• A 75 year old male, Mr.Sellamuthu, from Ramnad, Farmer by occupation, belonging to socioeconomic class 4,
• Presented with c/o ulcer in left undersurface of tongue for 1 month and pain at the site of ulcer for 10 days.
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HISTORY OF PRESENTING ILLNESS
The patient was apparently normal 1 month back after which he noticed an
• Ulcer in left undersurface of tongue - present for 1 month, insidious in onset, started as a small ulcer and gradually progressed in size to reach the present size, not associated with discharge.
• H/O pain – present for 10 days at the site of ulcer, insidious onset, progressive, dull aching continuous pain, non radiating & not referred to ear, aggravated by speech and food intake, no relieving factors.
• H/O excessive salivation.
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• H/O foul smell.
• H/O difficulty in speech.
• H/O dysphagia.
• H/O difficulty in tongue protrusion and mobility.
• H/O loss of appetite and loss of weight.
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• No H/O difficulty in opening the mouth.
• No H/O hoarseness of voice.
• No H/O trauma.
• No H/O evening rise of temperature.
• No H/O tobacco or betel nut chewing.
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• No H/O neck swelling.
• No H/O swelling elsewhere in the body.
PAST HISTORY
• No H/O similar complaints in the past.
• No H/O tuberculosis, bronchial asthma, epilepsy, diabetes mellitus, hypertension, jaundice.
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• No H/O tooth extraction with delayed healing.
• No H/O ill fitting dentures.
• No H/O sexually transmitted diseases.
• No H/O chronic drug intake.
• No H/O previous surgeries.
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PERSONAL HISTORY
• Smoker for the past 40 years, smokes 3 beedi per day. Number of pack years – 6.
• Consumes alcohol for the past 40 years occasionally.
• H/O spicy food intake.
• No H/O tobacco or betel nut chewing.
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• Normal bowel and bladder habits.
FAMILY HISTORY
No significant family history.
GENERAL EXAMINATION
• Conscious, oriented, moderately built and moderately nourished.
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• No pallor, icterus, cyanosis, pedal edema, generalized lymphadenopathy.
• Grade 2 clubbing.
• Halitosis present.
• Drooling of saliva.
VITAL SIGNS
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• Pulse rate – 76/min, regular rhythm, normal volume, no specific character, no radio-radial or radio-femoral delay, felt equally in all peripheral palpable vessels, no vessel wall thickening.
• BP- 120/80 mmHg measured in left upper arm in sitting posture.
• Respiratory rate- 18/min, regular in rhythm, abdominothoracic.
• Temperature- afebrile
EXAMINATION OF THE ORAL CAVITY
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INSPECTION:
• Commissures, lips – normal.
• Gums, alveolus, buccal mucosa – normal.
• Teeth : Dental formula – LEFT RIGHT
UPPER JAW - 2121 2121
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LOWER JAW - 1123 1123
Absence of teeth – Lower 2 central incisors
Upper 2nd & 3rd molar on both sides
Diffuse staining of teeth present.
Dental caries – 2nd premolar of left lower jaw.
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Sharp teeth is present adjacent to the ulcer.
TONGUE :
• A single ulcer of size 4 x 3 cm is present in the left ventral surface of the tongue, irregular in shape, extending anteriorly upto tip of the tongue, posteriorly upto 1st molar teeth, laterally upto lateral margin of tongue and medially it crosses the midline. Margins are ill defined. Edges are everted. Floor consists of white patches which is covered by slough. There is no discharge from the ulcer and surrounding areas appear normal.
• Inability to protrude the tongue.
• Mobility of tongue is restricted in left side.
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• There is deviation of tongue to right side.
• Tongue appears pale.
• No fissures.
• Retromolar trigone is normal.
• Floor of the mouth appears normal.
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• Hard and soft palate is normal.
• Anterior and posterior pillars normal.
• Uvula is in midline.
• No tonsilar enlargement.
• Posterior pharyngeal wall is normal.
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PALPATION
• Not warm, it is tender.
• Inspectory findings of size, shape and extent are confirmed.
• Hard in consistency.
• Induration is present at the base of ulcer covering 1 cm around the ulcer.
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• Induration is also present in the left side of floor of mouth.
• Ulcer is not mobile.
• It bleeds on touch.
• There is no mandibular thickening.
EXAMINATION OF NECK NODES
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• Multiple discrete nodes of size 2 x 2 cm is palpable in right submandibular, right upper jugular, right middle jugular and left posterior triangle levels.
• The lymph nodes are hard in consistency, mobile and non tender, skin over swelling is normal.
OTHER SYSTEM EXAMINATION
• RS – NVBS heard and no added sounds.
• CVS – S1, S2 heard. No murmur.
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• ABDOMEN – soft, non tender, no organomegaly, no palpable mass, no free fluid, hernia orifices are free.
• CNS – No focal neurological deficit.
• Spine and cranium – normal.
DIAGNOSIS
Carcinoma of tongue involving left ventral surface of tongue with TNM staging of T4aN2cM0 (STAGE 3) and involvement of 1a, 2, 3, 5a levels of lymph nodes in the neck.
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INVESTIGATIONS
ROUTINE:
• Complete hemogram, bleeding time, clotting time.
• Urine routine.
• Chest X Ray
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• ECG, ECHO
• Renal function test
• Liver function test
SPECIFIC INVESTIGATIONS :
• Edge wedge biopsy
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• Orthopantomogram
• USG neck
• FNAC of the lymph node
• Direct and indirect laryngoscopy
• CT scan / MRI scan
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• USG abdomen
• Panendoscopy
TREATMENT
MULTIMODALITY TREATMENT
• Radiotherapy + chemotherapy.
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• Total glossectomy with reconstruction of tongue using rectus abdominus free flap.
• Modified radical neck dissection of both sides.
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This download link is referred from the post: MBBS Final Year Case Presentation (Clinical Case Examination, Discussion and Treatment)