Al-Azhar University

Faculty of Medicine
General Surgery
Department
Tongue Ulcers, Tumors of the
Tongue and Lip, Ranula
 ILOs
By the end of this topic, you have to;
 Enumerate anatomical parts of the tongue
 Classify types of tongue ulcers
 Describe dental ulcer of the tongue
 Define aphthus ulcer
 Enumerate benign tumors of the tongue
 Mention the commonest malignant tumor of the tongue
 Enumerate the predisposing factors of the carcinoma of the tongue
 Recognize the site incidence of the carcinoma of the tongue
 Describe naked eye picture of the carcinoma of the tongue
 Describe the spread of carcinoma of the tongue
 Describe the clinical presentation of carcinoma of the tongue
 Outline the treatment of carcinoma of the tongue
 Mention the commonest site of lip cancer
 Describe naked eye picture of lip cancer
 Enumerate complications of lip cancer
 Outline the treatment of lip cancer
 Define ranula, its presentation, & treatment
Tongue
 Tongue Ulcers

Definition;
A localized defects or erosions in the tongue mucosa, in which the
covering epithelium is destroyed leaving an inflamed area of
exposed connective tissue.
 Tongue Ulcers

Classifications;
1- Traumatic ulcers
Dental ulcers; due to repeated trauma by a broken tooth or ill fitted
denture
 Site; side of the tongue near the affected tooth
 Clinically; acute cases (painful ulcer with painful enlarged
drainage lymph nodes), chronic cases (raised edge, indurated
base, biopsy is needed to exclude malignancy)
 Treatment; removal of the offending cause, and the use of an
antiseptic mouth wash
Post pertussis ulcer; due to repeated trauma of fully protruded
tongue during bouts of severe cough
Physical or chemical ulcers; due to exposure to hot or cold objects or
chemicals
 Tongue Ulcers

Classifications;
2- Inflammatory ulcers
Acute ulcers;
 Dyspeptic ulcer (aphthus); its etiology is not exactly known. There are multiple,
small, painful ulcers. Treated by antiseptic mouth wash and anesthetic jell
 Lichen planus; supposed to be due to autoimmune mechanisms, it affect the
skin and oral mucosa
 Herpetic ulcer; painless, multiple, small ulcers in children
Chronic ulcer;
 TB; multiple ulcers occur at the sides and tip of the tongue, they are small,
shallow, oval, very painful with undermined edge, enlarged submandibular
lymph nodes. Treated by anti TB therapy, oral hygiene, anesthetic jell
 Syphilis; snail track ulcer or gummatous ulcer
 Ulcers due to chronic superficial glossitis

3- Malignant ulcer
 Usually squamous cell carcinoma
 Tongue Ulcers

Dental ulcers Dyspeptic ulcers

 Tongue Ulcers

TB ulcers Herpetic ulcers

 Tongue Ulcers

Malignant ulcers
 Tumors of the Tongue

Benign tumors;
 Papilloma; sessile or pedunculated
 Fibro-epithelial polyps
 Hemangioma & lymphangioma
 Plexiform neuroma & neurofibroma
 Granular cell myoblastoma; firm mass with overlying hyperkeratosis
 Juvenile fibroma

Malignant tumors;
 Squamous cell carcinoma (commonest)
 Basal cell carcinoma (rare)
 Adenocarcinoma (from minor salivary glands)
 Carcinoma of the Tongue

Incidence & etiology;

 Anterior 2/3, affect more males
 Posterior 1/3 equal in both sexes.
 Age over 60 years.
 More in India; due to tobacco chewer & high consumption of spices

Predisposing factors;
 Smoking, sepsis, spices, spirits, sharp teeth, clay pipe, bad oral hygiene
 Precancerous lesions;
o Chronic mucosal atrophy
o Chronic superficial glossitis
o Chronic dental ulcers
o Syphilitic, leukoplakia and erythroplakia
o Papilloma
 Carcinoma of the Tongue

Pathology;
 Squamous cell carcinoma (90%) of malignant lesions
Site; lateral edge of tongue (47-55%), tip of tongue (2‑4%), dorsum
of tongue (6%), posterior 1/3 (20%)
Naked eye appearance;
 Malignant ulcer; deep irregular, raised nodular everted edge,
hard indurated base
 Raised oval plaque
 Hard submucosal nodule
 Deep indurated fissure
 Diffuse infiltrating tumor (wooden base)
Microscopic appearance; usually squamous cell carcinoma with
variable degree of differentiation
 Carcinoma of the Tongue

Staging (TNM);
T
Tis carcinoma in situ
T1 < 2.0 cm
T2 2.1 – 4.0 cm
T3 4.1 – 6.0 cm
T4 > 6.1 cm or invading adjacent structures
N
N0 No regional adenopathy
N1 Ipsilateral adenopathy
N2 single Ipsilateral node node 3-6 cm or multiple Ipsilateral nodes < 6.0 cm
N3 Massive Ipsilateral or contralateral nodes
M
M0 No evidence of Metastases
M1 Metastases beyond the cervical lymph nodes
Mx Metastases not assessed
 Carcinoma of the Tongue

Spread;
 Direct spread; to nearby structures
 Lymphatic spread; it disseminated early to lymph
nodes of the neck;
o Tip; to sudmental then to both submandibular and
upper deep cervical nodes on both sides
o Anterior two third; lateral third to ipsilateral
submandibular and to upper deep cervical nodes. Those
near the midline disseminate bilaterally
o Posterior third; directly to the upper deep cervical
nodes
 Blood spread; more likely for tumors of posterior third
 Carcinoma of the Tongue

Clinical presentation;
 Early; may be symptomless, patient may complain of a persistent ulcer
 Late;
o Pain; first due to infection, later due to infiltration of lingual nerve, referred
to the ear
o Salivation; due to pain and restricted tongue movement
o Inability to articulate clearly
o Secondaries in the neck
Complications;
o Inhalation of necrotic tissues, leading to bronchopneumonia
o Cancer cachexia and starvation, due to pain and dysphagia
o Hemorrhage from erosion of lingual artery
Investigations;
o Biopsy from the edge of the ulcer
o FNAC from suspected cervical lymph nodes
o CT of the neck and mandible
 Carcinoma of the Tongue

Treatment;
 Surgery & Radiotherapy are the main lines of treatment
 Chemotherapy is used as an adjuvant therapy in some cases

Surgery
Indications; early (Tis, T1, T2), incomplete regression by radiotherapy, recurrence after
radiotherapy, cancer on top of precancerous lesions, cancer infiltrating the bone

Procedures;
 Carcinoma in situ; excision with 1cm safety margin
 Carcinoma of anterior two third; excision with 1.5 cm safety margin (partial, hemi, or
near total glossectomy), then reconstruction by flaps
 Carcinoma of the posterior third; either by total glossectomy or radiotherapy
 Lymph node affection; complete neck dissection
 If the mandible is affected; excised together with the tongue and the affected lymph nodes
(Comando operation)
 Carcinoma of the Tongue

Radiotherapy
T1 and T2 (less than 4 cm) may equally benefit from surgery or radiotherapy
Advantage; avoid the disfiguring side effects of surgery
Disadvantage; mucositis, dysphagia, osteoradionecrosis
Methods;
 Caseum or iridium needles
 External beam radiotherapy

Prognosis (prognostic factors)

1- Lymph node involvement is the most important
2- TNM
3- The degree of tumor differentiation
4- Extension of the tumor posteriorly to the oropharynx
Carcinoma of the Tongue
 Carcinoma of the Lip

Etiology;
• Chronic irritation; chronic ulcer, irradiation, leukoplakia, sepsis, spirits, smoking
pipe, spices
• Benign tumors; papilloma
Pathology;
Site; lower lip at the junction of the middle & outer third
Naked eye picture;
• Malignant ulcer (commonest)
• Malignant nodule
• Diffuse infiltrating type (woody lip)
• Malignant fissure
Microscopically; squamous cell carcinoma
Spread;
• Direct; in the substance of the lip, check, gum, mandible
• Lymphatic; is late and slow, to submental, submandibular, upper deep cervical
• Blood; extremely late & rare
 Carcinoma of the Lip

Clinical picture;
• Age & sex; common in elderly male
• Rapidly growing ulcer having the characters of malignant ulcers
• Examine for fixity & local infiltration
• Examine for lymph node involvement
Complications;
• Hemorrhage
• Infection
• Dysarthria & dysphagia
• Upper respiratory tract infection
Investigations; biopsy
Treatment;
• Surgery; for (small lesion, bone infiltration, recurrent ulcer, or resistant to
radiotherapy), excision of the tumor with 1.5 cm safety margin & plastic reconstruction
• Radiotherapy; radium needle
• Lymph nodes; no lymph nodes (no surgery), if palpable (suprahyoid block dissection is
sufficient). Total block neck dissection if upper deep cervical lymph nodes are affected
Carcinoma of the Lip
 Ranula

Definition; is a retention cyst arising from a sublingual salivary

gland
Clinical picture;
• A translucent, bluish, cystic swellings on one side of midline of
the floor of the mouth
• It may extend behind the posterior margin of mylohyoid muscle,
hence it will appear in the neck (known as Plunging or
Thomson’s ranula)
Treatment;
• Partial excision of the roof, the edges of which are sutured to
mucosal lining of the floor of the mouth (marsupialization)
Ranula
 Quiz
 Enumerate anatomical parts of the tongue
 Classify types of tongue ulcers
 Describe dental ulcer of the tongue
 Define aphthus ulcer
 Enumerate benign tumors of the tongue
 Mention the commonest malignant tumor of the tongue
 Enumerate the predisposing factors of the carcinoma of the tongue
 Recognize the site incidence of the carcinoma of the tongue
 Describe naked eye picture of the carcinoma of the tongue
 Describe the spread of carcinoma of the tongue
 Describe the clinical presentation of carcinoma of the tongue
 Outline the treatment of carcinoma of the tongue
 Mention the commonest site of lip cancer
 Describe naked eye picture of lip cancer
 Enumerate complications of lip cancer
 Outline the treatment of lip cancer
 Define ranula, its presentation, & treatment
THANK YOU