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B CA
Figs. 3.50A to C: Carcinoma lip—different locations in the lower lip. SCC is most common
SRB's Manual of Surgery
Predisposing Factors Cheilitis—actinic type
Solar keratosis.
Papilloma.
Leukoplakia.
Smoking, U-V rays, pipe smokers, reverse smoking.
Tobacco chewing, Khaini chewers (tobacco+lime).
Agriculturists who are commonly exposed to sunlight get
in lower lip; in upper lip BCC is common.
carcinoma lip and is called as countryman’s lip.
Differential Diagnosis
Keratoacanthoma.
Basal cell carcinoma. BCC occurs only in upper lip.
Minor salivary gland tumours.
Often carcinoma of lip is an extension from carcinoma of cheek.
Pyogenic granuloma in early cases only.
Malignant melanoma in case of pigmented SCC.
Diagnosis
Wedge biopsy, FNAC of lymph nodes, CT/MRI head and neck.
Treatment
If lesion is less than 2 cm, then curative radiotherapy, either
brachytherapy or external beam radiotherapy. It gives a
good cure.
If tumour is more than 2 cm, wide excision is done. Exci-
sion of lower lip up to one-third can be sutured primarily, in
layers keeping vermilion border in proper apposition without
causing any microstomia.
Excision of more than one-third of the lip requires reconstruc-
tion using different flaps.
Lymph nodes are dealt with by radical neck dissec tion on one
side and functional block or supraomohyoid block dissection
on other side. For central tumour N0 disease, bilateral elective (prophylactic) supraomohyoid dissection is done. For
lateral tumour N
dissection is done.
disease, elective ipsilateral supraomohyoid
0
Fig. 3.51: Primary repair of lip after wide excision of small tumour
One-third of the lip can be sacrificed. Lip is sutured in layers. First layer,
muco-muscular layer with absorbable suture. Second layer is skin with
non-absorbable monofilament sutures like polypropylene.
Fig. 3.52: Lower lip tumour after excision when primary suturing
not possible, then upper lip flap based on upper labial artery can be
used—Abbe-Estlander flap.
Post-operative radiotherapy is given if tumour is large or if
lymph nodes are involved.
When mandible is involved, segmental resection is done.
Methods of Reconstruction
1. Abbe-Estlander’s rotation flap used for either upper or
lower lip lesions (of less than ½ of lip) located at the angle
based on labial artery. Here base at a later stage need not
be disconnected unlike in Abbe lip.
2. Fries’ modified Bernard facial flap—reconstruction using
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lateral facial flaps. It is used when defect is more than ½ of
lip and midline.
3. Microvascular flaps.
4. Nasolabial flap: It is used when defect is more than ½ of lip
laterally or defect is in the floor of the mouth.
5. Cheek flap.
6. Free radial artery flap.
7. Abbe flap (switch flap) is used for upper or lower lip lesions
at the middle or at the site other than angle based on the
A B C
labial artery. Here at a later 2nd stage base of the flap should
be released once flap takes up.
8. ‘W’ flap plasty: It is done for lower lip middle tumour which
is less than 1/3rd of the lip.
9. Gillies fan flap: It is a cheek flap usually bilateral but can be
unilateral. Incision is full thickness around commissures
extending into nasolabial fold and upper lip upto upper lip
vermilion border. Flap which is based on labial vessels is
advanced towards the defect. Vermilion is reconstructed
with tongue mucosal flap which is divided in 3 weeks.
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CHAPTER 3 Oral Cavity
D
Figs. 3.53A to E: For upper lip tumour when primary repair is not possible, then lower lip flap based on
inferior labial artery can be rotated to upper lip—Abbe flap.
Fig. 3.54: It is used for central lip tumours. Angles of the lower part of
the defect and upper part of the angles of the mouth are rotated inwards
with burow’s triangles at the site of rotation—Bernard flap.
E
Fig. 3.55: It is done for lower lip middle tumour
which is less than 1/3rd of the lip—‘W’ flap.
Attitude is a small thing that makes a big difference.
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Parts
1. Tip: Anterior free end lies behind the upper incisor teeth.
2.
Root: Attached to the mandible above and hyoid bone below.
Body: Dorsal surface is rough due to papillae; and is divided
3.
into anterior 2/3rd (oral part) and posterior 1/3rd (pharyngeal
part) by sulcus terminalis. Ventral surface is smooth, has a
median fold, ‘frenulum linguae’ and deep lingual vein on either
side.
SRB's Manual of Surgery
A B
Figs. 3.56A and B: Gillies fan flap.
BA
Figs. 3.57A and B: Nasolabial flap used in extensive lower lip defect or
over the defect after wide excision of a tumour in the floor of the mouth.
10. Karapandzic flap: It is modified version of the Gillies flap
used for lower lip defect with less angulation towards upper
lip. Reverse Karapandzic flap is used for upper lip defect.
11. Johansen ‘stepladder’ procedure is used for extensive
carcinoma of lower lip.
12. Other regular flaps like forehead flap, deltopectoral flap also
can be used.
PROGNOSIS IN CARCINOMA LIP
B
Prognosis is good, 5 years survival is 70%.
Lip has best prognosis.
Nerve involvement, fixation, nodal spread, upper lip or
commissure lesions, age less than 40 years—are poor
prognostic factors.
Fig. 3.58: Anatomy of the tongue showing parts and papillae.
Papillae
1. Vallate—large, located in front of sulcus termi nalis.
Fungiform—lies over the tip and margin of the tongue.
2.
3.
Filiform—lies over the dorsum of tongue, gives the velvety
appearance—commonest.
4. Foliate—over the margin.
Muscles of Tongue
Intrinsic muscle: Superior and inferior longitu dinal, trans-
verse and vertical.
Extrinsic muscle: Genioglossus, hyoglossus, stylo glossus,
palatoglossus.
Blood supply is from lingual artery, a branch of external
carotid artery. Venous drainage by deep lingual vein which drains
into fascial vein or internal jugular vein.
MOVEMENTS OF THE TONGUE
B
x Forward protrusion—genioglossus—most commonly affected
by carcinoma
x Backward movement—styloglossus
x Elevation of tongue—palatoglossus
x Depression of tongue—hyoglossus
Lymphatic Drainage of the Tongue
TONGUE
Anatomy of Tongue
Tongue is a muscular organ located in the floor of the mouth.
Tip of tongue drains into submental lymph nodes.
Lateral margin drains to submandibular lymph nodes and into
upper deep cervical lymph nodes. Many lymphatic vessels
pass as subperiosteal lymphatics of mandible. So carcinoma
can involve the bone through this route.
Lymphatics in the midline of tongue freely cross communi-
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cate with each other and so spread of malignancy can occur
to both side neck lymph nodes.
Lymphatics from posterior third of tongue drain into phary-
ngeal group of lymph nodes, as well as to the upper deep
cervical lymph nodes. Early spread to the pharyngeal lymph
nodes from carcinoma of posterior third of tongue has a
poor prognosis.
LYMPHATIC VESSELS ARE NAMED AS
B
x Apical vessels x Marginal vessels
x Central vessels x Basal vessels
Development and Nerve Supply of the Tongue
Anterior 2/3rd develop from first branchial arch through two
lingual swellings and one tuberculum impar. It is supplied by
lingual nerve for general sensation and by chorda tympani
for taste sensation.
Posterior 1/3rd develops from third arch from cranial half of
hypobranchial eminence. It is supplied by glossopharyngeal
nerve for both general and taste sensations.
Posterior most part develops from the fourth arch. It is
supplied by vagus nerve (internal laryngeal nerve).
Muscles of the tongue are derived from occipital myotomes
and are supplied by hypoglossal nerve except palatoglossus,
which is supplied by cranial part of accessory nerve.
TONGUE ULCERS
DIFFERENTIAL DIAGNOSIS FOR TONGUE ULCERS
B
x Dental ulcers—painful
x Aphthous ulcers—painful
x Ulcers in lichen planus—pain-
less
Dental Ulcer
It is common on sides of tongue due to sharp tooth, denture,
and broken tooth. Usually it is acute painful, self-limiting ulcer.
Occasionally repeated trauma form an indolent chronic ulcer
which mimic carcinoma; it should be excised to rule out carcinoma and to cure the ulcer.
Aphthous Ulcer
It can be:
1. Minor aphthous ulcer, common in menstruating women as a
crop with painful, round, yellow-based ulcer with red margin.
It regresses spontaneously in 2 weeks.
2. Major aphthous ulcer, large and deep which often becomes
chronic and takes more time to subside with a scar. Chlorhexidine gluconate, local application of triamcinolone acetate,
choline salicylate gel are different local applicants used to
promote healing.
x Syphilitic ulcers—painless
x Tuberculous ulcers—painful
x Malignant ulcers—painless
3.
Behcet’s syndrome is genital ulcer, conjunctival ulcer and
multiple oral ulcers. Reiter’s syndrome is urethritis, arthritis,
periarteritis nodosa, conjunctivitis, and oral ulcers.
Herpetiform aphthous ulcer is not due to herpes simplex.
4.
They are small, 1–2 mm diameter ulcers in crops which heal
by usual drugs mentioned above.
Fig. 3.59: Aphthous ulcer tongue. It is one of the common
benign ulcers of the tongue.
Syphilitic Ulcer
Extragenital chancre often occurs in tongue in primary
syphilis which is painless with shotty, submental and
submandibular lymph nodes. In secondary syphilis, multiple
shallow snail track ulcers in the margins and undersurface;
mucous patches on the tongue and fauces; Hutchinson’s
condyloma wart in midline of tongue can occur. In tertiary
syphilis, gummatous ulcer occurs in anterior 2/3rd of tongue
as a deep punched out painless ulcer as gumma with wash
leather slough. Endarteritis is the cause for the punched
out look. Interstitial glossitis with loss of papillae causes
longitudinally fissured bald lobulated tongue in tertiary
syphilis. In carcinoma arising from syphilitic ulcer, RT is
questionable as blood supply is precarious due to endarteritis;
RT further compromises it leading to tongue necrosis.
Tuberculous Ulcer
It is undermined shallow, often multiple, painful ulcer. Ulcer can
occur in margins, tip or anterior 2/3rd of tongue. Neck nodes
may be involved. Associated tuberculous larynx and lung may
be present.
Herpetic Lingual Ulcer
It is involvement of lingual nerve presenting as acute neuralgia
with vesicles which form multiple superficial painful ulcers.
Other Ulcers
Multiple ulcers in smokers due to glossitis (smoker’s ulcer),
ulcers due to vasculitis, eosinophilic granuloma. Post-pertussis
ulcer in whooping cough occurs on upper part of frenum linguae
and under the tip of tongue.
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CHAPTER 3 Oral Cavity
Faith makes all things possible; hope makes all things bright.
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MACROGLOSSIA (MEGALOGLOSSIA/PACHYGLOSSIA)
B
It is a disorder in which the tongue is larger than normal. It is
commonly painless, diffuse enlargement of the tongue. Macroglossia
is usually caused by an increase in the amount (volume) of tissue
on the tongue, rather than by a growth, such as a tumour. It is often
seen in haemangioma, lymphangioma, muscular macroglossia
(in cretins), acromegaly, Beckwith-Wiedemann syndrome (hypoglycaemia, abdominal wall defects, Wilms’ tumour, macroglossia,
adrenal tumour), Down’s syndrome, mucopolysaccharidoses,
primary amyloidosis, occasionally plexiform neurofibromatosis. Often
it causes functional and cosmetic problems.
Causes
Lymphangioma—soft, painless enlarged tongue with ulcers—
1.
SRB's Manual of Surgery
bilateral; prevents closure of lip and jaw.
2.
Haemangioma—soft, fluctuant, compressible, bleeding, red/blue
lesion
i. Both are treated by sclerotherapy (ethona lamine oleate)/
partial excision
ii. Angiogram/MR angiogram is a must in haemangioma
iii. Ligation of lingual artery/ECA on both sides may be needed
in large lesions
Note:
– Varicosities of sublingual veins mimic haemangioma.
– Often causes unilateral enlargement of tongue.
– Pressure on alveolus causes spacing of teeth and incisor
deformity.
Combination of haemangioma and lymphangioma can occur:
Neurofibroma—partial excision is done
1.
2. Tongue muscular hypertrophy: Partial excision is done.
Elongation is corrected by wedge resection of anterior part of
extra tongue from midline.
Vertical thickening is rectified by slice cutting of lateral margins
without injuring lingual artery and nerve.
Fig. 3.61: Papilloma of the tongue. It is a premalignant
condition.It requires excision biopsy.
Fig. 3.60: Macroglossia.
BENIGN TUMOURS OF TONGUE
BENIGN TUMOURS OF THE TONGUE
B
x Papilloma
x Fibroepithelial polyp
x Haemangioma
x Lymphangioma
x Neurofibroma
x Lipoma
x Granular cell myoblastoma
Fig. 3.62: Pyogenic granuloma of tongue under surface.
Fibroepithelial Polyp: It is due to repeated trauma at one place
may be due to teeth (incisor) forming a thickened submucous
scar which gets pulled out like a stalked polyp due to sucking
and swallowing mechanism. It commonly enters the gap between
the lower incisor teeth.
Granular Cell Myoblastoma: It is a benign non-capsulated firm
mobile mass in the tongue showing pseudoepithelial hyperplasia
of mucosa of tongue with eosinophilic granular cells in deeper
plane. It is often mistakenly diagnosed as carcinoma of tongue.
It is treated by excision.
TONGUE FISSURE
Congenital fissures are transverse which run laterally from
midline with normal papillae in between. Candida infection
can occur on this.
Syphilitic fissures are deep bald and longitudinal.
GLOSSITIS
Median Rhomboid Glossitis: It is smooth, lobulated, trian-
gular firm patch anterior to foramen caecum of tongue in
midline with deeper colour. Candida infection can occur in it.
It mimics carcinoma. Biopsy rules out malignancy. Carcinoma
is uncommon in midline.
Fig. 3.63: Tongue showing fissuring. Fissuring is one of the
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presentations of carcinoma tongue.
381
CHAPTER 3 Oral Cavity
Fig. 3.65: Congenital fissures of tongue are transverse; syphilitic
fissures are longitudinal. Median rhomboid glossitis is persistent
tuberculum impar.
Fig. 3.64: Horizontal fissures of tongue.
Glossitis Migrans (Geographic Tongue): It begins as benign
small red patches with white furred margin which spread and
recede in an irregular way to appear as fresh patches. White
margin contains keratinized epithelium and inflammatory
cells over filiform papillae. It is often seen in patients with
congenital heart diseases and acute gastrointestinal diseases.
Etiology is unknown.
Hunter’s glossitis is seen in pernicious anaemia.
Hairy tongue is overgrowth of filiform papillae with black/
brown stain on it due to bacteria, fungi, tobacco or drugs.
There are no hairs. It is a misnomer. Cessation of causative agent, mechanical scraping, cleaning are the treatment
methods.
Agranulocytosis glossitis.
Non-specific glossitis.
Pellagra glossitis, Pellagra glossitis, is due to deficiency of
niacin/nicotinamide (B3). Dementia, dermatitis, diarrhea with
glossitis—are the features.
Anything the mind of man can conceive and believe, it can achieve.
Fig. 3.66: Severe superficial glossitis.
Chronic superficial glossitis in malnutrition, iron and vitamin
B deficiencies.
TONGUE TIE
It is short, thick, fibrous frenum linguae.
During protrusion lateral margin and tip of the tongue is
everted with dorsal mid part heaping.
It causes speech defect, difficulty in cleaning the inner part
of lower teeth.
It is treated surgically under local anaesthesia (or general in
child). Tongue lifted upwards with a stay suture at the tip;
fibrous frenum is divided using fine scissor; linear wound
is closed longitudinally using fine catgut from the tip of the
tongue towards the margin of the floor of the mouth.
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A
Figs. 3.67A and B: Tongue tie—on table photo.
SRB's Manual of Surgery
CARCINOMA TONGUE
B
Incidence is equal in both sexes. Presently its incidence is increasing
in females due to increase in number of female smokers.
Aetiology
Leukoplakia, Erythroplakia.
All ‘S’s (as mentioned in leukoplakia).
Premalignant conditions mentioned earlier.
TYPES
B
Gross
Papillary.
1.
2.
Ulcerative or ulceroproliferative 60%.
Fissure with induration.
3.
4.
Lobulated, indurated mass—frozen tongue.
Histologically
Squamous cell carcinoma—commonest.
1.
2.
Adenocarcinoma, may arise from minor salivary glands or
mucous glands.
3. Melanomas.
Transitional cell carcinoma and lymphoepithelioma rarely can
4.
occur in posterior 1/3rd of tongue.
Fig. 3.68: Carcinoma tongue—lateral margin but involving
extensively.
Fig. 3.69: Anatomy and lymphatic drainage of tongue.
Sites
1. Lateral margin—commonest—47–50%.
Posterior third—20%.
2.
3.
Dorsum—6.5%.
Ventral surface—9%.
4.
5.
Tip—10%.
Clinical Features
Painless ulcer/swelling in the tongue which later may become
painful. Pain in the tongue due to infection or ulceration or
due to the involvement of lingual nerve (pain is referred to
ear). Pain on swallowing, in case of carcinoma of posterior
third of tongue.
Excessive salivation. Saliva is often blood stained.
Dysphagia either due to fixed tongue or due to the involve-
ment of genioglossus or growth in the posterior third of the
tongue.
Visible ulcer in anterior two-thirds of tongue. Ulcer can bleed
on touch; edge, base and surrounding areas are indurated.
Fig. 3.70: Frozen tongue is feature of carcinoma tongue with
ankyloglossia.
Often indurated area is much more extensive than the primary
tumour (it is also common in carcinoma penis). Edge is
everted commonly. Ulcer may cross the midline; may extend
into the floor of the mouth/alveolus/mandible. Growth or
ulcer in posterior third, is usually not visible.
Ankyloglossia—involvement of muscles of the tongue.
Movements of the tongue especially forward protrusion is
commonly affected.
Fig. 3.71: Carcinoma tip of tongue. Well-circumscribed raised
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edge is seen.
Change in voice. Occurs in posterior third tumours. Tumour
in posterior third area is more aggressive.
Palpable lymph nodes in the neck which are hard, nodular and
get fixed to underlying tissues in advanced stages.
Features of bronchopneumonia—due to aspiration during
lying down/sleeping mainly to lower segment of lung.
Spread of Carcinoma Tongue
Local spread: In case of anterior two-thirds of tongue, the
spread occurs to genioglossus muscle, floor of the mouth,
opposite side and mandible. In case of poste rior third of
tongue it spreads locally to tonsil, side of pharynx, soft palate,
epiglottis, larynx and cervical spine.
Lymphatic spread: From tip of tongue it spreads to
submental nodes. From lateral margin it spreads to submandibular lymph nodes and later to deep cervical lymph nodes.
Lymphatics in the tongue are freely communicating, and so
involvement of bilateral neck lymph nodes is common. From
posterior third it spreads to pharyngeal nodes and upper deep
cervical lymph nodes.
Note:
• Any tongue lesion more than 4 mm depth has 30% metastasis to
lymph nodes.
• Among oral cancers, carcinoma tongue is more aggressive, rapidly
growing tumour with high potential for lymph node spread.
• Bilateral neck lymph node spread is common due to crossing of lymph
vessels in tongue.
• Clearance of lingual lymph node which is located between tongue
and submandibular lymph glands has to be done which may contain
micrometastasis.
• Carcinoma tongue has got highest incidence of nodal spread.
383
CHAPTER 3 Oral Cavity
A
B
Figs. 3.72A and B: Carcinoma tongue lateral
margin (commonest site).
Inability to articulate.
Foetor (Halitosis). Due to infection and necrosis in the oral
cavity. It is due to release of ammonia, butyric acid and
mercaptan by tumour cells.
Investigations
Wedge biopsy; FNAC of lymph nodes.
Indirect and direct laryngoscopy to see posterior third growth.
CT scan to see the extension of posterior third growth, or to
see the status of lymph node secon
daries. MRI is also very
useful to assess the extent of primary tumour.
Chest X-ray to see bronchopneumonia.
Orthopantomogram.
Note:
Staging is same as carcinoma cheek.
Treatment
Surgery, radiotherapy, chemotherapy.
Surgery
Wide excision with 1 cm clearance in margin and depth is
done in tumour less than 1 cm in size or in carcinoma in situ.
Laser (CO2/diode) can be used.
Tumour between 1–2 cm in size, partial glossectomy is done
with 2 cm clearance from the margin with removal of 1/3rd
of anterior two-thirds of the tongue.
He who believes, is strong; he who doubts, is weak.
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c
a
b
SRB's Manual of Surgery
Fig. 3.73: (a) Wide excision is done in small lateral margin tumour of
1 cm size with 1 cm clearance; (b) Tumour between 1 and 2 cm size is
treated by partial glossectomy with 2 cm clearance; (c) Tumour larger
than 2 cm requires hemiglossectomy.
POSTOPERATIVE MANAGEMENT
B
x Control of infection and oedema; Regular mouth wash
x Maintaining the airway; Prevention of aspiration
x Nutrition (through nasogastric tube commonly/TPN often)
Radiotherapy
In small primary tumour—curative radiotherapy (Brachy-
therapy using caesium or iridium
Large primary tumour—initial radiotherapy is given to reduce
the tumour size so that the resection will be better later.
Advanced primary as well as secondaries in the neck can be
controlled by palliative external radiotherapy.
Post-operative radiotherapy is given in large tumours to
reduce the chances of relapse.
In case of growths in the posterior third of tongue, radio-
therapy is of curative as well as palliative mode.
192
needles).
Tumour larger than 2 cm, hemiglossectomy is done with
removal of anterior 2/3rd of tongue on one side up to sulcus
terminalis.
¾
Raw area in these procedures can be left alone when area
is wide allowing it to granulate and heal by epithelialisation. If area is small like in wide excision it can be closed
by primary suturing. Wide raw area can also be covered
with PMMF or quilted split-skin-graft.
Larger primary tumour can be given pre-opera tive radio-
therapy, then later hemiglossectomy is done.
Same side palpable, mobile lymph nodes are removed by
radical neck block dissection.
Bilateral mobile lymph nodes are dealt with one side radical
block and other side modified radical block dissection with
essentially retaining internal jugular vein (on opposite side)
to maintain the cerebral venous blood flow. Other option is
doing same side radical neck dissection and on opposite side
supraomohyoid block dissection.
Wide excision is done when growth is in the tip of the
tongue.
Posterior third growth can be approached by lip split and
mandible resection, so as to have total glossectomy—
Kocher’s approach. It is not done commonly as it carries
significant morbidity and mortality due to difficulty in speech,
swallowing, aspiration, sepsis.
When mandible is involved hemimandibulectomy is done.
The procedure that involves wide excision or hemi-
glossectomy, hemimandibulectomy and radical neck dissection together is called as Commando Operation.
Reconstruction of tongue and other area after surgery: By
deltopectoral flap, forehead flap, pectoralis major muscle
flap, skin grafting.
Prophylactic block dissection is becoming popular at
present.
COMPLICATIONS OF RADIOTHERAPY
B
x Loss of sensation like taste
x Trismus and ankyloglossia
x Pharyngeal and laryngeal oedema
x Dermatitis and severe sepsis
Chemotherapy
Given in post-operative period and also for palliation.
Price-Hill regimen is commonly used. Drugs are methotrexate,
vincristine, adriamycin, bleomycin and mercaptopurine.
It is either given intra-arterially, as regional chemo therapy
through external carotid artery using arterial pump or through
IV. It can also be given orally.
COMPLICATIONS OF CHEMOTHERAPY
B
x Megaloblastic anaemia x Alopecia
x Bone marrow suppression x Sepsis
For melanoma, Melphalan and DTIC are used.
Anterior chemotherapy (pre-operative) is be coming popular
to downstage the tumour.
TERMINAL EVENTS
B
x Inhalational bronchopneumonia
x Haemorrhage from erosion of lingual artery. In poste rior third of
the tongue, erosion of internal carotid artery can occur
x Cancer cachexia
x Asphyxia due to pressure on air passages or due to oedema glottis
Prognosis
Five-year survival for females is 50%, for males is 25%.
NODAL PROGNOSTIC FACTORS
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B
x Positive histology in node reduces the survival
x Level III and IV has poor prognosis
x Bilateral/contralateral nodes carry poor prognosis
x Extracapsular spread/size >3 cm carry poor survival
x >3 in number of nodes involved is poor sign
Poor Prognostic Factors
Size of the tumour >4 cm caries poor prognosis.
Site of tumour (posterior third has got poor prognosis).
Tumour crossing the midline.
Lymph nodes status.
Poor differentiation.
Bone involvement.
CARCINOMA OF POSTERIOR ONE-
THIRD/BASE OF THE TONGUE
Lesion may remain asymptomatic for long time.
Clinically may be missed easily.
Earlier symptoms are features mimicking sore-throat and
throat discomfort.
Dysphagia and change in voice (hot potato voice) occurs later.
Referred pain in the ear, bleeding from mouth, visible mass
in posterior third of tongue is late local features.
Induration on palpation in posterior third tongue is diagnostic
of the carcinoma.
As posterior third tongue has got abundant lymphatics which
cross communicates on either side, lymph node spread is
common (70%). Bilateral nodal spread is common. Massive
nodes and involvement of jugulodigastric node are also
common.
Infiltration into the tongue muscles like genioglossus,
epiglottis, pre-epiglottic space, tonsillar pillars and
hypopharynx are common.
Carcinoma posterior third of the tongue is often poorly differ-
entiated and so caries poor prognosis.
Blood spread can occur into bones, liver and lungs in poste-
rior third cancers.
Palpation under anaesthesia gives better idea about the
tumour, its spread and also allows the biopsy.
Presentation as unknown/occult primary and often with blood
spread can occur.
CT scan/MRI is always needed to plan the staging and
therapy.
T
, T2, N0 and N1 diseases are treated by surgical wide exci-
1
sion or often by total glossectomy using midline mandibulotomy incision (mandible split) with neck dissection on
both sides (MRND one side). Post-surgery radiotherapy is
needed if it is a poorly differentiated type or nodal status is
more than N1.
Advanced lesions need palliative radiotherapy or chemotherapy.
T
lesions are often treated by total glossectomy with laryn-
4
gectomy and neck dissection but overall outcome is not good.
In many centres primary curative radiotherapy is used.
Lymphoepithelioma and transitional cell carcinoma can occur
in posterior third tongue (rarely).
CARCINOMA ALVEOLUS
B
x It is squamous cell carcinoma arising from gums
x It is common in males
x It is common in India
x It is commonly due to tobacco/pan chewing
x Features and precipitating factors are similar to other oral carci-
nomas
x There will be invariable bone involvement by direct extension
x Nodal spread is also common
x Wide excision with mandibulectomy and block dissection of neck
is the treatment
CARCINOMA FLOOR OF THE MOUTH
B
x It is usually aggressive tumour
x It is rare in India
x It is 2nd common site of oral carcinoma (SCC) in western
countries
x It invades hyoglossus, mylohyoid, genioglossus and anterior
mandible early
x Bilateral neck nodes are commonly involved
x Rim resection of mandible with wide excision of tumour with
muscles and soft tissues and bilateral neck dissection is necessary
x Often visor anterior approach with anterior mandible resection
followed by proper reconstruction with bone graft and plates
is needed
x Post-operative radiotherapy and later chemotherapy is used to
prevent recurrence
x Prognosis is poor and also has poor cosmetic results
Fig. 3.74: Carcinoma of floor of the mouth.
It has got poor prognosis.
NASOPHARYNGEAL CARCINOMA
Nasopharynx lies above the level of the soft palate which
divides it from oropharynx below.
It is also called as post-nasal space or epipharynx. Eustachian
tube opens on its anterolateral wall. Fossa of Rosenmuller is
located above and behind the opening of the Eustachian tube
as a small depression.
Nasopharyngeal carcinoma is common in China and
Mongolia. In India it is common in North-East region. It is
385
CHAPTER 3 Oral Cavity
Hope sees the invisible, feels the intangible and achieves the impossible.
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