Long Case History — Carcinoma of the Lateral Tongue

PATIENT IDENTIFICATION

CHIEF COMPLAINTS

1. Swelling on the lateral part of the tongue — 6 months
2. Pain in the tongue — 4 months
3. Difficulty while eating and swallowing food (dysphagia/odynophagia) — 2 months
4. Difficulty in speech (dysarthria) — 2 months

HISTORY OF PRESENT ILLNESS

• Difficulty in eating — she was unable to chew food properly due to pain and restricted tongue movement. She began avoiding hard food items and shifted to a soft/liquid diet.
• Difficulty in swallowing (dysphagia/odynophagia) — initially for solids, later progressing to semi-solids. No difficulty swallowing liquids at present (or describe current state accordingly).
• Difficulty in speech (dysarthria) — she complained of slurring of words, inability to pronounce certain letters clearly (lingual consonants like /t/, /d/, /n/, /l/), and others noted a change in her voice quality.

• Trismus (difficulty opening mouth)
• Neck swelling noticed by the patient herself (though clinical examination will be done)
• Nasal regurgitation of food
• Breathlessness or stridor
• Significant weight loss (or mention if present)
• Ear pain (otalgia — referred pain via lingual nerve/auriculotemporal nerve territory)

PAST HISTORY

• No history of similar complaints in the past
• No previous surgeries or hospitalizations
• No history of radiation to the head and neck region
• No known history of diabetes mellitus, hypertension, or tuberculosis
• No history of any known drug allergies

PERSONAL HISTORY

HABITS (Critical for Oral Cancer Risk Assessment)

• Tobacco chewing: She has been chewing tobacco/betel nut (gutka/pan masala/areca nut with lime) for the past 15–20 years, approximately 4–6 times/day.
• Betel quid (paan): Regular habit for 10 years.
• Smoking: Non-smoker (or mention if smoking is present — bidi/cigarette).
• Alcohol consumption: Denies alcohol intake (or mention if present).

Note: In non-smoking females, lateral tongue carcinoma may arise due to chronic dental trauma from sharp/broken teeth, ill-fitting dentures, or chronic irritation — a well-established risk factor (Cummings Otolaryngology, Perry et al. — "nonsmoking females were more likely to develop carcinoma in sites like the lateral tongue where dental trauma is more common").

• Dental history: History of sharp/broken tooth adjacent to the swelling, or presence of ill-fitting dentures (if applicable).
• Oral hygiene: Poor.

FAMILY HISTORY

• No similar illness in any family member.
• No known family history of malignancy.
• No consanguineous marriage.

SOCIOECONOMIC HISTORY

• Belongs to lower/middle socioeconomic class (as per modified Kuppuswamy scale).
• Likely reason for delay in presentation: financial constraints, fear, lack of awareness, self-medication with analgesics.

GENERAL PHYSICAL EXAMINATION

• General condition: Moderately built, adequately nourished / Ill-looking due to pain and reduced oral intake
• Pallor: Present / Absent (anemia due to chronic disease or bleeding)
• Icterus: Absent
• Cyanosis: Absent
• Clubbing: Absent
• Lymphadenopathy: Examine carefully — cervical lymph nodes (submandibular, submental, upper deep cervical — levels I–III most commonly involved in tongue carcinoma)
• Edema: Absent
• Pulse: __ bpm, regular
• Blood pressure: __ mmHg
• Respiratory rate: __ /min
• Temperature: Afebrile
• SpO₂: __ %
• Weight: __ kg (note weight loss if any)

SYSTEMIC EXAMINATION

A. Local Examination — Oral Cavity

• Mouth opening (interincisal distance): Normal or reduced
• Facial asymmetry: Absent / Present
• Submandibular swelling: Absent / Present (if nodal metastasis)

• Oral hygiene: Poor
• Dentition: Presence of carious, sharp, or broken teeth adjacent to lesion
• Tongue: A proliferative/ulceroproliferative growth seen on the lateral border of the tongue (right/left side)
  • Size: approximately __ cm × __ cm
  • Surface: Irregular, ulcerated, with indurated edges
  • Colour: Reddish / whitish patches / mixed
  • Base: Indurated (hard)
  • Surrounding mucosa: Erythematous / leukoplakic patches may be present
  • Floor of mouth: Assess for involvement
  • Tongue mobility: Restricted (due to pain and/or muscular invasion)

• Swelling is hard, non-tender (or tender on touch)
• Induration of the surrounding tissue
• Edges: Everted, indurated
• Base: Fixed / mobile (assess fixity to floor of mouth and mandible)
• Tongue movement: Restricted — reduced ability to protrude, lateralize
• Submandibular salivary gland: Palpate to differentiate from nodal mass

B. Neck Examination — Regional Lymph Nodes

• Submental nodes (Level IA): Palpate
• Submandibular nodes (Level IB): Palpate
• Upper deep cervical — Jugulo-digastric (Level II): Palpate
• Note: Size, consistency, number, fixity, tenderness
• Ipsilateral/bilateral involvement

C. Other Systemic Examinations

• Respiratory system: Normal
• Cardiovascular system: Normal
• Abdomen: Soft, no organomegaly (liver metastasis in advanced disease)
• CNS: Grossly intact; assess tongue deviation (hypoglossal nerve involvement), loss of sensation on tongue surface (lingual nerve involvement)

PROVISIONAL DIAGNOSIS

1. Traumatic ulcer / chronic traumatic ulcer
2. Tuberculous ulcer of the tongue
3. Aphthous ulcer (major aphthae)
4. Syphilitic ulcer (gumma)
5. Granular cell myoblastoma
6. Leiomyosarcoma / rhabdomyosarcoma (submucosal)
7. Non-Hodgkin lymphoma
8. Median rhomboid glossitis (dorsal tongue variant)

INVESTIGATIONS

Routine

• Complete blood count (CBC): Rule out anemia, leukocytosis
• Blood glucose (fasting & postprandial): Diabetes screening
• Renal function tests (BUN, creatinine): Pre-anesthetic workup
• Liver function tests: Rule out hepatic metastasis
• Coagulation profile (PT, aPTT): Preoperative
• Chest X-ray (PA view): Rule out pulmonary metastasis
• VDRL/TPHA: Rule out syphilis
• HIV serology

Specific

• Incisional biopsy with histopathological examination (HPE): Confirmatory — most likely SCC (graded as well, moderately, or poorly differentiated)
• Contrast-enhanced CT (CECT) of neck and oropharynx: Assess primary tumor extent, mandibular invasion, depth of invasion, lymph node metastasis
• MRI tongue and neck: Superior soft tissue delineation — assess intrinsic tongue muscle invasion, floor of mouth involvement, perineural spread
• Orthopantomogram (OPG): Rule out mandibular involvement
• CECT chest / PET-CT: Staging — rule out distant metastasis (lung, liver, bone)
• Ultrasound-guided FNAC of cervical nodes: If palpable nodes present
• HPV testing (p16 immunohistochemistry): Molecular subtyping of tumor

CLINICAL STAGING (TNM — AJCC 8th Edition)

Depth of invasion (DOI) is a critical component of T staging in oral tongue SCC (AJCC 8th edition). Each 5 mm increase in DOI upstages the T category.

MANAGEMENT PLAN

Surgical

• Hemiglossectomy or partial glossectomy with adequate margins (≥1 cm) for T1/T2 lesions
• Elective or therapeutic neck dissection (supraomohyoid or modified radical neck dissection, levels I–IV) depending on N staging
• Reconstruction with local/pedicled/free flap (radial forearm free flap) if large defect

Radiotherapy

• Adjuvant postoperative radiation therapy if: positive margins, perineural invasion, lymphovascular invasion, multiple nodes, extracapsular spread
• Concurrent chemoradiotherapy (cisplatin-based) if high-risk features present

Supportive

• Nutritional support (nasogastric or PEG feeding if oral intake inadequate)
• Pain management (analgesics per WHO pain ladder)
• Oral physiotherapy and speech therapy (post-treatment)
• Dental rehabilitation
• Psychosocial counseling
• Cessation of tobacco/areca nut habits

PROGNOSIS

• Depends on stage at presentation, depth of invasion, nodal status, and surgical margins
• 5-year survival: ~80% for Stage I/II; ~50–60% for Stage III; <30% for Stage IV
• Lateral tongue SCC in non-smoking females (as in this case) may represent a biologically distinct subset, often associated with dental trauma rather than tobacco — prognosis is stage-dependent