A 48-year-old female presented with a 6-month history of pain and a 4-month history of an ulcerative lesion on the right side of her tongue. Examination revealed a 4cm x 3cm x 1cm tender ulcerative growth that bled on touch, consistent with early carcinoma of the tongue. Given her history of tobacco and betel nut chewing for 30 years, squamous cell carcinoma was considered the most likely diagnosis. Investigations including biopsy and imaging of the neck were planned to confirm diagnosis and assess spread, and right hemiglossectomy with neck dissection was proposed as treatment.

1. Case Presentation

2. Carcinoma Tongue
Dr. Aravind.K.R.
3rd yr Junior Resident
General Surgery
Rajendra Institute of Medical Sciences, Ranchi.
Prof. Dr. D. K. Sinha
Professor - Dept of General Surgery
Rajendra Institute of Medical Sciences, Ranchi.

3. Chief Complaints
• Mrs. X, 48 yr old housewife from
Dhanbad, Hindu by religion and of low
socio economic status presented to
the OPD with complaints of
1. Pain in the tongue for the past 6
months
2. Ulcer over the front part of right
side of tongue - for the past 4
months
3. Swelling in front of the ulcer - for
the past 3 months

4. History of Presenting Illness
• Pain
Insidious in onset, Non progressive in nature, Intermittent and burning type of
pain. Mild severity. Duration - 6 months.
Localized to the tongue, referred to right ear for 1 month
Aggravated while chewing and tongue movements.
Relieved on taking cold and sweet food
• Ulcer:
Insidious in onset, Progressive in nature
Duration - 4 months
Right lateral and front part of the tongue
Occured due to trauma following tongue bite
Associated with pain, discharge and occasional bleeding
which subsequently progressed to form a swelling in front of the ulcer (upper
part)for the past 3 months
swelling is associated with difficulty in chewing and prone to tongue bite.
No relieving factors

5. • H/O difficulty in speech for 2 months
• H/O excessive salivation present
• H/O loss of weight present due to reduction in food intake
• H/O bad odour from mouth present
• No H/O loss of taste sensation
• No history suggestive of complaints related to ear, nose and throat.
• No H/O neck swelling
• No H/O swelling or lumps in other parts of the body
• No H/O fever, jaundice, difficulty in breathing, recent onset bony
pain
• Known case of Hypertension for the the past 2 years on treatment

6. Past History
• H/O repeated trauma to the tongue due to mis directed tooth
for the past 6-7 years
• She was adviced for removal of her tooth (right 1st premolar),
but she apllied locally used topical medication with no
permanent relief and finally tooth extraction was done 2
weeks back.
• No H/O sexually transmitted disease
• No H/O any other surgical intervention

7. Personal History
• Non vegetarian by diet.
• H/O Tobacco chewing for the past 30 years
• H/O intake of betal nut and pan for the past 20 years.
• No H/O smoking, alcohol intake.
• Bladder and bowel habits normal.
• Family History - not significant

8. Obstetric and Menstrual
History
• She is married, having two live childen both by normal vaginal
delivery
• Attained menopause three years back.

9. General Examination
• Patient is conscious, co-operative, oriented to time, place and
person, afebrile.
• Average built and nourished.
• Mild pallor +, not icteric, no clubbing, no cyanosis, no pedal edema,
no generalized lymphadenopathy.
• Hydration adequate
• Karnofsky Performance Status - 80
• ECOG Performance status - Grade 1
• Vitals:
• BP: 124/80mmHg(arm) in sitting posture
• Pulse Rate: 84/min, normal volume, regular rhythm, no radioradial
& no radiofemoral delay.
• RR: 16/min, thoraco abdominal type.
• BMI: 22.5kg/m2

10. After getting informed consent, the patient is
examined in a well lit room in sitting posture

11. Local Examination
• Inspection:
• No facial deformity
• Mouth opening - Adequate.
• Staining of teeth present
• Tongue: Normal in size and shape. Pinkish red in colour.
Movement present in all directions.
No fibrillation. Undersurface and Posterior 1/3rd – Normal
Anterior 2/3rd tongue: A single ulcero-proliferative growth of size
approx. 3cmX3cmX1cm from about 2cm lateral to tip of the tongue extending
posteriorly on the right side upto 2 cm anterior to the sulcus terminalis, which
is almost oval in shape, pink in colour, irregular surface, anteriorly well defined
and posteriorly ill defined margins.
An ulcer of size approx 2cmX1cm present over posterior part of the swelling
with everted and rolled out edges, floor contains pale granulation tissue and
yellowish white slough
Surrounding area – looks normal.
• Retromolar trigone and other areas in oral cavity – Normal

13. Palpation
• Tenderness present over the ulcerated surface.
• A single oval ulcero proliferative growth of size 4cmX3cmX1cm
in the right lateral part of the tongue extending 2.5cm lateral to
tip of tongue upto 2cm anterior to sulcus terminalis, irregular
and rough surface, firm in consistency, anteriorly well defined
margins and posteriorly ill defined and do not cross midline. The
ulcer of size 2cmX1cm is present over the growth posteriorly
with everted and rolled out edges, irregular margins, base is
indurated.
• Floor has pale granulation tissue with yellowish white slough at
places. It bleeds on touch.
• No extension into floor of mouth, alveolar region and retro molar
region
• Tonsilar region, Posterior pharyngeal wall - Normal

14. • Inspection of Neck - Normal
• Cervical lymph node Examination – Not palpable.

15. Other system examination
• Ear Nose and Throat examination - within normal limits
Indirect laryngoscopy:
Posterior 1/3rd tongue, posterior most part of tongue,
Hypopharynx Epiglottis, pyriform fossa - Normal (No
growth/ulceration)
Vocal cord - mobility present; no growth or ulceration
• Cardio vascular system, Respiratory system, Central Nervous
sytem, Abdominal examination – within normal limit.

16. Summary
A 48 year old female presented with history of pain for 6 months
and ulcero proliferative lesion over the right antero-lateral
aspect of the anterior 2/3rd tongue for last 4 months with
history of tobacco and betal nut chewing for about 30 years. On
examination, a tender ulceroproliferative growth of size
4cmx3cmx1cm with everted and rolled out edges, indurated
base was felt which bleeds on touch. Hence.....
Provisional Diagnosis:
Right side Early Carcinoma Tongue -
Anterior 2/3rd
Stage – T2 N0 Mx

17. Differential Diagnosis
• Squamous Cell Carcinoma – Most common
• Verrucous Carcinoma
• Undifferentiated Carcinoma
• Small cell neuro-endocrine tumor
• Adenocarcinoma of minor salivary glands
• Lymphoepithelioma

18. Investigations
• Confirmation of Diagnosis:
• Wedge biopsy of Growth and Histopathological examination
• CECT of Head and Neck from skull base to upper chest -
To see for bony infiltration (cortical bone abutment) into
mandible, pterygoid plates and for occult metastasis to cervical
lymph nodes
• MRI Tongue - To check for infiltration to extrinsic and intrinsic
muscles of tongue, nerves and vessels.
• Routine blood investigations and Chest Xray
• Orthopantomogram

19. Treatment
• Surgery:
• Right sided Hemi-glossectomy with right side Elective Supra-
omohyoid neck dissection.
• Post Operative follow up:
• Clinical examination every 3 monthly in 1st year, then every 4
monthly in 2nd year, every 6 monthly upto 4th year and then
once in a year.

20. • This slide presentation was awarded 1st prize in Regional
Refresher Course (Zonal) of ASI in 2020.