--- title: "Clinical Case Discussion: Buccal Carcinoma (Oral Cavity Cancer)" description: "A step-by-step ENT clinical case discussion on Buccal Carcinoma, covering history, examination, diagnosis, and management." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/buccal-carcinoma-case-presentation" categories: ["Clinical Case Presentations"] video: "https://www.youtube.com/watch?v=7R8AXSNANwc" image: "https://media.theentresident.com/og-images/buccal-carcinoma-case-presentation.png" --- # Clinical Case Discussion: Buccal Carcinoma (Oral Cavity Cancer) A step-by-step ENT clinical case discussion on Buccal Carcinoma, covering history, examination, diagnosis, and management. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=7R8AXSNANwc ## 🦷 Clinical Case Discussion: Carcinoma of Buccal Mucosa Today, we'll have a clinical case discussion on a very common ENT presentation: **Carcinoma of Buccal Mucosa - Oral Cavity cancer.** This case discussion format will be helpful for both undergraduates and postgraduates. We'll go through the patient's history, discuss how history guides us to a provisional diagnosis, cover the clinical examination findings and their significance, summarize the case, arrive at a provisional diagnosis, and outline the management plan. --- ### 👤 Patient Profile - **Age:** 65 years - **Sex:** Male - **Occupation:** Farmer - **Residence:** Hyderabad ### 🗣️ Chief Complaint - **Ulcer in the inner aspect of the right cheek** since **4 months** --- ### 📜 History of Present Illness - Patient was apparently asymptomatic **4 months back** - Developed an **ulcer on the inner aspect of right cheek** - **Insidious onset**, **rapidly progressive** - Initial size: **1 × 1 cm** - Present size: **2 × 3 cm** - **Initially painless**, pain started since **last 2 months** - Associated with **loss of appetite** > What are the differential diagnosis of ulcer in Buccal mucosa? > What does Rapidly progressive VS Gradually progressive increase in size of buccal ulcer indicate? > What does late onset of pain in buccal cancer indicate? --- ### ❌ Relevant Negative History (with Clinical Significance) | Negative History Point | Clinical Significance | | --- | --- | | **No bleeding from lesion** | Suggests absence of surface necrosis, friable or highly vascular tumor | | **No difficulty in opening mouth (trismus)** | No involvement of muscles of mastication, masticator space, or temporomandibular joint | | **No history of trauma / sharp tooth** | Rules out traumatic ulcer as a cause | | **No halitosis** | Indicates minimal necrosis and absence of secondary anaerobic infection | | **No difficulty in chewing or speech** | Suggests buccinator, tongue, and masticator space are not involved | | **No excessive salivation / drooling** | Oral competence intact; no significant mucosal irritation or dysphagia | | **No recurrent ulcers / red or white patches** | No evidence of pre-existing premalignant lesion (leukoplakia / erythroplakia) | | **No loosening of teeth** | Suggests no alveolar process or mandibular bone invasion | | **No prior radiation exposure** | Excludes radiation-induced second primary malignancy | | **No difficulty in tongue protrusion** | Indicates tongue muscles, floor of mouth, and pterygomandibular space not involved | | **No dysphagia** | No posterior extension to retromolar trigone, oropharynx, or soft palate | | **No neck swelling** | Clinically node-negative neck (N0) | | **No weight loss** | Suggests early or localized disease; cachexia unlikely | | **No ear or nasal complaints** | No referred otalgia (V3 involvement) or nasopharyngeal extension | | **No cough, hemoptysis, breathlessness** | Lung metastasis unlikely | | **No bone pain, abdominal pain, jaundice** | No evidence of distant metastasis to bone or liver | > What is Trismus? What is it's clinical importance? > Name the muscles of mastication. > What are the sites of Distant metastasis in oral cavity cancer? What is the most common site amongst these? --- ### 🕰️ Past History - No previous surgeries - No drug allergies - No family history of malignancy --- ### 👤 Personal & Addiction History - **Decreased appetite** for last 3 months ### 🚬 Addiction History - **Bidi smoking:** 8/day for **40 years** - **Betel quid chewing:** 4/day for **45 years** - Keeps quid in **right gingivobuccal sulcus** > What are the carcinogens found in tobacco? > What is the mechanism of action of carcinogenesis by Tobacco? > What are the carcinogens found in quid contributing to oral cancer? --- ### 🦷 Local Examination (Oral Cavity) #### Inspection - **Single ulceroproliferative growth** - Size: **2 × 3 cm** - Site: **Right buccal mucosa** - Extent: - Anterior: 0.5 cm from oral commissure - Posterior: up to first molar - Superior: 3 cm from upper gingivobuccal sulcus - Inferior: 2 cm from lower gingivobuccal sulcus - **Averted (rolled) edges** - **Irregular margins** - **Floor covered with slough** #### Palpation - Tenderness present - **Induration extending 0.5 cm beyond visible margins** - Base: **firm, non-mobile** - **Not fixed to mandible** - Does **not bleed on touch** --- ### 🧠 Interpretation of Examination Findings ### Ulceroproliferative Growth - Indicates **squamous cell carcinoma** ### Everted / Rolled Edges - Due to peripheral tumor proliferation with central necrosis ### Induration - Hallmark of malignancy - Indicates **submucosal tumor spread** - Determines **true tumor extent and surgical margins** ### No Fixation to Mandible - Suggests **no bone invasion** - Rules out **T4 disease** > What is Edge of ulcer? What is Margin of ulcer? > What are the Types of Edges of Ulcer? What is the mechanism behind each one of them? Give examples of each type. > What is Floor of ulcer? What is Base of ulcer? > What is Induration? What is the Pathology behind Induration? What is it's clinical significance? --- ## 🆚 Benign vs Malignant Ulcer | Feature | Benign | Malignant | | --- | --- | --- | | Edges | Sloping | Rolled / everted | | Margins | Regular | Irregular | | Floor | Clean | Slough, necrotic | | Base | Soft, mobile | Hard, indurated | | Pain | Painful early | Painless early | | Bleeding | Rare | Common | | Induration | Absent | Present | > What are the Key Clinical Hallmarks of Malignant Ulcer? > What is Field Cancerization? What is it's Clinical Implications? > What is Synchronous VS Metachronous Tumors? What is Warren and Gates criteria? --- ### 📝 Case Summary - 65-year-old male - Chronic smoker and quid chewer - Rapidly progressive ulcer in right buccal mucosa - Ulceroproliferative lesion with: - Rolled edges - Induration - Slough-covered floor - No neck nodes --- ### 🩺 Provisional Diagnosis **Carcinoma of right buccal mucosa**, Clinical stage:** **T2N0MX (Stage II)** >What are the points in favour of your diagnosis? >What is the Differential Diagnosis of Buccal carcinoma? What are points in favour and against in each one of them? > What are the Anatomical Boundaries of Buccal Mucosa? > What is the most common site of oral cavity cancer worldwide? > What is the most common site of oral cavity cancer in India? > What is the TNM Staging of Oral Cavity cancer? > What is the difference between Premalignant lesions VS Premalignant disorders? Give examples of each. > What is Leukoplakia & Erythroplakia? Which has the highest malignant potential? > What is Oral Submucous fibrosis? What is the Pathophysiology of Oral Submucous fibrosis? --- ### 🏨 Management Plan Management always consists of two parts: Investigation and Treatment. #### 🔬 Investigations 1. **Incisional biopsy** - From **edge of ulcer** 2. **CECT / MRI** 3. **OPG** - If mandibular involvement suspected 4. **USG neck** - Occult nodes 5. **Chest X-ray / CT** - Lung metastasis 6. **PET-CT** - Advanced / recurrent disease > What is the purpose of doing CECT? > Which Lymph nodes get involved in buccal carcinoma? > What are the Features suggestive of Nodal malignancy on USG? > What is Broder’s Grading? --- **🩻 Treatment** 1️⃣ **Primary Tumor** - **Wide local excision** - **1 cm margin** - Depth up to buccinator / periosteum 2️⃣ **Reconstruction** - Local flaps (< 3 cm) - Free flaps (large defects) 3️⃣ **Neck** - **Elective supraomohyoid neck dissection** - Levels **I–III** - Due to 15–20% occult metastasis risk > What surgery is done when there is cortical or medullary invasion of mandible? > Name some local flaps and free flaps used in buccal carcinoma for reconstruction. > Classify Neck Dissection and define each one of them. > What are the different types of Selective Neck Dissection? > What are the Contraindications of Neck Dissection? > What are the Indications of Post op Adjuvant Radiotherapy? > What is Residual Tumor Classification? --- ## About This Note This free ENT note on Clinical Case Discussion: Buccal Carcinoma (Oral Cavity Cancer) was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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