A Non-Healing Tongue Ulcer in a Patient About to Travel
A 62-year-old man attends for a routine scale and mentions a sore on the left side of his tongue that he first noticed about 7 weeks ago. It has not healed. Three weeks ago his GP prescribed amoxicillin 500 mg three times daily for 7 days; the ulcer did not change. He smokes 20 cigarettes a day (45 pack-years) and drinks about 15 standard drinks a week. He takes amlodipine 5 mg and aspirin 100 mg daily.
On examination there is an 18 × 12 mm ulcer on the left lateral tongue posterior to the midline, with rolled, raised margins and an indurated, fixed base. It is not tender to palpation. There is no cervical lymphadenopathy. His dentition is heavily restored but no sharp cusp, fractured restoration or denture border contacts the area.
He is flying to Melbourne in 10 days to stay with family for three months, and asks for "a stronger antibiotic and a mouthwash" before he goes.
1. What is the most likely diagnosis, what else must you consider, and which features in this history and examination make it a red flag?
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Most likely diagnosis: oral squamous cell carcinoma of the left lateral tongue.
The differential includes a traumatic ulcer, major aphthous ulceration, drug-related ulceration, syphilis, tuberculosis, lymphoma, chronic hyperplastic candidiasis and necrotising sialometaplasia. Traumatic ulceration is effectively excluded here: there is no offending tooth, restoration or denture, and a traumatic ulcer is not indurated and fixed.
Red flags in this case:
- Male, over 45, with a 45 pack-year smoking history plus regular alcohol - the two act synergistically.
- A single ulcer present for more than three weeks.
- Site: lateral tongue and floor of mouth are the highest-risk mucosal sites.
- Indurated, fixed base with rolled, everted margins.
- Painless - malignant ulcers are typically painless until late, which is why patients delay.
- No response to a course of antibiotics.
Antibiotics were never going to work: this is not a treatable bacterial infection. Empirical antibiotics for a chronic oral ulcer are worse than useless, because partial reduction in surrounding inflammation can falsely reassure both patient and clinician. Stage at diagnosis is the strongest predictor of survival in oral cancer, and diagnostic delay measured in months is what changes stage. The 7-week history plus a 3-week antibiotic trial already represents lost time; a further 3 months in Australia could change a small resection into surgery plus adjuvant radiotherapy.
2. Set out your immediate management, including referral urgency, what you tell him about his travel, and what must be documented.
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Refer today - not a review in two weeks. In New Zealand this goes directly to oral medicine or oral and maxillofacial surgery as a suspected head and neck cancer referral, marked urgent, with a target of specialist assessment within two weeks. Send it before he leaves the surgery and give him a copy.
The referral must contain the duration (7 weeks), the failed antibiotic trial, smoking and alcohol history, medication, the exact site and dimensions, the indurated fixed base, the absence of lymphadenopathy, and a clinical photograph. Photograph the lesion with a scale reference and store it in the notes - it also allows the specialist to compare later.
Travel: tell him plainly that this needs to be assessed before he goes, and that a specialist appointment can usually be arranged within days. Do not soften this into "get it checked when you're back". If he insists on travelling, arrange onward referral in Australia before departure, ensure records and images are transferred, and document that you advised against delay, what you said, and his response.
Also: brief smoking cessation intervention with referral to Quitline, continue aspirin, no further antibiotics, mouthwash is not treatment, and no biopsy in general practice - incisional biopsy and imaging are the specialist's call. Record all of this contemporaneously.
3. He becomes defensive, says the antibiotics just needed longer, and refuses to be referred. How do you manage this, and what are your obligations?
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First, find out what is driving the refusal - fear of a cancer diagnosis, worry about cost in New Zealand (referral to a public hospital is free), concern that travel plans will be ruined, or simply not believing you. Name the concern rather than arguing about the antibiotics.
Explain in plain language without overpromising either way: "This needs to be looked at by a specialist because of how it looks and how long it has been there. If it is nothing, they will tell us quickly. If it is something, three months could make the treatment much bigger." Give the specific red flags in writing, and the symptoms that should send him to an emergency department abroad (bleeding, difficulty swallowing or breathing, a rapid neck lump).
He has the right to refuse (Code of Health and Disability Services Consumers' Rights, Right 7 - informed choice and consent). Establish that he has capacity, then document what you explained, the risks of delay, and that he declined. Send the referral anyway so that the information exists if he changes his mind, and ask his permission to do so - document if he refuses permission. Offer to speak to his GP with consent, give him the photograph and a copy of the referral, and arrange a phone follow-up before he flies.
The single worst outcome is a polite end to the conversation. Keep the relationship open: the patient who feels heard is the one who comes back.