A non-healing floor-of-mouth ulcer in a smoker
A 61-year-old man presents with a 3.2 cm ulcer of the left floor of mouth present for 9 weeks. He has smoked 25 cigarettes/day for 40 years and drinks 30 units of alcohol weekly. The ulcer has a rolled, indurated border and a granular base; it is fixed to the underlying tissue but the overlying mucosa is intact at the anterior margin. He reports otalgia on the left and a 4 kg weight loss over 3 months. There is a 1.5 cm firm, non-tender left level IB node. He is edentulous and wears a lower denture; the denture was made 2 years ago and the ulcer does not correspond to the denture border. He has had two courses of antibiotics from his GP with no improvement.
1. What is your leading clinical diagnosis and which features in the history and examination most strongly support it over a traumatic or infective ulcer?
Read the worked answer
The leading diagnosis is squamous cell carcinoma of the floor of mouth.
Supporting features:
- Site: floor of mouth is a high-risk site, especially in a smoker/drinker.
- Duration and behaviour: 9 weeks without healing despite two antibiotic courses argues against a simple traumatic or infective cause.
- Morphology: rolled, indurated border with a granular base is the classic malignant ulcer; induration and fixation indicate invasion.
- Non-correspondence with the denture: the ulcer does not match the denture border, so a denture-induced traumatic ulcer is unlikely (and would usually heal on removal).
- Referred otalgia: suggests involvement of the lingual nerve or deeper structures.
- Weight loss: systemic effect.
- Firm level IB node: suspicious for metastasis.
A traumatic ulcer would be expected to heal within 2–3 weeks once the cause is removed; an infective ulcer (e.g., TB, syphilis, fungal) would usually have a different morphology and would not typically produce a fixed, indurated, painless-firm node in this pattern. The combination of risk factors, site, induration and cervical lymphadenopathy makes malignancy the working diagnosis until biopsy proves otherwise.
2. Outline the investigations you would arrange, in order, and explain what each is intended to establish.
Read the worked answer
- Incisional biopsy of the ulcer edge (including adjacent normal tissue): the definitive diagnostic test. It establishes histology, grade and confirms malignancy. Avoid taking only the necrotic centre.
- Fine needle aspiration (FNA) of the left level IB node: to assess for metastatic squamous carcinoma and guide staging.
- Imaging: contrast-enhanced CT or MRI of the neck to assess primary tumour extent, depth of invasion, and nodal disease; chest imaging (CT chest) for staging and to exclude a second primary or pulmonary metastasis.
- Panendoscopy / examination under anaesthesia if indicated: to exclude synchronous primaries in the aerodigestive tract, given the smoking and alcohol history.
- Baseline bloods and nutritional assessment: FBC, U&E, LFTs, and consideration of nutritional optimisation before any surgery.
The sequence matters: biopsy first to confirm the diagnosis, then staging investigations. Do not proceed to definitive treatment without histological confirmation and staging.
3. The biopsy confirms moderately differentiated squamous cell carcinoma. What management principles guide the next step, and what would you tell the patient about prognosis and the need for multidisciplinary input?
Read the worked answer
Management should be discussed at a multidisciplinary team (MDT) meeting with oral and maxillofacial surgery, oncology, radiology, pathology and specialist nursing.
Principles:
- Staging (TNM) based on clinical examination, imaging and nodal status determines treatment.
- Surgery is the mainstay for early floor-of-mouth SCC: wide local excision with clear margins, often with elective neck dissection (levels I–III) given the risk of occult nodal disease.
- Adjuvant radiotherapy (with or without chemotherapy) is considered for adverse features: positive or close margins, extranodal extension, multiple involved nodes, perineural or lymphovascular invasion.
- Reconstruction planning (e.g., free flap) should be discussed preoperatively.
- Smoking and alcohol cessation advice is essential: it reduces recurrence and second primary risk and improves surgical outcomes.
Prognosis depends on stage, nodal status and margin status; early-stage disease has a good prognosis, but nodal involvement substantially worsens it. The patient should be told that treatment is likely to involve surgery and possibly radiotherapy, that follow-up will be long-term, and that cessation of smoking and alcohol is part of the treatment plan.