Non-healing ulcer of the lateral tongue in a smoker
58-year-old male
§Chief complaint
Painful ulcer on the side of the tongue for 3 months
§Medical & dental history
- 0130 pack-year smoking history
- 02Daily alcohol intake
- 03Hypertension on amlodipine
- 04Irregular attender
- 05No sharp restorations or trauma at the ulcer site
§Clinical examination
- 01Indurated ulcer 25 mm on the left lateral border of the tongue with rolled everted margins
- 02Restricted tongue protrusion, deviation to the left
- 03Single firm, mobile 2 cm left level II lymph node
- 04No trismus; airway patent
§ figuresFigures (2)
Fig. 1Oral pseudomembranous candidiasis on the dorsum of the tongue
“Oral pseudomembranous candidiasis on the dorsum of the tongue of a 59-year-old male (third week of RT for a squamous cell carcinoma of the floor of the mouth, T3N0M0, daily dose 1.8 Gy)” · Ourania Nicolatou-Galitis et al. · CC0 · Wikimedia Commons
Fig. 2A large squamous cell carcinoma of the tongue
“SquamousCellCarcinomaTongueCT” · James Heilman, MD · CC BY-SA 4.0 · Wikimedia Commons
Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Oral Squamous Cell Carcinoma figures pending faculty review.
§Differential diagnosis
§Final diagnosis
Moderately differentiated squamous cell carcinoma of the left lateral tongue, cT2 N1 M0
Induration is the single most important clinical sign — it distinguishes carcinoma from every soft-based ulcer. Duration beyond 3 weeks in a patient with tobacco and alcohol exposure mandates biopsy rather than empirical treatment.
§Investigations
- 01Incisional biopsy from the ulcer margin, not the necrotic centre
- 02Contrast MRI of tongue and neck — 24 mm lesion, depth of invasion 9 mm, single level II node
- 03CT thorax — no metastasis
- 04Full blood count, orthopantomogram for dental clearance
§Treatment plan
- 01Multidisciplinary team discussion
- 02Wide local excision with 1 cm clinical margins plus ipsilateral selective neck dissection (levels I-IV)
- 03Reconstruction with a radial forearm free flap
- 04Adjuvant radiotherapy based on final pathology
§Surgical procedure
- 01Peroral hemiglossectomy with frozen section margin control
- 02Selective neck dissection levels I-IV preserving accessory nerve, IJV and SCM
- 03Radial forearm free flap inset, anastomosis to facial artery and IJV branch
§Histopathology report
Moderately differentiated invasive squamous cell carcinoma, size 24 mm, depth of invasion 9 mm, perineural invasion present, no lymphovascular invasion. Closest margin 6 mm. One of 32 nodes positive without extranodal extension. pT2 pN1.
§Follow-up & outcome
- 01Adjuvant radiotherapy 60 Gy completed
- 02Monthly review year 1, 2-monthly year 2
- 03Speech and swallowing rehabilitation; disease-free at 30 months
§Clinical pearls / learning points
- 01Any oral ulcer persisting beyond 3 weeks requires biopsy, whatever the presumed cause.
- 02Depth of invasion, not surface diameter, drives T stage in the current AJCC system.
- 03Biopsy the edge of the ulcer including adjacent normal tissue; the centre is often only necrosis.
§ evidenceReferences & Evidence
Current Classification
WHO Classification of Head and Neck Tumours
5th Edition — Volume 9
WHO Classification of Tumours Editorial Board · 2022
The authoritative international classification of head and neck, odontogenic and salivary gland tumours. Current terminology on this site follows this edition.
Evidence summary
Highest level of evidence linked to this page: WHO / Official Classification.
- L1 · Classification — 2
- L3 · Systematic review — 2
- L4 · Research — 2
- L6 · Textbook — 3
2 linked sources were published from 2024 onwards. Where guidance is limited or contested, rely on the higher-level sources above rather than this summary. Educational use only — not a substitute for clinical judgement.
Content last reviewed
September 2026
Evidence last reviewed
September 2026
Next scheduled review
September 2027
Review status
EVIDENCE REVIEWED
Search latest PubMed evidence
Last literature search: 7 September 2026
Current Classification
WHO Classification of Tumours Editorial Board. IARC / World Health Organization · 2022
The authoritative international classification of head and neck, odontogenic and salivary gland tumours. Current terminology on this site follows this edition.
IARC / WHO. IARC · 2022
Continuously updated online edition of the WHO head and neck tumour classification.
Systematic Reviews & Meta-Analyses
de Almeida-Silva LA, Lupp JDS, Sobral-Silva LA et al.. Oral surgery, oral medicine, oral pathology and oral radiology · 2024 · 138(1):66-78
Systematic review of osteoradionecrosis incidence after intensity-modulated radiotherapy for oral cavity cancer.
Walsh T, Liu JL, Brocklehurst P et al.. The Cochrane database of systematic reviews · 2013 · 2013(11):CD010173
Cochrane review of conventional oral examination and adjuncts for detecting oral cancer and potentially malignant disorders.
Key Research
D'Cruz AK, Vaish R, Kapre N et al.. The New England journal of medicine · 2015 · 373(6):521-9
Randomised trial showing survival benefit of elective neck dissection over therapeutic dissection in node-negative oral cancer.
Ang KK, Harris J, Wheeler R et al.. The New England journal of medicine · 2010 · 363(1):24-35
RTOG 0129 analysis establishing HPV status as an independent prognostic factor in oropharyngeal carcinoma.
Histopathology References
Barnes L. CRC Press · 2008
Detailed histopathological reference for head and neck diagnostic criteria.
Textbook References
Neville BW, Damm DD, Allen CM et al.. Elsevier · 2024
Standard reference textbook of oral and maxillofacial pathology used throughout this atlas.
Rajendran R, Sivapathasundharam B. Elsevier · 2020
Undergraduate and postgraduate oral pathology textbook widely used in BDS and FCPS curricula.
Additional sources cited on this page
- AJCC Cancer Staging Manual, 8th ed.
- NCCN Guidelines, Head and Neck Cancers.
§Similar cases
81 cases in the library