What are the typical clinical presentations and appearances of tongue cancer, particularly in patients with a history of tobacco or alcohol use, or human papillomavirus (HPV) infection?

Tongue Cancer Clinical Appearance

Tongue cancer typically presents as non-healing ulcers, red or white patches (erythroplakia or leukoplakia), or fungating masses, with the oral tongue showing symptoms earlier than base of tongue lesions, which often remain asymptomatic until advanced stages. 1

Primary Clinical Presentations by Location

Oral Tongue (Anterior Two-Thirds)

• Non-healing ulcers are the most characteristic finding, persisting beyond 2 weeks 1
• Red patches (erythroplakia) carry particularly high malignant transformation risk and should prompt immediate biopsy 1
• White patches (leukoplakia) may represent precursor lesions or early carcinoma 2
• Localized discomfort is the most common presenting complaint (66.5% of cases), typically present for up to 6 months before diagnosis 3
• Fungating, infiltrating lesions represent more advanced disease with highly variable appearance 2
• Decreased tongue mobility or tenderness to palpation indicates deeper invasion 1
• Oral tongue tumors are more likely to be well-differentiated and diagnosed at earlier stages compared to base of tongue lesions 3

Base of Tongue (Posterior Third)

• Often asymptomatic in early stages, making visualization and early detection difficult 1
• Neck masses are frequently the first presenting sign, with 25% of patients having cervical metastases at initial presentation 4
• Dysphagia (difficulty swallowing) indicates mass effect or ulceration 1
• Referred otalgia (ear pain with normal ear examination) suggests pharyngeal involvement 1
• Unexplained weight loss from difficulty swallowing or cancer cachexia 1
• Base of tongue tumors are typically poorly differentiated and present at advanced stages 3

Morphologic Characteristics

Tumor Appearance Patterns

• Exophytic lesions: outward-growing masses 1
• Infiltrating lesions: invasion into deeper structures without prominent surface changes 1
• Ulcerative lesions: crater-like defects with raised, irregular borders 1
• Mixed patterns combining multiple morphologic features 1

Suspicious Physical Characteristics

• Firm texture due to absence of tissue edema, distinguishing malignant from inflammatory nodes 1
• Reduced mobility from capsular invasion and fixation to adjacent structures 1
• Size >1.5 cm for associated neck masses 1
• Nontender masses are more likely neoplastic than infectious 1
• Ulceration of overlying skin indicates capsular breakthrough 1

Risk Factor-Specific Presentations

Tobacco/Alcohol-Associated Disease (75-85% of cases)

• Predominantly affects patients >40 years of age 1, 5
• More commonly involves the oral tongue with earlier symptom onset 3
• Associated with HPV-negative disease showing poorer prognosis 1
• Synergistic effect when both exposures present 5, 6

HPV-Associated Disease (30-35% of oropharyngeal cancers)

• Primarily affects the base of tongue and oropharynx 1, 5
• HPV-16 accounts for the vast majority of cases with odds ratio of 22.4 6, 7
• Patients tend to be younger, nonsmokers, and nondrinkers 7
• Significantly better prognosis than HPV-negative disease 1
• HPV-positive disease outside the oropharynx is rare (<6%) 1

Critical Warning Signs Requiring Immediate Evaluation

• Chronic sore tongue persisting beyond 2 weeks 1
• Non-healing ulcers of any duration 1
• Red/white patches in the mouth, particularly erythroplakia 1
• Painful or difficult swallowing 1
• Neck masses present ≥2 weeks or of uncertain duration 1
• Tonsil asymmetry suggesting unilateral enlargement 1

Common Diagnostic Pitfalls

Any suspicious oral lesion must be biopsied—clinical appearance alone cannot reliably distinguish benign from malignant disease 1. The highly variable appearance of tongue cancer, ranging from asymptomatic white patches to large infiltrating masses, means that any abnormality persisting >2 weeks requires tissue diagnosis 1, 2. Base of tongue lesions are particularly problematic as they often remain asymptomatic until advanced stages, requiring high index of suspicion in high-risk patients with neck masses or referred otalgia 3, 4.