A non-healing tongue ulcer in a water-pipe smoker

Ranking: 1. Squamous cell carcinoma. 2. Traumatic ulcer. 3. Erosive lichen planus. 4. Major aphthous ulcer. 5. Rarer mimics - primary syphilis, tuberculosis, lymphoma, deep salivary gland malignancy.

Why carcinoma leads:

• Site. The lateral border of the tongue is a high-risk, high-friction area bathed in pooled carcinogens.
• Exposure. Twenty years of water-pipe smoking is a substantial risk factor independent of cigarettes; alcohol is not required.
• Duration. An ulcer persisting beyond two to three weeks without a cause is suspicious by definition.
• Morphology. Rolled, everted margins with an indurated base and fixation to deep tissue are the classic triad of malignancy, not of a reactive ulcer.
• Failure to respond to antiseptic and topical steroid argues against an inflammatory cause.
• Neck node. A firm, non-tender submandibular node suggests metastatic spread.
• Weight loss suggests systemic disease.

Alternatives that must still be considered: a traumatic ulcer from a sharp tooth or restoration, which would have an identifiable cause and would heal after its removal; erosive lichen planus, usually bilateral with reticular striae and more pain; a major aphthous ulcer, which is very painful with a yellow slough and no induration; a primary syphilitic chancre, painless and indurated but typically resolving within weeks; tuberculosis; and lymphoma, which can present as an ulcerated mass.

No clinical feature can exclude carcinoma. The ranking changes urgency, not the need for biopsy.

Immediate management:

1. Urgent referral for biopsy on a suspected-cancer pathway, ideally to oral and maxillofacial surgery within two weeks. State clearly on the referral that the lesion is suspicious for malignancy, its size, site and duration, the nodal findings and the weight loss.
2. Incisional biopsy, taken from the indurated margin and including some clinically normal adjacent tissue. The necrotic centre is misleading and should be avoided. Excisional biopsy of a 2.5 cm suspicious lesion is inappropriate.
3. Examine the whole oral cavity for a second primary or field change, palpate both neck levels, and record mouth opening.
4. Ask about hoarseness, dysphagia and otalgia, which would indicate deeper or more advanced disease and may change the referral urgency.
5. Staging is arranged by secondary care - ultrasound of the neck with fine needle aspiration, and CT or MRI. Ordering these yourself can duplicate or delay the pathway.
6. Record the discussion and the two-week referral in the notes, and give the patient written contact details.

Actions that would be wrong:

• Prescribing another course of steroid paste or antibiotics, or arranging review in four weeks after an allegedly short trial.
• Reassuring the patient that the lesion is benign on clinical grounds.
• Performing an excisional biopsy in primary care.
• Removing a suspected causative tooth without first excluding malignancy.
• Delaying referral to see whether the lesion responds to stopping water-pipe smoking.

Communicating without diagnosing: explain that the ulcer has features that are not typical of a simple sore and that the only reliable way to know what it is, is a biopsy. Use plain language such as: the appearance is suspicious and needs checking urgently; this does not confirm cancer, but it must be excluded. Avoid both false reassurance and a definitive cancer diagnosis, because only histopathology can provide that.

Explain the pathway: what a two-week urgent referral means; that an incisional biopsy takes a small piece of tissue under local anaesthetic; that the result usually takes one to two weeks; and that further scans and a specialist team may be involved.

Address the delay honestly: the pharmacist's treatment was reasonable first-line management, but a six-week non-healing ulcer now needs investigation. Do not blame the patient or the pharmacist, and do not apologise in a way that implies negligence.

Advise: stop water-pipe smoking, since continued exposure worsens outcomes and increases the risk of a second primary; maintain oral hygiene; avoid irritants and hot, spicy food; return immediately if bleeding, rapid growth, breathing difficulty or swallowing difficulty develops.

Document: the lesion description with measurements and a diagram, node findings, the exact wording of the referral, that the possibility of malignancy was discussed, the patient's understanding and agreement, and that written information and contact details were given. A chaperone should be present, and the conversation should be recorded contemporaneously in case of later complaint.