ENT (Otorhinolaryngology) · MU Sofia

43. Malignancies of the oral cavity and tongue.

Covers malignant epithelial tumours of the oral cavity and tongue, mainly squamous cell carcinoma, beginning with sites and the base-of-tongue distinction. It then moves through risk factors, pathogenesis, classification, and the AJCC 8th edition TNM staging with depth of invasion. Clinical signs, diagnostic tests, surgical and adjuvant treatment, complications, and differential diagnoses follow, with a staging table-like list and a note on leukoplakia and erythroplakia.

Inside: 1 section · 3 labelled pictures · 14 flashcards · 4 min

Topic 43 of 52 in the MU Sofia syllabus for ENT (Otorhinolaryngology) (Medicine, Year 4). The free AceMed note covers it in 1 section, about 653 words (4 min of reading), with 14 flashcards.

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  1. Malignancies of the oral cavity and tongue.

Malignancies of the oral cavity and tongue.

1. Definition: Oral cavity malignancies are malignant epithelial tumors, most commonly squamous cell carcinoma, arising from the lower – common, lips, the anterior two-thirds of the tongue, the floor of the mouth, the buccal mucosa, the upper and lower alveolar ridges, the hard palate, and the retromolar trigone. The base of tongue is anatomically part of the oropharynx, not the oral cavity.

2. Etiopathogenesis - often a progression from potentially malignant disorders (PMDs) due to chronic mucosal irritation.

  • Chemical Carcinogens:
  • Tobacco: most important.
  • Alcohol: Acts as a solvent for tobacco carcinogens (synergistic with tobacco).
  • Mechanical Irritation: Sharp teeth, ill-fitting dentures, or chronic cheek biting.
  • Nutritional Deficiencies: Iron deficiency (Plummer-Vinson syndrome) and Vitamin A/C deficiency.
  • Actinic Radiation: Primary risk factor for cancer of the lower lip (UV exposure).
  • HPV infection (especially tongue base / oropharynx)

Pathogenesis

  • Epithelial dysplasia → carcinoma in situ → invasive SCC
  • Early local invasion, perineural spread
  • Early regional lymph node metastasis (especially cervical nodes)

3. Classification

  • Squamous Cell Carcinoma (SCC): Most common.
  • Minor Salivary Gland Tumors: Adenoid cystic carcinoma, mucoepidermoid carcinoma (often on the palate).
  • Verrucous carcinoma (low-grade SCC variant)
  • Melanoma: Rare but highly aggressive.

TNM Staging (AJCC 8th Edition) - A key update in the 8th edition is the inclusion of Depth of Invasion (DOI):

  • T1: 2 cm and DOI5 mm.
  • T2: 2 cm and DOI > 5 mm OR 2–4 cm and DOI10 mm.
  • T3: > 4 cm OR any tumor with DOI > 10 mm.
  • T4: Invasion of adjacent structures (cortical bone, maxillary sinus, skin of face).

4. Clinical Picture

  • The Non-healing Ulcer: Any ulcer persisting for more than 2–3 weeks must be biopsied.
  • Exophytic or Endophytic growth: A "cauliflower-like" mass or a deep, indurated (hard) crater.
  • Leukoplakia/Erythroplakia: White/red patches that cannot be scraped off. Erythroplakia has greater risk of malignancy.
  • Tongue Symptoms: Pain or burning, Bleeding from lesion, restricted mobility, and dysarthria (slurred speech).
  • Difficulty chewing, swallowing, or speaking
  • halithosis
  • Advanced Signs:
  • Loose teeth or bleeding.
  • Numbness (mental nerve involvement in the jaw).
  • Neck Mass: Often the first sign of spread (metastasis to level I, II, or III lymph nodes).

5. Paraclinical and Radiological Examinations

  • Biopsy (Incisional): definitive diagnostic gold standard. It must include the edge of the lesion and some healthy tissue.
  • Toluidine Blue Staining: A clinical aid to highlight areas of high DNA activity for biopsy.
  • CT Neck with Contrast: To assess for bone invasion (mandible/maxilla) and cervical lymphadenopathy.

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