A non-healing tongue ulcer in an areca-nut and tobacco chewer who wants antibiotics and is about to travel
Mr R, 61, attends asking about a mouth ulcer that will not heal. He has chewed areca nut with tobacco three times a day for 20 years and smokes 20 cigarettes daily. On the left lateral border of the tongue there is a 25 x 15 mm ulcer that has been present for 6 weeks. Its edges are raised and rolled, the base is indurated and fixed to deeper tissue, and it is only mildly painful. No sharp tooth or denture contacts the area. Oral hygiene is fair, with tobacco staining. A firm, mobile 15 mm ipsilateral submandibular node is palpable. He has lost 3 kg unintentionally in 2 months. He asks for a strong mouthwash and antibiotics because he is travelling abroad for work in 3 weeks and cannot attend hospital appointments. He has not seen a doctor in 10 years.
1. Give your differential diagnosis and identify the single most important action you will take today, with the reasoning behind the urgency.
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Differential, in order of probability and danger.
- Squamous cell carcinoma of the lateral tongue: duration over 2 weeks, induration, fixation to deep tissues, rolled everted edges, mild pain (malignancy is often less painful than expected), ipsilateral firm node, unintentional weight loss, and two synergistic risk factors (areca nut with tobacco, and smoking).
- Chronic traumatic ulcer - effectively excluded: no identifiable cause, and the base is indurated and fixed.
- Major aphthous ulcer - would normally be intensely painful, recurrent and not fixed.
- Tuberculosis, primary syphilis, deep fungal infection, lymphoma, necrotizing sialometaplasia - rarer, but each is a reason why tissue, not a prescription, makes the diagnosis.
The action. Same-day urgent referral on the suspected-cancer pathway to oral and maxillofacial surgery or a head and neck unit, for incisional biopsy and staging, with the referral marked urgent and the findings stated explicitly. Telephoning the receiving unit the same day is good practice.
Why the speed matters. Stage at diagnosis dominates prognosis. A tongue cancer with a clinically involved node is already at least stage III, and every added week of delay risks further nodal spread and a larger resection. Six weeks of 'wait and see' or empirical treatment is exactly how these cases are missed. Explain to the patient what you have found and why you are not offering a mouthwash.
2. He insists on a mouthwash and antibiotics and says he cannot attend hospital for 3 weeks. How do you handle this, and what do you tell him about biopsy and imaging?
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Do not collude with the delay. Say plainly: this ulcer does not look like an infection, it has the features of a growth, and antibiotics or an antiseptic mouthwash will not treat it and may waste the only window when treatment is straightforward. Be honest but not brutal - use the word 'suspicious' and explain that only a tissue sample can tell.
Address the practical obstacle rather than the stated one. Ask what specifically prevents attendance - fear, cost, work, language - and offer solutions: telephone the hospital while he is in the chair to request the earliest slot, ask the GP to expedite, write a letter he can carry, and identify a unit near where he will be travelling so the referral can be transferred rather than abandoned. If he still declines, document the information given, his decision, his capacity to make it, and arrange a short-interval review with a safety net; keep the GP informed.
Biopsy. An incisional biopsy taken from the edge, including abnormal and adjacent normal tissue, avoiding the necrotic centre, is the diagnostic standard. Brush cytology and other sampling methods cannot exclude malignancy and must not be presented as an alternative.
Imaging. Ultrasound of the neck assesses nodal status; CT or MRI is used for local and regional staging, usually after histological confirmation. Imaging does not replace histology and does not remove the need for urgent referral today.
Record the conversation verbatim in the notes, including the risks you described.
3. The biopsy confirms moderately differentiated squamous cell carcinoma with a metastatic ipsilateral node. Outline the likely treatment and the preventive advice for the remaining mucosa.
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Treatment. Management is decided by the multidisciplinary team. Expect primary surgery - wide local excision with appropriate margins plus neck dissection - with adjuvant radiotherapy, sometimes with chemotherapy, depending on margin status, extranodal extension, number of involved nodes and depth of invasion. Reconstruction may involve a free flap. Before radiotherapy he needs a dental assessment: eliminate infection, extract teeth with a hopeless prognosis within the pre-radiotherapy window, and plan fluoride and xerostomia care to reduce radiation caries and osteoradionecrosis risk.
Prognosis, communicated carefully. Nodal involvement substantially reduces survival compared with node-negative disease; give a range from the treating team rather than your own figure, and let them break the news of stage and prognosis.
Prevention in the remaining mucosa. This is field change: the whole aerodigestive mucosa has been exposed, so second primary tumours are a real risk.
- Complete cessation of areca nut and tobacco, with pharmacological and behavioural support; reducing rather than stopping is not sufficient.
- Reduce or stop alcohol.
- Structured surveillance of the oral cavity and neck at short intervals for the first 2 years, then lengthening intervals, with a clear route back if a new lesion appears.
- Emphasise that he should never again accept a 'wait and see' approach for an ulcer lasting more than 2 weeks.