A five-week tongue ulcer and a patient who wants it frozen off
Mr S, 59, attends as a new patient. He has had a sore on the left side of his tongue for five weeks. Two weeks ago a pharmacist supplied chlorhexidine mouthwash and a two-week course of amoxicillin; neither helped. The lesion is 18 mm across and lies on the left lateral border of the tongue, with raised, rolled, indurated margins and a granular base. It is fixed to the underlying tissue, non-tender on gentle palpation and does not bleed. He describes pain radiating to the left ear on swallowing and has lost 4 kg unintentionally over three months. He smokes 20 cigarettes a day (35 pack-years) and drinks about 30 units of alcohol a week. There is a firm, non-tender 15 mm node in the left level IB region. His dentition is a complete upper and lower denture with no sharp areas. He asks you to freeze it off or give him something stronger.
1. State your differential diagnosis and the single most appropriate next step today, with your reasoning.
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Leading diagnosis: oral squamous cell carcinoma of the left lateral border of the tongue with a clinically involved ipsilateral level IB node. The site, the duration beyond three weeks, induration, fixation to deeper tissue, raised everted margins, otalgia (referred pain), unintentional weight loss, and a firm non-tender node in an older smoker-drinker make this the working diagnosis until proven otherwise.
Differential: other malignancy (lymphoma, minor salivary gland malignancy, metastasis); major aphthous ulceration; chronic traumatic ulcer; chronic hyperplastic candidosis; tuberculosis; primary syphilis; medication-related ulceration (for example nicorandil); eosinophilic ulcer.
Next step: an urgent referral today to an oral and maxillofacial surgery or oral medicine service on a suspected-cancer pathway, to be seen within two weeks. Telephone the receiving clinician if the electronic referral will not be triaged promptly, and state the suspicion explicitly in the referral letter.
What I would not do:
- Empirical antibiotics, antifungals or topical steroids - these delay diagnosis and have already cost this patient two weeks.
- 'Freeze it off', cauterise or apply a laser.
- Watch and review in another two weeks.
- Take a biopsy in primary care. Incisional biopsy is normally performed at the specialist centre, where the sample can be taken from the active margin, oriented and correlated with imaging and staging.
Document the clinical findings, the referral, the safety-netting advice and the conversation.
2. Which features raise and which lower suspicion of malignancy in a persistent oral ulcer? How would your answer change if the ulcer were on the buccal mucosa next to a sharp cusp?
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Features that raise suspicion:
- Duration over three weeks with no identified reversible cause.
- High-risk sites: lateral border and ventral surface of the tongue, floor of mouth, retromolar region, soft palate.
- Induration on palpation, fixation to underlying tissue, rolled or everted margins, granular or easily bleeding base.
- Pain, particularly referred otalgia, dysphagia or a change in speech.
- A firm, non-tender, fixed cervical node.
- Unintentional weight loss, age over 40, tobacco and alcohol exposure, previous head and neck cancer or field change.
- Absence of pain does not lower suspicion - many oral cancers are painless until late.
Features that lower suspicion (but do not eliminate it):
- A clear mechanical cause that resolves within about two weeks of removing it.
- Short duration, tenderness, mobility of the lesion with the mucosa, absence of induration, no lymphadenopathy.
- A young patient with a history of recurrent, identical, self-healing aphthous ulcers.
If it were beside a sharp cusp: I would still not simply reassure. I would smooth or adjust the offending tooth, give analgesia and review in two weeks - with a clear rule that any lesion not fully healed by then, or any lesion that is indurated or has a fixed node at any point, goes straight to urgent referral. The dangerous error is using the presence of a sharp cusp to explain away a lesion that does not behave like trauma.
3. How do you explain the situation to Mr S and arrange the referral, and what must you avoid saying?
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How I would say it: 'This ulcer has been there for five weeks, and it has features I would not expect from a simple sore or an infection. The mouthwash and antibiotics have not helped, and I do not think another course of anything will help. I am referring you urgently to a specialist unit that deals with this kind of problem. They will examine it properly and will probably take a small sample, under local anaesthetic, to find out exactly what it is. You should be seen within two weeks.'
Then: ask whether he has questions, give him the appointment and contact details in writing, and say that if he has not heard about an appointment within a week he should call us so we can chase it.
What I must not say:
- 'It is definitely cancer' - I cannot know that without histopathology, and it causes avoidable distress.
- 'It is nothing to worry about' or 'let us wait and see' - false reassurance is the single most harmful thing in this scenario.
- 'Stop smoking and it will settle down' - cessation advice is appropriate but is never a substitute for referral, and must not be used to defer it.
- Anything that implies I can remove it in the surgery.
Additional actions:
- Record findings, photographs with consent, the exact referral wording and the safety net.
- Offer smoking and alcohol cessation advice separately, framed as beneficial for treatment outcomes and general health.
- Ensure the referral includes his medical history, medications and the nodal finding.
- Flag the record for audit so the outcome of the referral is reviewed when the specialist report arrives.