口腔病理科 口腔病理科 Case Report Case Report
報告者報告者 : : 戴延亘戴延亘 黃柏棋黃柏棋 歐凱捷歐凱捷 楊東翰楊東翰 鄭羽婷鄭羽婷 (Intern B
(Intern B組組))
指導老師指導老師 : : 口腔病理科全體醫師口腔病理科全體醫師 報告日期報告日期 : 96.1.26: 96.1.26
General Data General Data
• •
Name:Name: 王王 X XX X• •
Chart No:233xxxxxChart No:233xxxxx• •
Sex : Sex : 男男• •
Age :Age : 55 55 y/oy/o• •
Native: Native: 台南台南• •
Occupation: Occupation: 工程師工程師• •
First visit: 95.12.25 First visit: 95.12.25Chief Complaint Chief Complaint
Severe tooth mobility of
Severe tooth mobility of R R ’ ’ t t upper posterior upper posterior teeth &
teeth & R R ’ ’ t t facial numbness facial numbness
Present Illness Present Illness
This 55
This 55 y/oy/o male male pp’’tt felt facial numbness fromfelt facial numbness from
RR’’tt eye to nasal alareye to nasal alar and to and to RR’t’t upper lip for 1 year.upper lip for 1 year.
His right eyesight was involved recently. He went to His right eyesight was involved recently. He went to
see the
see the neurologist and ophthalmologistneurologist and ophthalmologist, but in, but in
vain. Therefore he went to our ENT for treatment on vain. Therefore he went to our ENT for treatment on
95.12.25.The ENT doctor referred him to our OPD for 95.12.25.The ENT doctor referred him to our OPD for
dealing his teeth problem due to severe mobility of his dealing his teeth problem due to severe mobility of his
right upper posterior teeth.
right upper posterior teeth.
Past Medical History Past Medical History
• • Hepatitis B Hepatitis B
• • Drug allergy Drug allergy – – 抗發炎藥物 抗發炎藥物
• • Food allergy Food allergy – – Denied Denied
Past Dental History Past Dental History
• • Extraction Extraction
• • OD OD
• • Endo Endo
• • Prosthesis Prosthesis
• • Attitude to dental treatment: cooperative Attitude to dental treatment: cooperative
Personal Habits Personal Habits
• • Alcohol drinking ( Alcohol drinking ( - - ) )
• • Betel quid chewing ( Betel quid chewing ( - - ) )
• • Cigarette smoking ( Cigarette smoking ( - - ) )
Extraoral
Extraoral findings findings
• •
Numbness from Numbness from RR’’tt eye to nasal eye to nasal alaralar and to and to RR’’tt upper lipupper lip
• •
The right eyesight was involved recentlyThe right eyesight was involved recentlyIntraoral
Intraoral findings (95/12/25) findings (95/12/25)
• •
Massive gingival ulcer at Massive gingival ulcer at buccalbuccal aspect to tooth 15aspect to tooth 15• •
Ulceration and Ulceration and exophyticexophytic mass grows at tooth 17, distal mass grows at tooth 17, distal sideside• •
Dimension: 0.5 X 0.7 cmDimension: 0.5 X 0.7 cm• •
Rubbery in consistencyRubbery in consistency• •
SessileSessile• •
PainlessPainless• •
Tenderness (Tenderness (--))• •
IndurationInduration ((--))Intraoral
Intraoral findings (95/12/25) findings (95/12/25)
• •
Tooth 14, 15, 16, 17 hypermobilityTooth 14, 15, 16, 17 hypermobility: Grade : Grade ⅢⅢ• •
Tooth 16, 24 amalgam fillingTooth 16, 24 amalgam filling• •
Tooth 15 restorationTooth 15 restoration• •
Tooth 14~23, 25~26, 34~35, 31~44 PFMTooth 14~23, 25~26, 34~35, 31~44 PFM• •
Tooth 27~28 metal crownTooth 27~28 metal crown• •
Food debris deposition Food debris deposition• •
Poor oral hygienePoor oral hygieneRadiographic findings Radiographic findings
Panorex
Panorex (95.12.25) (95.12.25)
Panorex
Panorex findings findings
• •
There is an ill-There is an ill-defined, irregular margin defined, irregular margin radiolucencyradiolucency over right maxillary alveolar ridge, over right maxillary alveolar ridge, extending from tooth 13 to 17, measuring about extending from tooth 13 to 17, measuring about 5.0 x3.0 cm, with teeth 13, 14 external root
5.0 x3.0 cm, with teeth 13, 14 external root resorption
resorption, like floating in the air, and the lesion , like floating in the air, and the lesion involves right hard palate and sinus floor.
involves right hard palate and sinus floor.
• •
Sinus: the medial wall and floor of right Sinus: the medial wall and floor of right maxillary sinus are destroyedmaxillary sinus are destroyed
• •
CondyleCondyle: unremarkable: unremarkablePanorex
Panorex findings (Cont.) findings (Cont.)
•• CCariesaries: tooth 15 (M): tooth 15 (M)
•• Generalized horizontal bony defect Generalized horizontal bony defect
•• Circumferential bony defect tooth 34, 27, 28Circumferential bony defect tooth 34, 27, 28
•• MMissing toothissing tooth: tooth 11,12,18,21,26,35,36,37,38,46,47,48: tooth 11,12,18,21,26,35,36,37,38,46,47,48
•• EEndodonticndodontic conditioncondition: tooth 13, 14, 16, 22, 23, 33, 34, 45: tooth 13, 14, 16, 22, 23, 33, 34, 45
•• C & BC & B: tooth 14, 15x22 , 23 , 24 , 25x27, 28 , 33 , 34 , 41x45: tooth 14, 15x22 , 23 , 24 , 25x27, 28 , 33 , 34 , 41x45
•• AAmalgammalgam filling: tooth 16 filling: tooth 16
•• Resin filling: tooth 15Resin filling: tooth 15
•• Root Root resorptionresorption: tooth 13, 14: tooth 13, 14
•• Attrition: tooth 31, 32Attrition: tooth 31, 32
Differential diagnosis
Differential diagnosis
Peripheral or
Peripheral or Intrabony Intrabony Origin Origin
• • Bone destruction (+) Bone destruction (+)
• • Mucosal lesion (+) Mucosal lesion (+)
Peripheral or
Peripheral or Intrabony Intrabony Origin Origin
Inflammation , Cyst , Neoplasm??
z
Fever (-)
z
Local heat (-)
z
Pus (-)
z
Fluctuation (-)
z
Long duration (1 year)
Neoplasm
Benign or Malignant Benign or Malignant
• Ulceration (+)
• Numbness (+)
• Bony destruction and loosened teeth
• Lack of normal healing
Malignant
Malignant
Working diagnosis Working diagnosis
• •
Adenoid cystic carcinomaAdenoid cystic carcinoma• •
MucoepidermoidMucoepidermoid carcinomacarcinoma• •
Polymorphous lowPolymorphous low--grade grade adenocarcinamaadenocarcinama• •
Salivary Salivary adenocarcinomaadenocarcinoma, not otherwise , not otherwise specified (NOS)specified (NOS)
• •
FibrosarcomaFibrosarcoma• •
NonNon--HodgkinHodgkin’’s lymphomas lymphoma• •
SquamousSquamous cell carcinomacell carcinoma• •
EwingEwing’’s Sarcomas SarcomaAdenoid cystic carcinoma Adenoid cystic carcinoma
• • High compatible High compatible
–– 50% in minor salivary glands, palate is most common50% in minor salivary glands, palate is most common –– MiddleMiddle--aged adultsaged adults
–– Facial nerve paralysisFacial nerve paralysis
–– Palatal tumor can be smooth or ulceratedPalatal tumor can be smooth or ulcerated
–– Bone destruction (arising in the palate or maxillary Bone destruction (arising in the palate or maxillary sinus)
sinus)
• • Low compatible Low compatible
–– Slight female predilection (some studies)Slight female predilection (some studies) –– PainPain
Mucoepidermoid
Mucoepidermoid carcinoma carcinoma
• • High compatible High compatible
–– Most common malignant salivary gland tumorMost common malignant salivary gland tumor –– Second to seventh decadeSecond to seventh decade
–– AsymptomaticAsymptomatic
–– Facial nerve palsyFacial nerve palsy –– PalatePalate
• • Low compatible Low compatible
–– Slight female predilectionSlight female predilection –– PainPain
Polymorphous low
Polymorphous low - - grade grade adenocarcinama adenocarcinama
• • High compatible High compatible
–– Painless massPainless mass
–– Upper lip and Upper lip and buccalbuccal mucosa being the next common mucosa being the next common location
location
–– Bleeding or Bleeding or discomfortablediscomfortable
–– Tumor can erode or infiltrate the underlying boneTumor can erode or infiltrate the underlying bone
• • Low compatible Low compatible
–– 2/3 in females2/3 in females
–– Common in older adults (7th to 8th decades)Common in older adults (7th to 8th decades) –– Long time with slow growthLong time with slow growth
Salivary
Salivary adenocarcinoma adenocarcinoma not not otherwise specified (NOS)
otherwise specified (NOS)
• • High compatible High compatible
–– Asymptomatic masses or facial never paralysisAsymptomatic masses or facial never paralysis
• • Low compatible Low compatible
–– Common in the parotid glandCommon in the parotid gland
Fibrosarcoma Fibrosarcoma
• • High compatible High compatible
–– May invade local soft tissuesMay invade local soft tissues
–– If involve the course of peripheral nerves, If involve the course of peripheral nerves, sensory
sensory--neural abnormalities may occurneural abnormalities may occur –– ErythematousErythematous or ulceratedor ulcerated
• • Low compatible Low compatible
–– Pain usuallyPain usually
Non Non - - Hodgkin Hodgkin ’ ’ s lymphoma s lymphoma
• • High compatible High compatible
–– NontenderNontender
–– BuccalBuccal vestibule, posterior hard palate, vestibule, posterior hard palate, gingivagingiva –– ParesthesiaParesthesia
–– IllIll--defined radiolucencydefined radiolucency –– ErythematousErythematous or purplishor purplish
• • Low compatible Low compatible
–– Develop in the oral soft tissue or centrally within jaw Develop in the oral soft tissue or centrally within jaw
Squamous
Squamous cell carcinoma cell carcinoma
• • High compatible High compatible
–– White or red irregular lesionsWhite or red irregular lesions
–– Infiltration into adjacent muscle or boneInfiltration into adjacent muscle or bone –– Grossly loosened teethGrossly loosened teeth
–– Males are more commonMales are more common –– Most older than 50 Most older than 50 y/oy/o
• • Low compatible Low compatible
–– Central ulcerationCentral ulceration
–– Rolled or Rolled or induratedindurated borderborder –– Pain Pain
Ewing
Ewing ’ ’ s Sarcoma s Sarcoma
• •
High compatible High compatible–– Irregular , ill-Irregular , ill-defined defined radiolucencyradiolucency bony destructionbony destruction –– Slight male predominanceSlight male predominance
–– Swelling is a common symptomSwelling is a common symptom –– ParesthesiaParesthesia
–– White or red irregular lesionsWhite or red irregular lesions
• •
Low compatibleLow compatible–– Mandible > MaxillaMandible > Maxilla –– Age < 20 y/oAge < 20 y/o (80%)(80%)
–– Onion skin may appear Onion skin may appear radiographicallyradiographically
Impression Impression
• • Adenoid cystic carcinoma, right Adenoid cystic carcinoma, right maxilla
maxilla
CT View CT View
•• There is a roughly 5.5x2.2x2.6 There is a roughly 5.5x2.2x2.6 cmcm33 heterogeneously heterogeneously
enhancing soft tissue mass enhancing soft tissue mass lesion in the right maxilla lesion in the right maxilla alveolar ridge extended to alveolar ridge extended to right maxillary sinus, right right maxillary sinus, right medial
medial pterygoidpterygoid muscle, the muscle, the right aspect of hard palate and right aspect of hard palate and nasal cavity.
nasal cavity.
•• The adjacent bony structure of The adjacent bony structure of maxilla, hard palate and the maxilla, hard palate and the pterygoid
pterygoid process of sphenoid process of sphenoid bone, the inferior aspect of bone, the inferior aspect of right orbital apex are eroded.
right orbital apex are eroded.
CT View CT View
•• The pharynx and larynx are free The pharynx and larynx are free of abnormal space
of abnormal space--occupying occupying lesion.
lesion.
•• There are also small visible lymph There are also small visible lymph nodes in
nodes in submentalsubmental and bilateral and bilateral submandibular
submandibular spaces (< 1 cm). spaces (< 1 cm).
•• The bilateral submandibularThe bilateral submandibular and and parotid glands are unremarkable.
parotid glands are unremarkable.
•• The airway is patent. The airway is patent.
•• The visible portions of orbits and The visible portions of orbits and mastoid air cells are unremarkable.
mastoid air cells are unremarkable.
•• The visible portions of brain The visible portions of brain parenchyma and bilateral lung parenchyma and bilateral lung apices are also unremarkable.
apices are also unremarkable.
•• There is space with water density There is space with water density fluid collection between bilateral fluid collection between bilateral lateral ventricles.
lateral ventricles.
CT View CT View
• •
Carcinoma in the right maxillary alveolar ridge Carcinoma in the right maxillary alveolar ridge with adjacent bony erosion and muscle invasion with adjacent bony erosion and muscle invasion(T4).
(T4).
• •
No definite regional enlarge lymph node (N0).No definite regional enlarge lymph node (N0).• •
Cancer stage: IV A (T4 N0 Cancer stage: IV A (T4 N0 MxMx).).• •
Suspect tumor extension along right Suspect tumor extension along right infratemporalinfratemporal fossafossa with right inferior orbital with right inferior orbital fissure invasion.
fissure invasion.
• •
Small visible lymph nodes in Small visible lymph nodes in submentalsubmental and and bilateralbilateral submandibularsubmandibular spaces (< 1 cm).spaces (< 1 cm).
