Download MBBS Final Year Surgery Case Presentation Carcinoma Lip Clinical Examination Discussion and Treatment

CASE PRESENTATION

Mr. Krishnan

65 years old male

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from Teynampet

Working as watchman

Belonging to lower middle class

Came to the hospital with CHIEF COMPLAINTS of

• an ulcer on the right side of lower lip for past 2 years

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• Pain over ulcer for past 5 months

HISTORY OF PRESENTING ILLNESS

Patient was apparently normal 2 years back

After which he developed an ULCER

• For 2 years

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• Insidious in onset
• Initially small in size
• Gradually progressive
• To attain present size
• Associated with DISCHARGE – scanty serous, not foul smelling, not blood stained

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PAIN:

• For the past 5 months
• Over the ulcer
• Insidious onset
• Intermittent, pricking type of pain

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• Not referred, not radiating
• No aggravating and relieving factors
• H/O difficulty in chewing
• H/O difficulty in swallowing

• No H/O excessive salivation

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• No H/O difficulty in opening the mouth
• No H/O difficulty in protruding the tongue
• No H/O deviation of tongue
• No H/O difficulty in speech
• No H/O numbness or paresthesia

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• No H/O trauma, evening rise of temperature
• No H/O swelling elsewhere in the body
• No H/O loss of weight or appetite

PAST HISTORY

• Patient had no similar complaints in the past

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• No H/O previous surgery or hospitalization
• No H/O DM, HT, TB, Asthma, Epilepsy, Jaundice
• No H/O ill fitting dentures
• No H/O tooth extraction, sharp tooth
• No H/O STDs

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• No H/O chronic drug intake or irradiation

PERSONAL HISTORY

• Consumes mixed diet
• Normal bowel and bladder habits
• Smoker for past 40 years, 3 cigarettes/day

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• Alcoholic, consumes 180ml occasionally
• H/O spicy food intake
• No H/O drug or food allergy

FAMILY HISTORY

• No significant family history

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GENERAL EXAMINATION

• Patient is conscious, oriented, moderately built and nourished
• Pallor present
• No icterus
• No cyanosis

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• No clubbing
• No pedal edema
• No generalized lymphadenopathy

VITALS

• PULSE RATE: 82/min, regular in rhythm, normal in volume, no specific character, no radio radial/ radio femoral delay, felt in all peripheral pulses

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• BLOOD PRESSURE: 128/80 mmHg measured in the right upper arm in sitting posture
• RESPIRATORY RATE: 16/min, abdomino thoracic
• TEMPERATURE: afebrile

LOCAL EXAMINATION OF ORAL CAVITY

INSPECTION

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After getting consent, the patient is examined in bright light

LIPS: a single oval ulcer of 3x3cm, in the lower lip on the right side

Extent:

• Anterior - upto vermillion border
• Posterior - 2cm from lower gingivo buccal sulcus

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• Lateral - 0.5 cm from angle of mouth
• Medial - midline (not crossing the midline)

INSPECTION

• With well defined margins
• Everted and rolled out edges

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• Floor has necrotic material
• with serous discharge
• Surrounding skin – normal
• No scars, sinuses, dilated veins
• No pigmentation

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• GUMS : normal
• ALVEOLA : normal
• BUCCAL MUCOSA : normal
• TEETH :

  2123	2123
  2123	2123

• No dental caries

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• No sharp tooth
• No staining of teeth
• Good oral hygiene, no halitosis

• TONGUE :
• Pink in colour

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• Dorsal and ventral surfaces – normal
• No ulcers or lesions
• Able to protrude the tongue
• No deviation
• Mobility of tongue normal

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• RETROMOLAR TRIGONE : normal
• FLOOR OF MOUTH : normal

• HARD AND SOFT PALATE : normal
• UVULA: in midline
• ANTERIOR AND POSTERIOR PILLAR : normal

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• TONSILS: normal
• POSTERIOR PHARYNGEAL WALL: normal
• TEMPERO MANDIBULAR JOINT: normal, no restriction of movements

PALPATION

• Warmth +

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• Not tender
• Inspectory findings of site, size, shape, extent are confirmed
• Hard in consistency
• Base indurated
• Surrounding skin indurated upto 1 cm around lesion

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• Mobile
• Do not bleed on touch
• Not fixed to mandible
• No mandibular thickening

EXAMINATION OF LYMPH NODES

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A single, round, mobile, hard lymph node of size 2x1cm palpable in the right jugulo - digastric region (level 2)

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM:

• Normal vesicular breath sounds heard
• No added sounds

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CARDIOVASCULAR SYSTEM:

• S1,S2 heard
• No murmurs

CENTRAL NERVOUS SYSTEM:

No focal neurological deficit

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ABDOMEN:

• Soft, non tender, no organomegaly, no free fluid, no palpable mass
• Hernial orifices free
• External genitalia - normal

DIAGNOSIS

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• CARCINOMA OF LOWER LIP ON RIGHT SIDE
• INVOLVING LEVEL II LYMPH NODES OF NECK
• WITH TMN STAGING OF T2 N1 MO
• STAGE III

BASELINE INVESTIGATIONS

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• Complete hemogram – TC, DC, ESR, Hb%
• Urine - sugar, proteins, deposits
• Blood - sugar, urea, creatinine
• Xray chest
• ECG

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SPECIFIC INVESTIGATIONS

• Edge wedge biopsy
• USG neck
• FNAC of the node
• Orthopantomogram

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• CT for bone invasion
• MRI for soft tissue invasion
• Laryngoscopy
• FOR METASTASIS: Xray chest, USG abdomen

TREATMENT

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TUMOR OF SIZE >2 CM

Resection and Reconstruction

• Abbe's flap (flap based on labial artery)
• Bernard rotation flap

METASTATIC LYMPH NODE

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• Selective supra omohyoid neck dissection