ORAL CAVITY CASE
FOR LEARNING UNIT VI
ORL 251
Instructions: Accomplish the following tasks indicated in this case.
OPD SUBSPECIALTY CLINIC CONSULT: ORAL CAVITY
S> MD 44 Female from Iba, Zambales
Chief Complaint:
tongue mass, left lateral aspect
History of Present Illness:
1 year PTA: Patient noted a 1x1 cm ulceration on the L lateral side of the tongue initially
associated with tenderness on tongue movement, pain NRS 5/10, usually when eating food, with
no noted bleeding, Patient did not seek consult at this point in time.
In the interim, patient noted gradual enlargement of ulcer.
6 months PTA, Persistence of ulceration growing into a palpable mass prompted consult with a
private GP where she was diagnosed to have a slow-healing tongue ulceration secondary to
uncontrolled Diabetes Mellitus. Patient was given Metformin for sugar control.
2 months PTA: Non-resolution of ulcerated mass, in spite of anti-diabetic medication prompted
second opinion from another physician. Patient was prescribed Metformin, Glimeperide, Betadine
gargle. Still noted gradual enlargement of mass.
2 weeks PTA: Patient sought PGH ORL OPD consult where tongue tissue biopsy and Neck CT
were done.
Review of Systems:
ROS: (+) fever - occasional, low- (+) tongue pain, (-) headache (-) rhinorrhea
grade NRS 6/10 (-) vertigo (-) anosmia
(-) cough (-) dyspnea (-) ear pain (-)nasal
(-) colds (-) dysphagia (-) dizziness congestion /
(+) weight loss (-) odynophagia (-) BOV obstruction
(-) palpitation (-) hoarseness (-) diplopia
(-) tremors (-) otorrhea
(-) otorrhagia
Past Medical History:
(+) Diabetes Type II, on Glimeperide, (-) Bronchial asthma
Metformin (-) Allergies
(-) Diabetes mellitus
(-) Pulmonary tuberculosis
Family Medical History:
(-) Hypertension (-) Bronchial asthma
(+) Diabetes mellitus - mother (-) Allergies
(-) Pulmonary tuberculosis
Social History:
Smoker, 1 pack per day, from 21 years old to present
Occasional alcoholic beverage drinker
Occasional betel nut chewer
Currently a housewife; high school graduate
Lives in a 2-story apartment house with her husband and daughter
O> On PE, the patient has the following findings: (description)
Ear: The pinna and external auditory canal were unremarkable, with no noted lesions or swelling.
The right tympanic membrane and the left tympanic membrane were intact with positive cone of
light. No noted discharge.
Nose: The nasal septum was midline with no deviations or septal spurs. No congestion or erythema
was appreciated. On posterior rhinoscopy, there was no noted post-nasal drip, the turbinates and
eustachian tube openings were visualized with no noted obstruction. No noted tenderness of the
maxillary sinuses noted on palpation.
Oral: On inspection, noted left lateral tongue mass, more erythematous than the rest of the tongue,
around 3.5 x 2.5 x 1 cm firm. On palpation, mass is tender but does not seem to cross the midline,
not involving the base of tongue and floor of mouth. Tongue is still midline, uvula midline. Noted
no limitations of range in motion. No noted exudates or active bleeding. Not involved are the lip,
buccal mucosa, retromolar trigone, hard palate, gingiva, floor of mouth, base of tongue.
Indirect Laryngoscopy and Neck Exam: Fully mobile vocal folds without any mass.
On palpation of neck, noted 2x2x1 cm firm, nontender cervical lymphadenopathy on the left,
Level II area of neck. Trachea palpated to be at midline.
TASK 1: Translate the above findings into the ENT Physical Examination drawings then
take a picture or scan. (10%)
TASK 2: Based on the history and PE give at least 3 differential diagnoses and briefly
explain. (10%)
DIAGNOSTICS:
The following are the diagnostic findings for our patient
CT Neck with Contrast Contiguous axial images of the neck from the skull base to the
thoracic inlet were obtained during the intravenous injection of
non-ionic iodinated contrast. The visualized base of the skull
and brain parenchyma appear normal.
Focal defect possibly ulceration is noted along the left lateral
surface of the anterior tongue, around 3.2 x 1.0 x 0.9 cm.
Associated peripheral enhancement is appreciated. There is no
evidence of a mass in the rest of the oral cavity and
nasopharynx. The visualized sinuses are clear.
An enlarged lymph node with necrosis is noted at the left side of
the neck, Level II, around 1.9 x 1.4 x 1.5 cm. Several
unenlarged lymph nodes are noted in either side of the neck.
No mass is appreciated within the rest of the different neck
spaces in both sides. The visualized vascular structures show
normal enhancement with no evidence of thrombus formation
within.
The aerodigestive tract is patent. The submandibular, parotid,
and thyroid glands are normal. The laryngeal structures as well
as the hypopharyngeal region are normal. The thoracic inlet is
normal.
Impression: Focal defect possibly ulceration along the left
lateral surface of the anterior tongue with associated peripheral
enhancement. Consider an infectious/inflammatory etiology vs.
new growth. Tissue correlation is recommended.
Enlarged necrotic jugulodigastric lymph node, left.
Punch biopsy of the Tongue Squamous Cell Carcinoma, keratinizing
Fasting blood sugar 100 mg/dL (normal)
HbA1c 6% (normal)
Chest X-ray Essentially normal chest findings
Liver Ultrasound Essentially normal liver ultrasound findings
Serum chemistry AST 27 (normal)
ALT 81 (normal)
Alk Phos 81 (normal)
Alb 49 (normal)
Calcium 2.47 (normal)
A> TASK 3: Based on the history, PE and diagnostics give your complete assessment or
diagnosis. (5%)
P> TASK 4: What are the plans for the patient? (15%)
A. Pharmacologic if any
B. Diet if any
C. Maneuvers if any
D. Lifestyle modification if any
E. Other diagnostics
F. Surgical option/s
G. Follow-up or admission
SURGICAL PLAN:
Assuming the patient underwent or was diagnosed with Tongue mass, probably malignant;
Diabetes Mellitus, Type 2 and confirmed to have Tongue Squamous Cell Carcinoma Stage III
(T2cN1M0). She was advised admission to undergo Wide Excision of Tongue mass, Level I-V
neck dissection.
WARD 10 ADMISSION:
The patient was admitted at Ward 10. He/ she underwent Wide Excision of Tongue mass, Level
I-V neck dissection under Elective OR. The following were the OR findings: Noted left tongue
specimen positive for squamous cell carcinoma, well-differentiated, 2.5 centimeters in greatest
tumor dimension. Tumor depth of invasion of 1.0 centimeter. Lymphovascular space and
perineural invasion are present. Positive for tumor, 4/11 Level IIA Lymph nodes. Extranodal
extension (1 mm) present with a 2 mm distance from the lymph node capsule.
6 hrs post-op on dressing change, Jackson-Pratt drain noted to be 100 cc serosangunious
in amount. Noted expanding hematoma on neck area.
TASK 5: What are all the possible complications of doing a neck dissection? Explain the
signs and symptoms of the complications (things to watch out for). (15%)
TASK 6: What is most likely complication that the patient experienced? What is the
treatment or management? (10%)
The patient was managed, operated for exploration and ligation of bleeders as an
Emergency OR. After 2 days, noted decreasing trend in JP output, and JP drain removal was
done. She eventually got well.
TASK 7: What is the discharge diagnosis of the patient? (5%)
he post-op medications given to the patient were the following:
Paracetamol tablet 500 mg/tab q6 as needed for pain
Co- amoxiclav 625 mg/tablet 3x a day for 7 days
Chlorhexidine gargle 3x a day for 7 days
Mupirocin ointment, apply once a day on post-operative site
TASK 8: Write the prescription for the patient. Scan or take a picture and attach. (15%)
The patient was advised to have the post-op labs done.
Follow-up one week with ORL after discharge for suture removal; follow-up with
Oncology.
TASK 9: In your own words, preferably in Filipino, write your script on how you would
explain the discharge diagnosis, prescription, other plans and follow-up to the patient.
(15%)
