Dept. of General surgery,
Anatomy of Oral cavity
Extends from skin- vermilion junction of lips to
junction of hard and soft palate above
Below it is limited to circumvallate papilla of tongue.
Lips, Buccal mucosa, Upper and lower alveolar
ridges,the retromolar trigone,anterior two thirds of
tongue,floor of mouth and the hard palate.
Again it is divided into external compartment
vestibule and inner oral cavity proper by alveolar
ridges and teeth.
Importance of hard palate :
-Mucosa and periosteum are closely
-These foraminas are potential route of
spread of malignancies anteriorly to nasal cavity
and posteriorly to skull base.
-Lymphatic drainage through level II if in
posterior hard palate and both primary hard
palate drains into level I nodes.
-Sensation is by V 2
Importance of Retromolar trigone
Mucosa is closely adherent to the ascending
ramus of the mandible.
Carcinoma in this region often invades mandible.
Referred otalgia results from innervation by
V3,lesser palatine nerve, and the
Lymphatic into Level II nodes.
Sulcus terminalis divides the tongue into anterior
2/3rd and posterior 1/3rd.
Anterior 2/3rd is part of oral cavity and posterior
1/3rd part of oropharynx.
Anterior part is derived from lateral lingual
swellings of first branchial arch and got lingual
nerve as sensory supply.
Muscles of Tongue
Broadly divided into
1) Extrinsic and
2) Intrinsic group
Innervation and Drainage
Motor : Hypoglossal nerve
Sensory : Lingual/Taste by Chorda tymphani via facial
V3 also supplies EE,EAC,TM Tongue malignancy has
referred pain over ear.
Arterial : Lingual artery
Lymphatic : Tip – Level I A
Lateral aspect @ Level II nodes
Medial aspect into Level III nodes
Lateral drains only in Ipsilateral nodes
Medial can drain in both ways.
Incidence of Oral malignancy
India continues to report the highest prevalence
of oral cancers globally with 75,000 to 80,000
new cases of such cancers reported every year.
57.5 % of global head and neck cancer occurs in
Asia esp in India.
Head and neck cancer accounts 30% of all
cancers in Male and 11-16% of females in India.
Nearly 2/3rd of oral cancer in India occurs in
Gingivo-buccal sulcus and hence it is popularly
called “Indian oral cancer”.
Tobacco use in dose dependent fashion.
Alcohol has synergistic effect.
It takes 20 years for a smoker or tobacco chewer
who abstained from above to clear of their risk of
In India tobacco along with betel nut chewing
contributes 25 % of cancers in oral cavity.
75% of Squamous cell carcinoma occurs only in 10
% of mucosal areas.
Those are Gingivobuccal sulcus,lateral border of
tongue to retromolar trigone and the anterior tonsillar
This is due to flow and pooling of carcinogen
contaminated saliva in these regions.
Human papillomaviruses (HPVs) have been
associated with a risk for oral cavity .
These carcinomas may carry a better prognosis and
may respond better to therapy such as radiotherapy.
A nested case-control study suggested that the risk
may be with the HPV-16 serotype, with 50% and
14% of oropharyngeal and oral tongue carcinomas,
respectively, containing HPV-16 DNA.
The EBV is a human herpesvirus that has been
implicated in a number of human malignancies,
including nasopharyngeal carcinoma (NPC).
Squamous cell carcinoma accounts for 95% of all
malignant tumors in the oral cavity.
Other malignancies involving the oral cavity
include malignant salivary gland lesions, mucosal
melanoma, lymphoma, and sarcoma.
In the earliest recognizable stage, squamous cell
carcinoma appears as firm, pearly plaques or as
irregular, roughened, or verrucous areas of
Non healing ulcer
Other tell-tale sign of head and neck malignancy
Pertaining to tongue : Restriction of movement of
tongue,difficulty in pronounciation.
Complete head and neck examination
Examination under anaesthesia if necessary.
Biopsy(Wedge biopsy) of primary lesion or
FNAC of suspicious/enlarged/palpable
CT/MRI of primary and neck.
X-ray chest to rule out synchronous primary.
Other important things
Examination under anaesthesia
1) Direct laryngoscopy and pharyngoscopy
4) Palpation of tongue and oropharynx.
Councelling about speech loss and therapy.
Dr.Haris PS/ OMR36
T1N0, T2N0 Surgery ± RT
RT -External Beam
T3N0, T4N0 Surgery and Post op RT
N+ ± Chemotherapy
T4b, N3, M+ PALLIATION
- Primarily RT ± Chemo
T1-2 => Either Surgery or Radiotherapy.
T3-4 => Combination of chemoradiotherapy
Dr.Haris PS/ OMR39
Short time – compliance
Specimen available for HPE
Helps in planning adjuvant treatment
No radiation sequelae
Tissue & functional loss
They have equal success in controlling T1
They are part of treatment
Combination of therapy.
Pros and Cons of Radiotherapy
Provide better functional result with superior
speech and swallowing.
Disadvantage of altered taste,xerostomia and the
protracted nature of treatment course.
Requires atleast 6 weeks of treatment.
Osteonecrosis of mandible.
Newer technique of IMRT and brachytherapy
reduces above side effects.
Predictors of Poor prognosis:
Increasing tumor thickness(>4mm)
High grade tumors
Perineural,Vascular and lymphatic invasion.
DNA ploidy status such as aneuploid carry
Verrucuous Ca has better one