliflower like top. They may appear Oral Submucus Fibrosis
in clusters in the buccal or labial mucosa. While they may be a The Indian subcontinent has the highest incidence of oral
cause for concern for the patient they are harmless. submucus fibrosis (OSMF) in the world. OSMF is a condition
characterized by progressive atrophy of mucosa and fibrosis
Treatment in the submucosal layer and deeper tissues of the oral cavity.
The common affected areas in the mouth are the buccal
Other than reassurance, no treatment is needed.
mucosa, retromolar trigone, tongue and soft palate. The
changes are generalized and without discrete borders, often
Pigmentation Disorders present bilaterally and symmetrically.
The condition is premalignant although the exact
Peutz-Jeghers Syndrome incidence of cancer in oral submucous fibrosis has not
been established. One reason for association of OSMF
It is an autosomal dominant condition characterized by and malignancy may be because the two have a common
hamartomatous intestinal polyps. In addition pigmented etiological factor, the common causative agent being the
macules are almost invariably present involving labial and areca nut which is chewed in various forms in India. An
buccal mucosa. They are often confluent and of varying size
and shape.

Investigation
The patient should be investigated for intestinal polyps by a
barium enema or fiberoptic colonoscopy.

Treatment
These patients should be kept on life long follow-up and
biennial esophagogastroduodenoscopy and colonoscopy and
small bowel contrast studies to pick up malignancies early.

Amalgam Tattoo
It occurs due to implantation of amalgam into the oral
mucosa most often on the labial or alveolar region. It is a non-
ulcerated, soft blue-black or gray macule generally less than
0.5 cm in size. Fig. 34.3: Melanoma of the alveolus
 534 Head and Neck

alkaloid, arecoline, present in the nut causes activation of

fibroblasts and deposition of collagen below the mucosa
in the oral cavity. Areca nut (mistakenly called betel nut),
is consumed in pan, in preparations like pan masala, as a
combination with tobacco in gutka and occasionally directly.
In addition to areca nut, tobacco abuse, excessive use of
spices and malnutrition may be contributing factors.

Clinical Features
It leads to increased sensitivity to spices over the affected
areas causing burning sensation and pain when eating. The
affected mucosa looks white and blanched. The mucosa
SECTION

loses its normal elasticity and is firm on palpation. There

is progressive trismus and if the tongue is involved there
8

is decrease in movements of the tongue. The clinical

Fig. 34.4: Slightly elevated leukoplakia patches on the right cheek
examination should be thorough to identify areas that are
suspicious for cancer.

of the tongue where the tongue papillae are not developed

Investigation and the tongue appears bald. It is easily distinguished from
The diagnosis of OSMF is clinical and biopsy is carried out leukoplakia and it has no malignant potential. Leukoplakia
only in areas that are suspicious for malignant change. converts to cancer in about 5–8 percent of patients over their
lifetime. Patches that have erosions or are speckled have a
higher cancer conversion rate.
Treatment
Erythroplakia is similar but the patches are reddish
Cessation of areca nut chewing is the most important advice in color. An erythroplakia with a papillary surface or with
and this may result in some degree of spontaneous resolution. induration needs an excision biopsy to rule out cancer.
Sublingual and local steroids are not very effective. Retinoids Erythroplakia is more sinister, because it has a much higher
have been used with limited efficacy. malignant potential than leukoplakia. Leuko-erythroplakia
If trismus is severe, excision of buccal mucosa and is a condition with both characteristics of leukoplakia and
replacement by a free skin graft is required. These patients erythroplakia.
should be screened lifelong by regular oral examination, and
biopsy is required if changes suspicious of cancer appear.
Treatment
Leukoplakia and Erythroplakia Retinoids and B-carotene are known to cause regression of
oral leukoplakia if the irritant, like tobacco, is stopped and
These are the well known lesions which often precede sharp irritating teeth are abraded. Buccal leukoplakia which
development of squamous cell carcinoma (SCC) in the oral is flat and not ulcerated may be serially observed. However, if
cavity. They appear as white or red patches in the mucosa. it persists, it should be excised.
Histologically, the lesions show epithelial hyperplasia and Excision is required for all erythroplakia, leuko­
hyperkeratosis, which progresses to dyskeratosis. erythroplakia and leukoplakia present on the tongue or floor
Leukoplakia (literally white patch) presents as a flat white of mouth. CO2 laser has become the preferred treatment
patch in the mouth in a patient with history of tobacco abuse for excision of these lesions and even small oral cancers.
(Fig. 34.4). Sometimes, it may occur if there are sharp irritating It requires no reconstruction, gives minimal scarring and
teeth, and rarely, it may be idiopathic. Leukoplakia can affect provides optimum functional results.
any portion of the oral mucosa but the buccal mucosa and
gingiva are most commonly affected in tobacco chewers. In
smokers, the tongue or floor of mouth are common sites. Benign Papilloma
The lesions may be small or fairly large and may be multiple. Rarely, benign papilloma occurs in the oral cavity and may
Leukoplakic patches cannot be rubbed off and this helps to progress to a carcinoma.
distinguish them from candidiasis.
Differentiation from lichen planus can be difficult but the
Solar Keratosis
absence of tobacco abuse and presence of skin lesions will favor
the diagnosis of lichen planus. Median rhomboid glossitis Solar keratosis results from the effect of the actinic rays of
occurs in front of the circumvallate papillae on the dorsum the sun. It consists of a rough scaly elevated patch on the
 Oral Cavity and Tongue 535

lower lip, and occurs in fair-skinned persons with outdoor Pipe smoking or clay pipe smoking may produce cancer
occupation. It is not malignant even though actinic radiation of the lip if the stem of the pipe is kept at the same place in
can contribute to cancer of the lower lip. relation to the lip. In Assam, chewing of a fermented nut is
This lesion requires it to be removed by lip shave. a social habit and is responsible for the high incidence of
oral cancer. In Andhra Pradesh the habit of reverse smoking
Plummer-Vinson Syndrome (chutta) is prevalent. The cigarette is smoked with lighted-
end inside and this produces a cancer of the palate at the site
Plummer-Vinson or Patterson-Kelly syndrome is seen in where the lighted-end touches it.
women. It presents with atrophy of the mucous membrane of Smoking and use of tobacco snuff also have a carcinogenic
the pharynx and the oral cavity. The patient has iron deficiency effect.
anemia (sideropenic anemia). This syndrome usually leads to
postcricoid carcinoma and occasionally cancer of the tongue. Alcohol: Consumption of alcohol is an independent risk factor
and has a multiplier carcinogenic effect in smokers and when

CHAPTER
tobacco is used in other forms.
MALIGNANT

34
Bad teeth and poor oral hygiene: Poor oral hygiene is a risk
Oral Cancer factor. Sharp teeth produce consistent injury and ulceration
of the tongue or cheek mucosa which in the long-term may
The Indian subcontinent has a high incidence of cancer of the end in malignant change. Likewise an ill fitting denture may
oral cavity. Almost half of all oral cancers in the world occurs produce a chronic ulcer, leading to a malignant change.
in India. This burden also poses special challenges due to its
Sun exposure: Cancer of the lip may occur in fair individuals
late diagnosis and loss of function of speech and swallowing
with outdoor occupation like farmers. It is attributed to the
produced by the disease and its treatment. In its early stages
actinic rays of the sun on the lip. Solar keratosis precedes the
to the untrained eye, it may appear indistinguishable from
onset of carcinoma, and consists of a rough scaly elevated
many other inflammatory conditions. As a rule if oral cancer
patch.
appears to be a possibility after clinical examination, a biopsy
should be performed. Systemic disease: Plummer-Vinson Syndrome may lead
Oral cancer is followed by a high incidence of a second to oral cancer. In Plummer-Vinson there is atrophy of the
primary, either synchronous or metachronous in the upper oropharyngeal mucosa associated with iron deficiency
respiratory passages or in the bronchus. anemia. This syndrome usually leads to postcricoid
In Southeast Asia the most common cancer in the oral carcinoma, but oral cancer may sometimes occur.
cavity is a squamous cell cancer (SCC), and the common sites Human papilloma virus (HPV): It has a strong role to play in
where it occurs are the buccal mucosa and the tongue. The cancer of cervix. It is suspected to have a role in the etiology of
data from the Cancer Registry of Indian Council of Medical oropharyngeal and oral cancer. Current information indicates
Research (ICMR) lists oral cancer amongst the top five that HPV is strongly associated with the development of
cancers in Indian males. In some regions of the country, it oropharyngeal cancer as a risk factor, independent of tobacco
is the tongue which dominates and in others it is the cheek and alcohol. It has a similar role only in a small minority of
mucosa which dominates. In the cheek, it commonly occurs oral cavity cancers.
at the site where the quid is habitually kept. Tobacco abuse However, about 10 percent of oral cancers (particularly
in tongue cancer is usually in the form of smoking. Cancer in tongue) occur in patients with no history of tobacco or alcohol
the tongue often occurs at the edge in the posterior part of its consumption or other risk factors.
anterior two-thirds. It is rare for SCC to begin on the dorsum Pipe-smoking may lead to cancer of the lower lip.
of the tongue. Lower lip cancer is prevalent in people exposed Syphilis, uncommon today, too can contribute to oral cancer
to sunlight over their lifetime (countryman’s lip). Professions (6S-smoking (and smokeless tobacco), supari, sharp tooth,
leading to such exposure include farmers, fishermen and sub­mucous fibrosis, syphilis, spices).
other outdoor workers.
Pathology
Causes of Oral Cancer
By default, oral cancer refers to squamous cell carcinoma
Substance abuse: Chewing of a quid consisting of tobacco, (SCC), which comprises over 90 percent of all mouth cancers
lime and areca nut is a widespread habit in India and South- and arises from the mucosal lining. Less commonly, cancer
east Asia. The incidence of mouth cancer increases with the may arise from a minor salivary gland. Rarely, sarcomas and
duration of the habit and is high in those who keep the quid in melanomas may occur in the mouth.
the mouth all 24 hours of the day. The carcinogenic activity of The biologic model for SCC suggests increasing levels of
tobacco is enhanced by lime and areca nut when these form dysplasia involving the epithelium, occurring as a response
a part of the quid. to carcinogenic insults. When the abnormal cells breach the
 536 Head and Neck

basal membrane to extend into the subepithelium cancer is

formed.
On gross appearance a squamous cell carcinoma (SCC) of
the oral cavity may be of the following varieties:
• Infiltrating variety: This lesion rapidly invades the deeper
tissues. Thus, in the retromolar trigone the surface lesion
may be small, but it may infiltrate deeply into the muscles
of mastication (medial pterygoid and masseter) causing
trismus. In the tongue the lesion is small on the surface,
but deep infiltration causes severe pain and progressive
ankyloglossia. The infiltrating variety of SCC has the most
aggressive behavior.
• Exophytic variety: This is a protuberant cauliflower like
SECTION

lesion which has a tendency to minimal deep invasion

8

(Fig. 34.5). It is less aggressive in its behavior than the

other varieties. One variety of this type is called verrucous
carcinoma.
• Superficial ulcer: It is a malignant ulcer with moderate
surface protrusion and moderate deep invasion. The Fig. 34.5: Horizontal section of the mouth at the level of oral
aggressive level of behavior of this SCC is between the commissure and depicting spread of cheek mucosa cancer (T). Local
infiltrative and exophytic varieties. spread occurs to the (A) skin, (B) the mandible and maxilla, and (C) the
The tumor has all the features of a squamous cell muscles of mastication. Spread to the lymph nodes occurs first to the
carcinoma. The majority of tumors are well differentiated, submandibular nodes (E-level Ib) and then to the upper deep cervical
group (level IIa)
particularly those of the lip and buccal mucosa. The tumors
of the tongue tend to be poorly differentiated and more
aggressive.
In India, the common site of the tumor is cheek mucosa,
tongue and floor of the mouth in that order in contrast to the
west where the common site is the tongue, the floor of the
mouth and the lower lip.
Verrucous carcinoma (Ackermann’s tumor) is an
uncommon variant of SCC. The lesion has an exophytic
appearance and resembles fronds of seaweed. Histologically,
it is a well differentiated low grade tumor with absence of
mitosis, pleomorphism and hyperchromasia, and has minimal
deep invasion. Its deeper invasive edge is characterized by a
broad pushing front, and biopsies may not easily demonstrate
its invasive nature. Lymph node metastasis is extremely rare
in a verrucous carcinoma.

Spread Fig. 34.6: Coronal section of oral cavity depicting local spread of
tongue cancer (T). The principle directions of spread are to extrinsic
The spread of the tumor occurs to the adjacent structures, muscles of tongue (A) to cause ankyloglossia, floor of the mouth (B)
and the submandibular lymph node(C)
and to the regional lymph nodes in the neck. Hematogenous
spread by blood stream occurs late and in the terminal stages.
Spread beyond the clavicles is a rare event. Cancer arising on the gingival mucosa easily spreads into
In the cheek mucosa local spread is to the skin and the the mandible and its marrow spaces. This is more likely to
alveolus of mandible or maxilla (Fig. 34.5). Cheek mucosa happen in an edentulous mandible as the open tooth socket
tumors situated near the retromolar trigone (RMT) tend to allow egress of tumor into the bone and mandibular canal.
infiltrate the masticator muscles causing trismus. In late Spread to the cervical lymph nodes occurs in an orderly
stages these tumors encase the internal carotid artery. fashion. The submental group of lymph nodes (Level 1a) is
Tumors of the tongue and floor of the mouth spread into involved if the tumor is located near the midline on the tip
the intrinsic and extrinsic muscles of the tongue, causing of tongue, floor of the mouth or lip. In tumors not located
ankyloglossia (Fig. 34.6). near the midline, the first lymph node involved is the
 Oral Cavity and Tongue 537

submandibular node (Level 1b). The tumor then spreads in an

orderly fashion to Level 2, Level 3, and Level 4 lymph nodes.
Level 3 and 4 lymph nodes are involved in advanced disease.
The Level 5 nodes (in posterior triangle) are not generally
involved in tumors of the oral cavity. Spread to lymph nodes
on the contralateral side occurs in tumors which involve the
midline, are bulky and are poorly differentiated.
T1 tumors have a low risk of nodal disease; T2 tumors
have an intermediate risk of nodal disease; T3 and T4 tumors
have a high-risk of spread to the lymph nodes.
A B
Clinical Features Figs 34.7A and B: (A) An ulcerative cancer involving the buccal mucosa

CHAPTER
Oral cancer occurs more often in males, often in the sixth and and the gingiva; (B) Malignant ulcer tongue. It is elevated, and located
on the edge of the posterior part of anterior tongue

34
seventh decade in the western population. In India its peak is
a decade earlier.
The most common mode of presentation of early oral
cancer is a painless ulcer or a proliferative growth. Failure of
an ulcer or an erosion in the mouth to heal over a few weeks
should raise suspicion of oral cancer. The ulcer or growth
bleeds on touch and bleeds during cleaning of the mouth.
It may occur on a pre-existing premalignant lesion such as a
leukoplakia or erythroplakia or oral submucous fibrosis.
Pain as a presenting symptom is felt early in lingual
cancer. Pain in lingual cancer is felt locally and may be
referred to the ear. Painful loose teeth may be the first sign of
an alveolar cancer. In cheek mucosa cancer, pain is a signal of
advanced disease.
Trismus and ankyloglossia occur late in the disease and
indicate deep infiltration by the tumor.
Other symptoms of late disease are difficulty in
swallowing, and changes in speech. Involvement of facial skin
also appears late in the disease. Halitosis and loss of weight
occurs when the disease has been present for sometime. Fig. 34.8: An exophytic tumor of the lower lip
Oral cancer may sometimes present as an enlarged
(metastatic) lymph node in the neck, more frequent in cancers
of the oropharynx. Any patient with unexplained cervical
lymphadenopathy should have a thorough examination of
oral cavity and pharynx to exclude a primary cancer in these
areas.
Examination of the oral cavity should be performed under
good light, either on a dental chair or with a head lamp. The
blind spots in the mouth are the gingivo-buccal sulcus, the
floor of the mouth, and the retromolar trigone, and these
require a careful effort to examine. The oropharynx (including
the base of the tongue) requires to be inspected by indirect or
direct laryngoscopy.
Inspection may reveal an ulcer (Figs 34.7A and B)
with raised edges and a raised floor. The tumor may also
appear as a cauliflower like growth (exophytic) (Fig. 34.8),
or may have a small ulcer on the surface, but with deep
infiltration (endophytic). The mouth may also show patches
of leukoplakia or erythroplakia in areas beyond the ulcer (Fig.
34.9). Skin involvement, trismus (Fig. 34.10) and restriction Fig. 34.9: Early malignant ulcer of lip mucosa and gingiva.
of tongue movements are signs of advanced disease. Notice patches of leukoplakia beyond the tumor
 538 Head and Neck

Table 34.1: TNM staging of oral cavity tumors. Status of primary

tumor ‘T’
Tx Cannot be assessed, e.g. already excised.
T0 No evidence of primary tumor (occult primary)
Tis Carcinoma in-situ
T1 Equal to or less than 2 cm in greatest dimension
T2 More than 2 cm, but less than or equal to 4 cm
T3 More than 4 cm
T4a Moderately advanced local disease:
Lip and cheek-involvement of cortical bone, skin, inferior
alveolar nerve.
SECTION

Tongue-extrinsic muscles, skin.

T4b Very advanced local disease:
8

Cheek-involvement of masticatory space, base of skull,

internal carotid artery.
Fig. 34.10: Buccal mucosa cancer with skin
TNM staging of oral cavity tumors. Status of lymph nodes ‘N’
involvement and trismus
N0 No nodal
metastasis
Induration of the ulcer and around it, detected on N1 single ipsilateral Equal to or <3 cm
digital palpation is the most reliable clinical evidence of N2a single ipsilateral 3 to 6 cm
malignancy. Induration also defines the surface extent
N2b multiple ipsilateral None >6 cm
of the disease, and its depth. While exophytic growths do
not show deep induration, this is marked in endophytic N2c Single or Bilateral or None >6 cm
growths. multiple contralateral
The neck is carefully palpated for enlarged lymph nodes, N3 Single or Ipsilateral, Any node >6 cm
and their level, number and size is noted. Their fixity to each multiple bilateral,
other, the mandible or skin is noted. contralateral
TNM staging of oral cavity tumors. Status of systemic spread ‘M’
Staging of Oral Cancer M0 No distant metastasis

The TNM staging system gives a standardized format for M1 Distant metastasis present
documenting and reporting on oral cancers. The stage of the
tumor is the most important prognostic factor related to cure
and survival following treatment. It also influences the choice for oral cavity tumors to spread beyond the clavicle, but this
of treatment and the extent of surgery required. requires to be recorded. The anatomical staging is arrived
The TNM system has been devised by the American by collating the T-status, the N-status and the M-status
Joint Committee on Cancer in order to bring uniformity to (Table 34.2). The principal determining factor(s) for different
define the extent of disease. The primary lesion (T) stage stages are:
is determined by the size and deeper involvement by the • For stages 1 and 2, it is T- status (T1 and T2 respectively)
cancer. The nodal stage (N) is based on size and number of • For stage 3, these are T3, and N1 and N2 status
nodes involved. The metastatic status (M) is determined by • For stage 4a, these are T4a and N2 status
presence or absence of distant metastasis. • For stage 4b, these are T4b and N3 status
One of the parameters of status of primary tumor is bone • For stage 4c, it is M1 status.
involvement (Table 34.1). Involvement of bone implies
spread through the cortical bone. Invasion of the masticator Investigations
space occurs in cheek mucosa cancers located in the retro-
molar trigone. The spread involves the pterygoid plates and Pathology
pterygoid and masseter muscles. It leads to progressive
trismus. Encasing of the internal carotid artery is an extension
Biopsy and Fine Needle Aspiration Cytology
of tumor from the masticator space and is identified by A biopsy establishes the diagnosis and defines the grade of
imaging. In defining the status of lymph nodes, their number, the tumor. Multiple punch biopsies or wedge biopsies should
the size measured in the greatest dimension and spread to be performed from the edge of the lesion and the deeper
the opposite side are the factors considered. It is unusual indurated tissue should be included in the sample taken.
 Oral Cavity and Tongue 539

Table 34.2: Anatomic staging of oral cavity tumors

Stage 0 Tis, N0, M0
Stage 1 T1, N0, M0
Stage 2 T2, N0, M0
Stage 3 T3, N0, M0
T1, N1, M0
T2, N1, M0
T3, N1, M0
Stage 4a T4a, N0, M0
T4a, N1, M0
T1, N2, M0
T2, N2, M0

CHAPTER
T3, N2, M0

34
T4a, N2, M0
Stage T4b Any T, N3, M0
T4b, Any N, M0
Fig. 34.11: A 3D CT showing erosion of the alveolus by a tumor
Stage 4c Any T, any N, M1 in the retromolar trigone

Failure to include the subepithelial tissues may prevent the

pathologist from confirming invasion beyond basement
membrane, which is a hallmark for diagnosing carcinoma.
If the patient has considerable pain or trismus, the biopsy
may be performed under general anesthesia. If an enlarged
neck node is the presenting feature, an fine needle aspiration
cytology (FNAC) from the node establishes the diagnosis.

Radiology
CT or MRI
Imaging by a CT scan or MRI (with contrast) defines the extent
of disease. These modalities will accurately define the extent
of bone involvement (Fig. 34.11). In lingual and floor of the
mouth cancers, these define the extent of involvement of the
extrinsic muscles of the tongue. In cheek mucosa lesions,
CT/MRI will define the extent of involvement of masticator Fig. 34.12: A CT showing involvement of masticatory muscles
muscles (Fig. 34.12) and encasement of internal carotid on the right side
artery in advanced disease.

Ultrasound Treatment
An ultrasound of the neck defines the status of lymph nodes Prevention and Early Detection
when these are not palpable. This information on the lymph
node status is also provided by CT/MRI, but ultrasound Majority of squamous cell carcinomas (SCC) of the oral
enables an FNAB to be done under its guidance. cavity are eminently preventable. In India regional habits on
tobacco chewing vary. Educational campaigns high lighting
its adverse effects will yield dividends. Maintaining good oral
Chest X-ray
hygiene and attention to broken teeth will go a long way in
A chest X-ray and US of the abdomen would rule out distant preventing this disease.
metastasis. Because the disease rarely spreads beyond the Cancer of the oral cavity lends itself to early detection.
clavicle, extensive work-up is not required. Likewise PET-CT Extension of dental services and oral screening of vulnerable
gives no additional information. population will identify early cancers.
 540 Head and Neck

Withdrawal of Contributory Causes fails to resolve T1 and T2 disease, salvage surgery should be
carried out with satisfactory rate of cure.
Abuse of tobacco, most commonly for chewing is the most
important and preventable cause. It is also important to
encourage good oral hygiene. The predisposing causes can be
T3 and T4a (High Volume Disease)
identified and a program of education of the harmful effects When oral cancer is advanced, decision on resectability
of carcinogens should be initiated. has to be carefully arrived at. A stage 4c tumor has systemic
spread, and curative resection is out of question. All T3
Surgery tumors, though large in size are amenable to resection. In
such situations where no metastatic disease is present and
The options available for treatment of squamous cell cancer the disease is resectable, surgery followed by chemoradiation
of the oral cavity are surgery, radiation and chemotherapy. forms the standard of care. The principles of surgical excision
The primary treatment of choice for all resectable tumors is are similar to those for early oral cancer. However, since
SECTION

surgical excision. Surgery involves wide excision of the lesion the resections are larger in size, an elaborate reconstructive
with a margin of 1cm of normal tissue around the tumor. procedure follows resection.
8

Particular attention is paid to the margin on the deeper

aspect.
Cervical Lymph Nodes
Radiotherapy As oral cancer often spreads to the lymph nodes in the neck,
and addressing them at the time of treating the primary lesion
Radiation is given either by an external beam radiotherapy or is important. The lymph nodes in the neck are divided into
as brachytherapy. Radiation has the disadvantage of causing various levels for purposes of reporting location of involved
dryness of mouth. It is also prone to cause necrosis of the nodes. Oral cancer tends to follow a predictable pattern of
mandible or maxilla if these are involved by tumor or the spread and the nodes in Levels 1,2,3,4, and 5 in that order
segment of alveolus bears septic teeth. Radiotherapy is also form the first echelon of drainage.
ineffective in large volume tumors.

Chemotherapy Clinically Node Negative Neck (cN0)

Chemotherapy is generally given synchronously with A clinically negative neck (cN0) is as one where clinical
radiation because in oral cancer chemotherapy acts as a examination and imaging fail to demonstrate metastatic
radiosensitizer and the results are better than when given disease in the lymph nodes. The imaging used is ultrasound
sequentially. Recent studies have shown the advantage of and CT scan. An MRI and PET-CT are expensive and provide
combining radiotherapy with agents which target epithelial little additional information.
growth factor receptors (Cetuximab). The current recommendation in the management of
cN0 neck is a selective neck dissection (SND) for removal of
nodes which may harbor microscopic disease not apparent
Primary Lesion on clinical examination or imaging studies. This is done if
the risk of microscopic disease exceeds 20 percent based on
T1 and T2 (Low Volume Cancer) the nature of the primary tumor. Thus the following sets of
The primary treatment of T1 and T2 lesions is wide surgical tumors have a high predilection of spread to the neck nodes,
excision and is offered to all patients with T1 and T2 lesions and should be subjected to SND if the nodes are cN0.
where surgery combined with local reconstructive techniques • Tumors of tongue
is unlikely to create a visible defect. Most of lesions fall in this • T3 or T4 tumors of any subsite
category and include lesions of the lip, tongue and cheek • Poorly differentiated tumors.
mucosa. For tumors abutting on the mandible, a marginal For oral cancer, a SND involves removal of the Levels I, II
mandibulectomy, i.e. resection of the alveolus while and III of the neck nodes, and it is also called a supraomohyoid
preserving the continuity of the lower border, or resection of neck dissection (SOND). If these nodes are found negative
either the outer or inner cortex is performed. after histopathological examination, then it is assumed the
Adjuvant treatment with chemoradiation is indicated remainder of the neck is also not involved.
if the histopathology is unfavorable and shows a less than The role of sentinel lymph node dissection (SLND) in breast
5 mm tumor free margin, and lymphovascular or perineural cancer and melanoma is well established. The role of sentinel
spread. lymph node biopsy in oral cancer has not been established.
Chemoradiation as a primary treatment is recommended Oral cavity is a large area, and the primary drainage site varies
in low volume tumors where excision will give visible defects, from one site to another. Thus drainage from the center of lip,
such as in the upper lip or oral commissure. If chemoradiation alveolus and tip of the tongue is to the Level Ia nodes, while
 Oral Cavity and Tongue 541

the rest drain first to Level Ib nodes. Occasionally lingual Composite Resection (Commando Procedure)
cancers may skip Level Ib nodes and drain directly to Level
IIa nodes. Most patients of oral cancer fall into the category which
requires a major resection of a high volume primary disease
combined with radical neck dissection and followed by an
Clinically Node Positive Neck (cN+) immediate reconstruction. The resected tissues include a
When neck nodes are involved by cancer a more extensive full thickness of the cheek, a segment of the mandible, a
operation designed to remove all the nodal Levels (I-V) is variable extent of the muscles of mastication and the cervical
required. lymph nodes. This procedure has been in practice after the
The radical neck dissection (RND) was described by Crile Second World War and received its name as commando
over 100 years ago and involves removal of the nodal levels operation (the operation was compared to the heroism of
(I-V) along with the sternocleidomastoid muscle, the internal World War II commandos) (the procedure commando also
jugular vein and the accessory nerve to facilitate their fits as an acronym for combined mandibular neck dissection

CHAPTER
dissection and their removal causes significant scarring in the operation). The procedure results in a defect in which
the mouth communicates with the neck dissection field

34
neck and a frozen shoulder.
The modified or functional neck dissection (MND) was (Figs 34.13A to C). Reconstruction by a flap is always required
described to reduce some of the morbidity of the radical to close this defect.
neck dissection. In this operation, the three nonlymphatic
structures are preserved. The modified neck dissection is Reconstruction
suitable only for low volume disease in a N+ neck (N1 and
N2a). In high volume disease (N2b, N2c and N3) a Crile’s Simple Local Procedures
radical neck dissection is performed. In bilateral neck disease
The simplest reconstructive procedures fulfill the needs after
(N3), a Crile’s radical neck dissection is carried out on the
surgery for low volume disease. These procedures include:
side of primary lesion and modified neck dissection on the
opposite side. In high volume and bilateral neck disease, Primary repair: This is performed where the resections are
surgery is followed by chemoradiation. small such as for early buccal mucosa or tongue carcinoma,

A B C
Figs 34.13A to C: (A) Planning a composite resection. The edge of the tumor and the limit of excision are defined. The neck dissection is facilitated
by a lazy-S incision. Only the upper and lower incisions of the DP flap are used to expose the pectoralis major muscle. The skin paddle to be
carried by the segment of the pectoralis major muscle supplied is outlined; (B) The excised specimen with the tumor in the cheek, the mandible
with masticatory muscles, the alveolus of maxilla, and the radical neck dissection; (C) The defect left after excision. J is the stump of the mandible,
K is the edge of the tongue, and L is the maxilla, after removal of its alveolus
 542 Head and Neck

the pliant opposing mucosal edges can be pulled over and perforators of the internal mammary artery and provides skin
sutured for closure of the wound. for defects of neck and face. It has a limited reach, and can
provide only one epithelial surface and can replace either the
Skin graft: A split thickness skin graft can be used to line the
mucosal or the skin loss.
wound bed. It helps in early healing but cannot provide any
bulk for deep defects. Pectoralis major myocutaneous flap (PM Flap): This is a
composite flap of pectoralis major muscle and chest wall
Local flaps: For medium sized defects, tissue may be borrowed
skin. It receives its blood supply from the pectoral branch of
from adjacent structures and turned onto the operative
the thoracoacromial artery, which itself comes off the axillary
wound as a vascularized flap, e.g. of local flaps are tongue flap
artery. This myocutaneous flap has a long arc of rotation and
for a buccal defect, palatal mucosal flap for a contralateral
effectively replaces missing mucosal lining and the missing
palatal defect and an Abbe flap from the lower to the upper
skin cover of the cheek and the missing bulk. If the 6th rib
lip.
is harvested without separating it from the muscle and by
leaving its periosteum on the rib, it provides a live bone graft
SECTION

Major Reconstructions: Distant Flaps (Figs 34.14A to C). The difference in final result is superior
8

The requirement of major defects produced by composite when a PM flap is used (Figs 34.15A and B).
resections (commando operation) for high volume disease,
are more complex. The deficit tissues required to be Microvascular Free Flaps
replaced are the mucosal epithelial lining, the skin cover, the
These have gained popularity within the past decade and are
mandible, and bulk to replace the loss of masticator muscles.
replacing their pedicled counterparts as the flap of choice
Reconstruction should restore cosmetic appearance, and the
for medium to large defects. The free flap is harvested along
functions of speech, mastication and swallowing. However,
with its supplying artery and draining veins and is then
even the best reconstruction may leave the patient with some
transplanted into the recipient defect. The vascular supply of
functional deficits. Reconstruction of major defects requires
the flap is then re-established by anastomosing its supplying
distant flaps. The common flaps in use are:
artery to a branch of the external carotid artery and its draining
Deltopectoral flap: It is a fasciocutaneous flap described vein to a branch of the jugular vein. The common free flaps
by Bakamjian in 1965. It is based on the 2nd, 3rd and 4th used for oral cancer are, the radial artery based forearm free

A B C
Figs 34.14A to C: A PM flap. (A) Shows the dissected flap. (1) is the skin paddle anchored to the underlying muscle to prevent shearing. (2) is the
rib carried by the muscle pedicle. (3) is the muscle pedicle, and (4) is the defect left after raising the flap carrying skin and rib. Center-the flap (C) is
turned over to show the rib with its periosteum (B). Right- the pectoral artery (5) is shown. The pectoral artery can almost always be felt pulsating
over the clavicle as the flap is turned over
 Oral Cavity and Tongue 543

CHAPTER
34
A B
Figs 34.15A and B: (A) Appearance after a composite resection, where a PM flap was not used. Notice the depression on the right side created
by removal of the mandible and masticator muscles; (B) Appearance after composite resection and repair with a PM flap. The flap is bulky and
may be refashioned after 3 months

flap (skin), anterolateral thigh flap (skin) and fibula free flap shrink the tumor and prevent fungation. Chemotherapeutic
(bone and skin). The choice of flap is based on the type of agents effective for head and neck cancer are cisplatin/
tissue needed and the size of the defect. carboplatin, 5FU, taxanes and methotrexate.
Care of pain by the use of opioids is an important aspect
Palliative Treatment of palliation. Patients will need care of their respiratory
passages, and nutritional support.
Curative treatment is not indicated in advanced disease
such as metastatic, unresectable or recurrent oral cancer. The
following require only palliative care: Cancers of Specific Sites
T4b lesions Lip
These are locally advanced lesions with involvement of the Cancer of the lip is commonly seen in males. The lower lip (90%)
skull base, internal carotid artery, and masticator space, is more commonly involved as compared to the upper lip.
indicated by complete trismus. Due to progressive disease It is seen in pipe-smokers due to chronic thermal injury.
the patients will gradually lose oral function such as ability The lower lip is more protuberant and hence exposed to
to chew, swallow and speech. Extensive involvement of face ultraviolet radiation resulting in malignancy. Hence, lip
skin leads to a fungating mass. Pain is often severe and may cancer is more common in farmers and outdoor workers who
need narcotics for control. are exposed to sunlight. Lip cancer is also more common
among people in Europe and other western countries.
N3 Lymph Nodes Squamous cell carcinomas are most commonly
encountered in cancers of the lip. The lower lip is usually
A lesion with an N3 lymph node which is over 6 cm in its
involved. Cancer of the lip presents as an ulcer with typical
largest dimension is not amenable to be cured. Large nodes
everted edge (Fig. 34.16).
in the neck may erode through the carotid artery resulting in
carotid blowout and death.
Buccal Mucosa
Stage IVc (M1) Disease Buccal mucosa cancer is more commonly seen in men than
women. Carcinoma of the buccal mucosal occurs commonly
Disease beyond the clavicle indicating blood stream spread. in chronic tobacco chewers (Fig. 34.17) and in people who
Systemic spread is not amenable to treatment, however, is use pan in India and other parts of the subcontinent. The
unusual in oral cancer. disease is usually advanced at the time of presentation with
Such patients may be best managed by palliative lymph node metastasis (see Fig. 34.16). The route of invasion
chemotherapy or chemoradiation which aims to temporarily of epidermoid carcinoma of the buccal mucosa is through
 544 Head and Neck
SECTION
8

Fig. 34.16: Carcinoma of the lip in a cigarette smoker Fig. 34.17: Carcinoma of buccal mucosa presenting as a lump
(Courtesy Prof Anurag Srivastava)

the buccinator muscle and buccal fat pad dorsally toward the Prognostic Factors
pterygoid musculature or lateral to the skin. In either case, it
results in significant limitation of oral motion and discomfort Site
on chewing (trismus).
Lip lesions have the best prognosis, while lesions of the tongue
have the poorest prognosis. The outcome in lesions of cheek,
Hard Palate alveolus and floor of the mouth is between these two extremes.
Benign and malignant tumors of the minor salivary glands
are more common in this location. Squamous cell carcinoma
is usually seen in elderly male smokers and in certain areas of Type
India (Andhra Pradesh) where reverse smoking with bidis (a The nature of the lesion influences the outcome. Exophytic
form of cigarette) is practiced. lesions and verrucous carcinoma have better outcome than
Malignant tumors of the hard palate may spread to ulcerative lesions. Infiltrative lesions have the worst outcome.
involve the periosteum, and extend through the bone into the Poorly differentiated tumors on histology have an adverse
maxilla or the nose. influence on the outcome.

Floor of Mouth
Size
Floor of mouth is the second most common site in the oral
cavity in western countries. It is rare in India. The lesion is The size of the primary lesion has a bearing on the outcome.
in close proximity the hyoglossus and mylohyoid muscles T1 and T2 lesions with no lymph node disease have a cure
and invades the muscles and bone early. The rich lymphatic rate of about 80%.
supply also contributes to early involvement of the bilateral
lymph nodes in the submandibular triangle and other areas
in the neck. Midline growths tend to invade the tongue. Lymph Node
The status of lymph nodes has the most important bearing on
Alveolus cure rate. Involvement of Level 3 and Level 4 lymph nodes,
Squamous cell carcinoma arises from the gums, commonly, bilateral nodal disease, and invasion of lymph node capsule
in males owing to the habit of chewing betel-nut and keeping drastically brings down the cure rate.
a quid of tobacco between the gum and the cheek. Chronic Malignant tumors of the oral cavity and tongue cause more
trauma due to ill-fitting dentures may also lead to cancer disruption of local function in alimentation and respiration,
of the gums in the elderly. Involvement of the bone is early with resultant malnutrition, upper airway obstruction and
owing to a thin mucosal lining. recurrent aspiration pneumonia.
 Oral Cavity and Tongue 545

Median Rhomboid Glossitis

Tongue
This may occur on the dorsum of the tongue and present as
Ankyloglossia nodular tongue or macroglossia and should be distinguished
from soft tissue sarcoma by biopsy.
It is more commonly called as tongue tie. It results from a
short lingual frenulum (Fig. 34.18).
The child is unable to protrude the tongue. It causes NEOPLASMS
drooling of saliva and also leads to impairment in speech.
Benign
Treatment
Lymphangioma and Hemangioma
The short frenulum of the tongue should be divided under
general anesthesia. A few sutures may be employed to These are the common benign lesions of the tongue. They

CHAPTER
control the bleeding. The parents are advised to maintain oral may rarely assume such a proportion that they protrude out

34
hygiene. Sometimes speech therapy may be required. of the tongue (Fig. 34.19). More commonly, the patient will
present with frequent tooth-bite or bleeding.
Lingual Thyroid
Treatment
When the embryologic midline pharyngeal diverticulum from
the fourth pharyngeal pouch fails to descend, the thyroid may Local excision should be performed suited to the lesion and
not form in its usual position in the neck. This may result in a to have a good postoperative result.
lingual thyroid that presents as a swelling over the base of the
tongue. Lip Hemangiomas
It is a brownish-colored midline swelling that may lead
to difficulty in breathing and swallowing when large. The Present with swelling and disfigurement (Fig. 34.20). Can
thyroid in the neck may be absent. occasionally present with bleeding.
They are treated by injection sclerotherapy using steroids,
bleomycin, etc. If large, surgery is required.
Treatment
Prior to any surgical procedure on this thyroid tissue, a Malignant
radioiodine thyroid scan should be performed to identify
the thyroid in the neck. Thyroid suppression with thyroid
Cancer of the Tongue
hormone can be given to the patient to suppress the gland.
The lingual thyroid is likely to reduce in size. In the absence of Cancer of the tongue is a common malignancy of the oral
normal thyroid, the lingual thyroid is excised only if causing cavity more often seen in men. While in Europe and America,
obstructive symptoms. Thyroid replacement should be tongue is the most common site of cancer in oral cavity, in
lifelong after excision. India buccal mucosa is commoner. Alcohol and tobacco

Fig. 34.18: Tongue tie Fig. 34.19: Macroglossia due to a lymphangioma

 546 Head and Neck

and propel the food onwards into the oropharynx. A painful

chronic nonhealing ulcer or an exophytic growth on the
lateral margin or the tip of the tongue is easily noticed by the
patient when it occurs in the anterior two-thirds of the tongue.
Palpation of the ulcer will provide the vital sign of malignancy,
i.e. induraton. It will also define fixity to adjacent structures,
including the mandible. A lump in the neck is present when
regional lymph nodes are involved. The enlarged nodes
commonly lie in the submandibular area (Level Ib) or the
upper deep jugular chain (Level 2), and rarely enlarged nodes
may be felt in the jugulo-omohyoid group (Level 3) or even
on the contralateral side. Lesions in the posterior part of the
tongue may spread to the retropharyngeal nodes. Neck nodes
SECTION

are more common and early in cancer of the posterior third

of the tongue.
8

Fig. 34.20: Large tongue with lip hemangioma Investigation

Biopsy
smoking are a lethal combination causing tongue cancer. A punch biopsy should be performed from the margins of the
Poor orodental hygiene is another factor causing lingual ulcer or growth. FNAC should be performed from the lymph
cancer. In India, the habits of pan or tobacco chewing and nodes when these are enlarged.
occurrence of submucosal fibrosis are predisposing factors.
The tumor most frequently arises at the lateral margin of
midportion of the tongue. Histologically it is a squamous cell Radiology
carcinoma. CT Scan/MRI
It spreads radially into the intrinsic and extrinsic muscles
of tongue. Tumors arising from the ventral surface of the The extent of the tumor is difficult to assess clinically, and is
tongue invade the floor of the mouth early. Extensive lesions defined by MRI better than a CT. Magnetic resonance imaging
extend across the midline and posteriorly to involve the has been found to be useful in determining the extent of
base of the tongue, oropharynx and larynx. When it involves disease because the spread is into the soft tissues rather than
the lingual artery, it causes a blowout and severe bleeding. the bone, i.e. the mandible.
Involvement of the lingual nerve, leads to severe pain.
The tumor has a high incidence of nodal metastasis Treatment
because:
a. It is more invasive in nature The general principles enunciated in the treatment of SCC
b. It has abundant submucosal lymphatics of oral cavity apply to the treatment of cancer of tongue.
c. Of free tongue movements. However, owing to some unique features, the treatment
When the lesion is present in the anterior two-thirds of strategies vary.
the tongue (oral tongue), the patient is likely to present early
as compared to patients who develop a tumor in the posterior Anterior Two-thirds of Tongue
one-third (pharyngeal tongue) who present in late stages of
the disease. For T1 and T2 lesions, surgical resection is the primary
Tumors of the base of tongue are poorly differentiated treatment and requires a wedge excision or a hemi­
and generally locally advanced when first seen, owing to the glossectomy. For T3 and T4 cancers, the surgical resection is
inaccessibility of this site to inspection. They spread across more extensive and a hemiglossectomy or a total glossectomy
midline which makes surgical excision as a poor option. may be required. Reconstruction with distant flaps is needed
However, the tumor at this site is radiosensitive. after total glossectomy. Adjuvant postoperative radiotherapy
or chemoradiation is administered in all patients, except
those with very small T1 lesions, where a wedge excision may
Clinical Features
be adequate.
Pain is an early feature and when this is combined with Radiation may be delivered as an external beam by a Linear
limitation of tongue movements a patient is unable to eat Accelerator or as interstitial treatment by brachytherapy.
 Oral Cavity and Tongue 547

These modalities can deliver large doses over small areas. For
irradiation of local disease in tongue in the adjuvant setting, Key Points
brachytherapy is more suitable.
• The major area of concern is squamous cell carcinoma. It
Due to high propensity of lymph node involvement,
has a high incidence, and has correctible causative factors.
radical neck dissection is indicated in all patients. Thus
The treatment is mutilating, both function wise and
elective neck dissection is recommended even in patients
appearance wise.
with N0 neck as defined by clinical examination and imaging.
• The oral cavity has variety of components which show
Patients with locally advanced disease (T4b) and or
different response to cancer and other oral diseases.
extensive neck disease (N3) or with spread beyond the
• There are well-known premalignant conditions. In view of
clavicle require only palliative treatment.
the high incidence of malignant transformation, these are
also referred to as potentially malignant lesions.
Posterior One-third of Tongue • There are a number of benign conditions in oral cavity
which at times are difficult to distinguish from cancer, and

CHAPTER
Carcinomas of the posterior third of the tongue are more require a biopsy. A wedge biopsy or a punch biopsy is the

34
radiosensitive. Radiation provides cure in T1 lesions. most frequently done investigations.
However, advanced disease at the primary site requires • There are inflammatory conditions, which occur in
surgery, preceded by preoperative radiotherapy. The risks malnourished and immune compromised patients.
of radiotherapy in this setting are wound infection, wound
breakdown and bone necrosis. It is therefore wiser to extract
all teeth before radiating an oral cavity. SUGGESTED READING
For lesions of the posterior third of the tongue, the surgery
1. Bassi KK, Srivastava A, Seeenu V, Chumber S. The First and
required is a total glossectomy with or without laryngectomy.
Second Echelon Sentinel Lymph Node Evaluation in Oral
If the disease can be controlled at the primary site, and the Cancer. Indian Journal of Surgery. 2013;75(11):377-82.
cervical lymph nodes show evidence of metastases on clinical 2. Huang S, O’Sullivan, Oral Cancer: Current Role of Radiotherapy
examination or imaging, a radical neck dissection should be and Chemotherapy. Oral Medicine and Pathology. 2013;18(2):
carried out. 233-40.
3. Macgregor Ian A, Frances M Macgregor: Cancer of the Face
In conclusions at specialized centers, use of microvascular and Mouth. Churchill Livingstone.
anastomoses and free myocutaneous flaps is imperative 4. Misra A, Chaturvedi A, Misra NC. Management of Gingivo-
buccal Complex Cancer. Ann R Coll Surg Eng. 2008;90(7):548-53.
for manage­ment of locally advanced oral cancer. PET scan
5. Towns C, Beauchamp D, Evers M, Mattox K. Sabiston Textbook
is emerging as an important tool in primary staging of oral of Surgery : Biological Basis Of Modern Surgical Practice 19th
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investigation for early oral carcinoma. 2012. pp. 1829-72.

MULTIPLE CHOICE QUESTIONS

Q.1. The MOST appropriate treatment for oral submucous fibrosis is:
a. Commando operation b. Cessation of tobacco and betel chewing
c. Local steroid injections d. Radiotherapy
Q.2. ONE of the below is a premalignant condition of the oral cavity:
a. Aphthous ulcers b. Herpes simplex infection
c. Vincent’s angina d. Plummer-Vinson syndrome
Q.3. ONE of the following is true for neck dissection:
a. The internal jugular vein is preserved in radical neck dissection
b. The submandibular gland is preserved in modified radical neck dissection
c. Supraomohyoid dissection involves removal of node Levels I, II, III
d. The parathyroid glands are sacrificed in radical neck dissection
Q.4. The only indication for radical neck dissection for squamous cell carcinoma of the oral cavity is:
a. N+ neck with involvement of spinal accessory nerve
b. N0 neck
c. N+ neck with involvement of common carotid artery
d. T4 lesion is the lateral tongue

Answers: 1(b); 2(d); 3(c); 4(a)

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