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116                  THE PHARYNX AND NASOPHARYNX

do so the tongue should be protruded to its full extent and moved to either
side. Impaired mobility may be due simply to tongue tie, but it may be caused
by a tumour within the muscle of the tongue. Right and left movements of the
tongue may disclose ulceration of its lateral borders or an early tumour
arising at the junction of the palatoglossal fold and the tongue. The dorsum of
the tongue and the base of the tongue are examined with the aid of a laryngeal
mirror (p. 150).

Carcinoma may affect any part of the tongue. It may appear first as a
submucosal swelling, or it may erupt through a patch of leucoplakia. It is not
usually seen thus early, and patients generally do not present until there has
been a breakdown to form an ulcer with hard everted edges. Palpation of any
suspicious swelling or ulcer, using the gloved finger, will demonstrate the
hardness of the growth. There is early involvement of the cervical lymph
nodes, and the neck must be palpated systematically and routinely. Biopsy
should be performed from every hard swelling or ulcer, being careful to take
the specimen from the growing edge of the ulcer. Chest radiography and full
blood examinations must be carried out in every case as they will exclude
tuberculosis, syphilis and blood dyscrasias.

In general, malignant disease of the tongue and mouth occurs in those past
middle age, and is more frequent in males. Squamous carcinoma, in various
stages of differentiation, is the most common tumour.

Anterior Two-thirds of Tongue

Cancer in this region may be preceded by leucoplakia or by a papillomatous
growth. The swelling ulcerates early and this gives rise to foetor and limitation
of movement of the tongue. Bleeding may occur from the edges of the ulcer.
Pain is a late feature. The cervical lymph nodes are involved at an early stage
on account of the rich lymphatic supply, and enlarged glands must be sought
for. At first, the node may feel firm and not fixed, but this changes shortly to
the characteristic hard, fixed node. Cancer involving the tip of the tongue may
cause enlargement of the submental glands.

Buccal Mucosa and Floor of the Mouth

This area may be involved primarily, often near the openings of the
submandibular glands, or it may be affected by the spread of a tumour from
the tongue or the alveolus.

Base of Tongue

Tumours in this region may be exophytic or ulcerative. They give rise to
foetor and some dysphagia due either to the size of the growth or to the
invasion of the muscles. There may be bleeding from the edge of an ulcerated
lesion. As a rule the patient presents late, after cervical gland metastasis has

TREATMENT. Treatment is surgical or radiotherapeutic or a combination of
both. Surgical treatment involves a wide resection of the tumour area. It may
be possible to operate within the oral cavity on a small growth, but tumours
in the base of the tongue may require a hemiglossectomy, or a translingual
approach in which the tongue is split in the midline. Pharyngotomy may be
required, and access is gained medially through the thyrohyoid membrane or
laterally through the thyroid. The discovery of enlarged lymph nodes will call