General Data

(1)

指導老師：林立民、陳玉昆、王文岑、陳靜怡醫師

報告者：Intern H 組侯奕睿、陳凱熙、張竣傑、翁蔚任

(2)

指導老師：林立民、陳玉昆、王文岑、陳靜怡醫師

報告者：Intern H 組侯奕睿、陳凱熙、張竣傑、翁蔚任

Intern H 組侯奕睿、陳凱熙、

張竣傑、翁蔚任

(3)

General Data

y

Name : 謝明憲

y

Gender : male

y

Age : 41

y

Native : Taiwan

y

Occupation : 商

y

Attending V.S. : 謝天渝醫師

y

First visit :97/05/08

(4)

Chief Complaint

y

Ulcer at R`t border of tongue for 6 months, extending from posterior to anterior area.

(5)

Present Illness

y

This 41 y/o male suffered from the above episode for 6 months. He found that the ulcer was painful and

extending from posterior to anterior area. The ulcer over the posterior area was healed, but it extended to the

anterior area for 1^＋ months. So he came to our OPD for further evaluation.

(6)

Past History

y Past Medical History

y

Unknown

y Past Dental History

y

MPDS

y

Acute periodontitis

(7)

Personal History

y Alcohol ：(+)

y

Unknown detail

y Betel nut ： (+)

y

Unknown grains / day for 15 years

y

Quit for 6 months

y Cigarette ： (+)

y

Unknown detail

(8)

Intraoral Examination

y

An irregular‐shaped with rough surface ulcer was found over right border of the tongue, measuring about 2.2 x 1.5cm.

(9)

Physical Examination

y

Pain (+)

y

Induration (+) ：mild

y

Cough (+)

y

Swallowing pain (?)

y

Tenderness (?)

y

Fever or local heat (?)

y

Lymphadenopathy (?)

y

Over right border of the tongue

(10)

(11)

Neoplasm or Inflammation?

y

Fever or Local heat：unknown

y

Lymphadenopathy：unknown

y

Induration：mild (+)

y

Duration：6 months

Neoplasm

(but not rule out Inflammation)

(12)

Neoplasm Benign or malignant?

y

Ulceration: (+)

y

Induration：mild(+)

y

Duration : 6 months⁺

y

Pain：(+)

y

Margin：poor‐defined

Malignant

(13)

Infection or Not ?

y

Cough： (+)

y

Abnormal temperature：unknown

y

Specimen ：blood － unknown

urine － unknown

sputum － (++++)

Infection

(14)

Working diagnosis:Neoplasm

1.

Squamous cell carcinoma

2.

Metastatic carcinoma

3.

Spindle cell carcinoma

(15)

Working diagnosis:Infection

1.

Tuberculosis

(16)

Working diagnosis:Inflammation

1.

Major aphthous ulcer

2.

Necrotising sialometaplasia

(17)

Working diagnosis

1.

Squamous cell carcinoma

2.

Spindle cell carcinoma

3.

Metastatic carcinoma

4.

Tuberculosis

5.

Major aphthous ulcer

6.

Necrotising sialometaplasia

(18)

bov

^{Our case} ^SCC

Gender Male Male

Age 41 y/o Middle‐aged

Frequency 94%(in oral and jaw malignant )

Symptom Painful ulcer Painful/painless ulcer

Site Right border of the tongue (臨床照) Dorsum of the tongue (chart)

Tongue (posterior lateral and ventral surface )

Color Red and white Red and white

Shape Irregular (Stellate) Irregular

Size 2.2 x 1.5 cm ?

Induration Mild +

Surface Rough Rough

Duration 6 months Few months

Tenderness ? +

LAP ? +(meta)/‐

(19)

Squamous cell carcinoma

OUR CASE SCC

(20)

bov

^{Our case} Spindle cell carcinoma

Gender Male No sex predilection

Age 41 y/o Average 57 y/o

Frequency ?

Symptom Painful ulcer Pain and paresthesia

Lower lip, lateral posterior tongue, alveolar ridge

Size 2.2 x 1.5 cm ?

Induration Mild ?

Surface Rough Rough

Duration 6 months Grows rapidly

Tenderness ? +

LAP ? ?

(21)

Spindle cell carcinoma

OUR CASE Spindle cell carcinoma

(22)

bov

^{Our case} Metastatic carcinoma

Gender Male Male

Age 41 y/o Middle aged and older adults

Frequency ?

Symptom Painful ulcer May be painful

Gingiva(50%), tongue(25%)

Size 2.2 x 1.5 cm ?

Induration Mild ?

Surface Rough Rough

Duration 6 months ?

Tenderness ? +

LAP ? ?

(23)

Metastatic carcinoma

OUR CASE Metastatic carcinoma

(24)

bov

^{Our case} Tuberculosis

Gender Male ?

Age 41 y/o Middle‐aged、older

Frequency 0.5 – 1.5 %

Symptom Painful ulcer Chronic painful/painless ulcer Site Right border of the tongue (臨床照)

Dorsum of the tongue (chart)

Tongue (esp. dorsal side)、

Palate、lip

Shape Irregular (Stellate) Irregular (Stellate)

Size 2.2 x 1.5 cm ?

Induration Mild +

Surface Rough Rough

Duration 6 months ?

Tenderness ? +

LAP ? +

(25)

Tuberculosis

OUR CASE TB

(26)

bov

^{Our case} ^MAU

Gender Male Female

Age 41 y/o Typically after puberty

Frequency 1%

Symptom Painful ulcer Very painful

Movable mucosa, lips, BM, tongue, soft palate

Color Red and white White or yellow

Size 2.2 x 1.5 cm 1.0 cm~2.0 cm

Induration Mild ?

Surface Rough Smooth

Duration May persist for months May persist for months

Tenderness ? +

LAP ? May has painful LN swelling

(27)

Major aphthous ulcer

OUR CASE MAU

(28)

bov

^{Our case} Necrotizing sialometaplasia

Gender Male Male

Age 41 y/o Average 46 y/o

Frequency Uncommon

Symptom Painful ulcer Pain or parathesia

Posterior palatal

Size 2.2 x 1.5 cm <1 ~ >5

Induration Mild ‐

Surface Rough Smooth to rough

Duration 6 months 2 ~ 3 wks

Tenderness ? ‐

LAP ? ‐

(29)

Necrotizing sialometaplasia

OUR CASE Necrotizing sialometaplasia

(30)

(31)

Clinical impression

1. Squamous cell carcinoma

2. Tuberculosis

(32)

(33)

Biopsy ^97/05/08

y

Incisional biopsy was performed over right border of tongue at OS Dep.

y

Check HP report on 97/05/16.

(34)

Biopsy ^97/05/08

9

Main findings in HP report:

y

Several tubercles scattering in the underlying fibrous connective tissue.

y

Horse‐shoe shaped multinucleated giant cells and caseous necrosis are present.

y

Surrounded by epitheloid histiocytes.

y

The acid‐fast stain reveals positive reaction of micro‐

organism.

(35)

Biopsy ^97/05/08

Tuberculosis over tongue, oral cavity

(36)

Chest X‐ray examination ^97/05/16

9

Specific findings

y

Consolidation and suspect small nodules are noted in both upper lung fields.

y

Linear densities in both lung

(37)

Chest X‐ray examination ^97/05/16

9

Impression

1.

Consolidation and

suspect small nodules are noted in both upper lung fields. Suspect

bronchopneumonia.

2.

Mild fibrosis in both lungs. Upper lobes predominated.

(38)

Acid‐fast bacilli ^97/05/19

y

Specimen : Sputum

Positive reaction(++++)

(39)

Final Diagnosis

Tuberculosis,

lateral tongue border

(40)

References

y Oral and maxillofacial pathology Second edition

y Different diagnosis of oral and maxillofacial lesions fifth edition y Oral tuberculosis, D. P. Von Arx and A. Husain, British Dental Jurnal

APRIL 28 2001, VOLUME 190, NO. 8, PAGES 420‐422

y Oral mucosal ulceration: A manifestation of previously

undiagnosed pulmonary tuberculosis

, BAHAR SEZER, D.D.S., Ph.D.,

MERT ZEYTINOGLU, D.D.S., Ph.D., ÜMIT TUNCAY, D.D.S., Ph.D. and TAHA UNAL, D.D.S., Ph.D., J Am Dent Assoc, Vol 135, No 3, 336‐340

y Tuberculosis of gingiva

, D.K. SAMANTA RAY, V.S.S. Medical College, Burla, Orissa, Ind. J. Tub., Vol. XXVII No. 3

y Tuberculosis of tongue

, N.K. SONI,* P. CHATTERJI and S.K. NAHATA, Ind. J.

Tub., Vol. XXVIII, No. 1

y Primary syphilis remains a cause of oral ulceration

, F. Alam, A. S.

Argiriadou, T. A. Hodgson, N. Kumar and S. R. Porter., J Am Dent Assoc OCTOBER 14 2000, VOLUME 189, NO. 7, PAGES 352‐354

(41)