Carcinoma of Tongue

Causes of referred otalgia

Ear receives nerve supply from Vth (auriculotemporal), 1Xth (tympanic br.) and Xth (auricular br.) cranial nerves; and from C2 (lesser occipital) and C2 and C3 (greater auricular), pain may be referred from these remote areas

1. Via Vth cranial nerve

• Dental; Caries tooth, apical abscess, impacted molar, malocclusion.
• Oral cavity; Benign or malignant ulcerative lesions of oral cavity or tongue.
• Temporomandibular joint disorders; Bruxism, osteoarthritis, recurrent dislocation,  ill-fitting denture.
• Sphenopalatine neuralgia.

2. Via IXth cranial nerve

• Oropharynx; Acute tonsillitis, peritonsillar abscess, tonsillectomy. Benign or malignant ulcers of soft palate, tonsil and its pillars.
• Base of tongue; Tuberculosis or malignancy.
• Elongated styloid process.

3.   Via Xth cranial nerve. Malignancy or ulcerative lesion of: vallecula, epiglottis, larynx or laryngopharynx, esophagus.

4.   Via C2 and C3 spinal nerves. Cervical spondylitis, injuries of cervical spine, caries spine.

Traditionally, the gold standard for control of cervical metastasis has been the radical neck dissection (RND).

The classic RND removes levels I to V of the cervical lymphatics in addition to the SCM, internal jugular vein, and the spinal accessory nerve (CN XI). 

• N0: There is no evidence of regional metastasis
• N1: Metastasis occur to a single ipsilateral lymph node, 3 cm or less in greatest dimension
• N2a: Metastasis in single ipsilateral lymph node, >3 cm and
• N2b: Metastasis occur in multiple ipsilateral lymph nodes, all nodes
• N2c: Metastasis occur in bilateral or contralateral lymph nodes, all nodes

Answer- D

• Pain in the tongue is due to the involvement of the lingual nerve.
• In such cases, pain from the tongue can be referred to the ear and lower temporal region
• Ankyloglossia is restricted mobility of the tongue.
• It is due to infiltration of the floor of the mouth or mandible, or due to an advanced lesion.

B i.e. Larynx; C i.e. Ant 2/3 of tongue

• Radiotherapy is reserved for early larynx CA which has not involved cartilage or cervical lymphnodes & don’t impair cord mobilityQ.
• Surgery is the treatment of choice for early lesions suitable for simple infra oral excision, for tumors on the tip of tongue but brachy therapy with iridium wires has the advantage of preserving the tongue.
• Stomach, colon, lung CA in early stage are treated by surgery.

Ans is ‘d’ i.e., Carcinomatous ulcer 

Aphthous Ulcer-

It can be (1) Minor aphthous ulcer, common in menstruating women as a crop with a 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.

Tuberculous ulcer-

It is undermined shallow, often multiple, painful ulcer. An ulcer can occur in margins, tip or anterior 2/3rd of the tongue.

Herpes Ulcer- 

It is the involvement of lingual nerve presenting as acute neuralgia with vesicles that form multiple superficial painful ulcers.

Carcinomatous ulcer-

Carcinomatous ulcers are painless but may become painful in advanced stages, with extension into surrounding tissues.

Ans. is ‘d’ ie Radical neck dissection 

“For clinically Node positive necks, frequently the surgical treatment of choice is the MRND or RND.”- Schwartz 9/e p505

The management of cervical node metastasis has already been described in previous question.

Surgical management can be of 3 types: Radical neck dissection (RND), Modified radical neck dissection (MRND) & Selective neck dissection (SND)

Radical neck dissection

is the traditional gold standard for control of cervical metastasis.

–  RND involves removal of levels I to V of the cervical lymph nodes + Sternocleidomastoid, UV and the spinal accessory nerve (CN XI).

Modified radical neck dissection

– is modification of RND that preserves nonlymphatic structures i.e. CN XI, SCM and UV.

MRND has been found to be equally effective in controlling neck disease as RND with superior functional outcome.

Selective neck dissection

– Preservation of any of the levels I through V during neck dissection is known as Selective neck dissection.

– The principle behind preservation of certain nodal groups is that specific primary sites preferentially drain their lymphatics in a predictable pattern. Types of SND include the supraomohyoid neck dissection, the lateral neck dissection, and the posterolateral neck dissection.

“SND is performed on a clinically negative (NO) neck with preservation of nodal groups carrying less than 20% chance of being involved with metastatic disease”- Sabiston 18/e p819

Ans. is ‘b’ i.e., Lateral borders 

Most common site is middle of the lateral border or the ventral aspect of the tongue.

Ans. is ‘a’ i.e., Excision

Ans. is ‘c’ i.e., Commonly adeno carcinoma 

Ans. is ‘b’ i.e., Carcinomatous ulcer 

• Presents as painless mass or ulcer that fails to heal after minor trauma
• MC complaint: Mid-irritation of tongue
• MC site: Lateral border of the junction of the middle and posterior third.
• Primary basin for cervical metastasis is superior deep jugular nodes (Level II)
• Early symptoms: Sore throat, the feeling of a lump in the throat, and slight discomfort on swallowing

1. Septic ulcer – Sloping edges
2. Tuberculous ulcer -Undermined edges
3. Carcinomatous ulcer – Everted hard edges
4. Rodent ulcer – Barely visible pearly edges
5. Syphilitic ulcer – punched-out appearance with raised indurated edges 

Ans. is `d’ i.e., All of the above 

Ans. is ‘b’ i.e., Posterior tongue

See below

Here is the incidence of cervical lymphnode metastasis of various head & Neck tumours

• Posterior tongue —> 70% (Schwartz 7^th/e page 638)
• Hard palate            —> 10-25 % (7^thle page 632)
• Buccal mucosa —> 56% (7^th/e page 631)
• Maxillary Sinus —> Nodal metastases are rare and occur only in 10-15% cases (p 253 E.N.T. Dhingra 3/e)

Ans. is ‘d’ i.e., Excision of carcinoma of the tongue, the floor of the mouth, part of the jaw and lymph nodes enbloc

In carcinoma base of tongue pain is referred to the ipsilateral ear because of the common nerve supply of the base of tongue and ear i.e. Glossopharyngeal nerve.

• The anterior 2/3 of tongue is supplied by Lingual nerve
• Lingual nerve is a branch of mandibular N and auriculotemporal N which supplies ear is also a branch of mandibular N. Hence any pain of anterior 2/3 of tongue is referred to ear via mandibular N.
• Any pain in the posterior 1/3 of tongue is referred to ear via Glossopharyngeal and vagus N.
• Any pain in the base of tongue is referred to ear via glossopharyngeal N.

Most common site of carcinoma tongue is middle of lateral border or the ventral aspect of the tongue followed by tip and dorsum.

Tumor of lateral border of tongue

T₁ stage (< 2cm in size): Insterstitial irradiation or excision (partial glossectomy).

T₂ stage (> 2 cm) in size: External beam radiotherapy or hemiglossectomy

Referred causes of earache:

As the ear receives nerve supply from:

• Vth (auriculotemporal branch) cranial nerve-dental, oral cavity, temporomandibular joint disorders and sphenopalatine neuralgia
• IXth (tympanic branch) cranial nerve -oropharynx, base of tongue, elongated styloid process
• Xth (auricular branch) cranial nerve-vallecula, epiglottis, larynx, esophagus
• From C2 (lesser occipital) and C2 and C3 (greater auricular), pain may be referred from these remote areas.

Ans. B: Lateral border of anterior 2/3rd

• Tumors on the tongue may occur on any surface but are most commonly seen on the lateral and ventral surfaces.
• MC site – lateral border of the tongue at the junction of middle & posterior 1/3rd.
• Nonhealing ulcer, commonly on the lateral border of tongue in 60% of cases, with slough.
• Frozen tongue or indurated variety.

Ans. A: Squamous cell carcinoma