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Arab Board OMFS Part 1 study materials
Arab Board OMFS Part 1 study resources

Suspicious Oral Ulcer in a Smoker

Arab Board OMFS Part 1 · Put your knowledge to work in context.

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Suspicious Oral Ulcer in a Smoker

A 58-year-old man presents with a 2-month history of a non-healing ulcer on the left lateral border of the tongue. He smokes 20 cigarettes per day and drinks alcohol socially. The ulcer is 1.5 cm in diameter, has everted edges, and is indurated and fixed to underlying tissues. He reports pain radiating to the left ear and difficulty swallowing. There is a palpable, firm, non-tender submandibular lymph node on the left side. His past medical history includes hypertension and type 2 diabetes. He has no known allergies. Intraoral examination reveals poor oral hygiene and a few remaining teeth with sharp edges. He has not seen a dentist in 10 years.

1. What is your provisional diagnosis and what investigations would you order?

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Provisional diagnosis: Squamous cell carcinoma (SCC) of the left lateral tongue with regional lymph node metastasis (T2 N1 M0).

Investigations:

  1. Incisional biopsy of the ulcer (gold standard) for histopathology.
  2. Fine needle aspiration cytology (FNAC) of the submandibular lymph node.
  3. Imaging: CT scan or MRI of the neck to assess extent and lymph node involvement; chest X-ray or CT chest for staging.
  4. Panoramic radiograph to evaluate bone invasion.
  5. Blood tests: CBC, liver function tests, renal function, HbA1c (for diabetes control).
  6. HPV testing (though less common in oral cavity SCC).

Referral: Urgent referral to oral and maxillofacial surgery/oncology for multidisciplinary team (MDT) discussion.

2. Discuss the risk factors and how you would counsel the patient.

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Risk factors:

  • Tobacco: Smoking is a major risk factor; synergistic with alcohol.
  • Alcohol: Increases risk, especially when combined with smoking.
  • Age: >50 years.
  • Gender: Male predominance.
  • Poor oral hygiene and chronic irritation from sharp teeth.
  • Diabetes: May impair immune response.

Counseling:

  • Stop smoking and reduce alcohol intake; provide resources for cessation.
  • Explain the diagnosis and need for urgent treatment.
  • Discuss treatment options: surgery (wide local excision with neck dissection), radiotherapy, chemotherapy.
  • Address diabetes control pre-operatively.
  • Dental assessment and extraction of sharp teeth before radiotherapy to prevent osteoradionecrosis.
  • Nutritional support and speech therapy.
  • Follow-up and surveillance.