Case Report
報告者： Intern G 組 馮上于 王騮郴 唐松廉 張璨巖
指導醫師：陳玉昆主任 林立民教授 暨口腔病理科全體醫
師
General data
• Name : OOO
• Sex : Female
• Age : 64 y/o
• Marital status : Widow
• Native : 屏東
• Attending staff: OOO 醫師
• First visit : 2015/2/15
Chief Complaint
• Follow-up of swelling in right submandibular area
2016/01/09
Present Illness
• This 64-year-old female suffered from sud
den painful swelling in right submandibul
ar area in 2015/2. And she went to ENT cl
inic for help, the S/S didn‘t improve. I
n 2015/2/15, she came to ER of KMUH, the
S/S subsided after antibiotics control. I
n 2015/2/24, the swelling was subsided, b
ut the patient rejected extraction of the
stone under GA. In 2016/1/6, the patient
came back due to swelling over the left a
nd right submandibular areas. Op schedul
e was then arranged in 2016/01/12
Past History
• Past Medical History
• Systemic disease: DM, CVD
• Hospitalization ( ＋ ), Rt foot
• Surgery under GA: ( ＋ )
• Drug and food allergy: Denied
• Past Dental History
• General routine dental treatment
• Attitude to dental treatment: co-operative
Personal History
• Risk factor related to malignancy
• Alcohol drinking (-)
• Betel-quid chewing (-)
• Cigarette smoking (-)
• Denied any other dental oral habits
OMF Examination
• MMO: 54 mm
• Site: left and right mouth floor
• Size: Rt:0.5 x 0.4 cm
Lt: 0.4 x 0.3 cm
• Shape: oval
• Color : white and red
• Surface: smooth
• Mobility: movable
• Induration : -
• Consistency : rubbery
• Submandibular LAP: (+)
2016/01/09
2016/01/09
Panorex film(2016/1/4)
There is a well-defined oval shaped homogeneous radioluopacity without
corticated margin over right submandibular region, measuring approximately 0.5×0.4 cm in diameter. The density of radioluopaque is bone-like and not affects surrounding tissue.
-Missing: Tooth 11, 12, 13, 14, 17, 18, 21, 22, 24, 25, 26, 27, 28, 35, 36, 38, 45, 46, 47, 48
-Crown: Tooth 43
-residual root: Tooth 15, 23, 34
-Impaction: Nil
Occlusal film(2016/1/4)
There are several well-defined oval-shaped radioluopacities without corticated margin over right submandibular region, lingual side to mandible body, measuring approximately 0.5×0.4 cm to 0.1x0.1 cm in diameter. The density of radioluopaque is bone-like and not affects
surrounding tissue.
CT finding (2015/02/15)
Inflammation?
Cyst or neoplasm?
Benign or malignant?
Benign or malignant?
Working diagnosis
Inflammation, cyst, or neoplasm ？
Our case Inflammatio
n Cyst Neoplasm
Color Red Red Normal Variable
Fever - + - -
Consistency Rubbery Rubbery Intrabony : hard
Peripheral : Soft Variable
Shape Regular Irregular Regular Irregular
Discharge + + - +/-
Pain + + - +/-
Ulceration - - - +/-
Mobility movable Fixed Intrabony : fixed Peripheral : Fluctuation
Fixed
Duration ??? Days Years Months
Benign or Malignant ?
Our case Benign Malignant
Border Clear Clear Unclear
Surface Smooth Smooth Rough,
smooth
Ulceration - - +/-
Induration - - +
Pain + - +/-
Metastasis - - +/-
Mobility Movable Movable/fix ed
Fixed Duration ??? Years/Mont
hs Months
Intrabony or peripheral ？
→ Our case is a
Our case Intrabony Peripheral Bone
expansion
- + -
Bony destructio
n
- + -
Consistenc
y Rubbery Hard Soft, firm,
rubbery…
Peripheral imflammation or Benign
peripheral cyst
Working diagnosis
Sialoliths, right submandibular gland
Calcified lymph nodes, right submandibular gland area
Calcified atherosclerotic plaques, right submandibular gland a rea
Myositis ossificans, right submandibular gland area
Phleboliths, right submandibular gland area
WORKING DIAGNOSIS
Most possible
Least possible
Differential diagnosis
Sialoliths
Our case Sialoliths
Gender Female N/P
Age 64 y/o N/P
Site Bilateral submandibular area most often develop within the ductal system of the submandibular
gland V
S/S Pain (+) Tenderness(+) Pus discharge(+)
episodic pain or swelling of the affected gland, especially at
mealtime V
Size 0.5 x 0.4 cm to 0.1 x 0.1 cm < 1 cm V
Duration ??? Slow
Other features
Rubbery swelling Swelling of the affected gland V Homogeneous RO RO (homogeneous or with a
laminated structure) V
Calcified lymph nodes
Our case Calcified lymph nodes
Gender Female N/P
Age 64 y/o N/P
Site Bilateral submandibular area Submandibular and superficial and deep cervical nodes (most
common) V
S/S Pain (+) Tenderness(+)
Pus discharge(+) No S/S V
Size 0.5 x 0.4 cm to 0.1 x 0.1 cm Varies
Duration ??? Slow
Other features
Rubbery swelling hard, lumpy, round to oblong masses.
Homogeneous RO Usually both RO and RL with mottled and irregular borders
Calcified atherosclerotic plaques
Our case Calcified
atherosclerotic plaques
Gender Female Male
Age 64 y/o
men in their 40s and women in their 50s to 60s.
V
Site Bilateral submandibular area
common carotid : more laterally
facial artery :simulate V S/S Pain(+) Tenderness(+)
Pus discharge(+) asymptomatic Size 0.5 x 0.4 cm to 0.1
x 0.1 cm Variable V
Duration ??? Slow
Clinical features
DM(+) DM(+) V
Tobacco(-) Tobacco(+)
Smoking(-) Smoking(+)
Myositis ossificans
Our case Myositis
ossificans
Gender female none V
Age 64 y/o young adults X
Site Bilateral submandibular area
masseter (most common) temporalis medial and lateral
pterygoid
V
S/S Pain(+) Tenderness(+)
Pus discharge(+) Painful swelling
tender V
Size 0.5 x 0.4 cm to 0.1
x 0.1 cm Variable V
Duration ??? Slow
Clinical features
Trismus(-) Trismus(+)
Trauma(?) Trauma(+)
Phleboliths
Our case Phleboliths
Gender female N/P
Age 64 y/o N/P
Site Bilateral submandibular area most commonly are found in
hemangiomas V
S/S Pain(+) Tenderness(+)
Pus discharge(+) No S/S
Size 0.5 x 0.4 cm to 0.1 x 0.1 cm varies
Duration ??? slow
Other features
Rubbery swelling swollen, throbbing, or discolored by the presence of veins or a soft tissue
hemangioma V
Homogeneous RO bull’s-eye or “target” appearance X
Clinical impression
• Sialolithiasis of left and right submadibular g land
• Sialadenitis of left and right sublingual gland
Treatment cours
e
Treatment course
2015/2/15-KMUH ER
• Sudden painful swelling in right submandibular area
• Arranged appointment to OS dept.
2015/2/17
• Swelling in mouth floor, pus discharge(+)
• CT report : 七顆結石 over R't mouth floor
Treatment course
2015/2/24
• Swelling was subsided, but patie nt reject extract stone under GA 2016/1/6
• Follow-up of swelling in right s ubmandibular area
• Swelling on left and right mouth floor
• Occlusal film shows several radi oopaue over submanbular area
• Op schedule arranged on 2016/01/
12 for excision
2016/01/09
2016/01/09
2016/01/04
Panorex film(2016/1/4)
Image finding – Chest PA(2016/
1/5)
Image finding – EKG(2014/12 /05)
• EKG Diagnosis:
• ■ VPCs ( bigeminy, r/o RVOT origin )
• ■ LAE
Treatment Plan
• Excision (105/01/12)
Post-operation
Pathologic diagnosis
• Salivary gland, submandibular, right, excision, sialolith
• Salivary gland, submandibular, left, excision, sialolith
Discussion
introduction
1. most patients present with a single stone
2. Lustmann found that of 302 sialoliths studied, 7 9.8 per cent were 1 cm or less and only 7.6 per c ent greater than 1.5 cm
submandibular gland
system 80~90%
parotid gland 10~20%
sublingual gland 1%
case report
submandibular gland
1. viscous mucus
2. more alkaline pH
3. ascending course
4. narrow orifice
1. 94.7% detected by using intra-oral radiology alo ne(Lustmann)
2. 20% unseen(Blatt)
sialography 1. rarely indicated
2. suspected ductal stricture and obstruction without
calcification
ultrasound unnecessary
computed tomography
magnetic resonance
sialography.
moist heat
intake of fluids sialagogues
gentle massage
intraglandular sialoliths generally require removal of the gland
1. lingual n.
2. hypoglossal n.
3. haemorrhage
sialendoscopy
wire-basket 4mm fiberoptic laser lithotripsy
differential diagnosis
Mandibular torus
Osteoma continuous, no pain
Calcified lymph nodes
Phleboliths and other vascular calcifications variocity Tuberculosis of lymph nodes or of the salivary gland
itself
Calcified atherosclerotic plaques in major blood vessels
Myositis ossificans trismus
Metastasis from distinct calcifying neoplasms
醫學倫理討論
醫學倫理
• 生命的神聖性 (Sanctity of life)
• 六大原則
生命的神聖性 (Sanctity of li fe)
• 起源
• 生命應該是相對的，每個生靈都該是平等的，沒有所謂
的低賤與高貴之分，所以彼此是要相互尊重，不可被輕
視的。
Tom Beauchamp &James Childress 六大原則 1979
1. 行善原則 (Beneficence) ：醫師要盡其所能延長病人之生命且減輕 病人之痛苦。 >>>>> ( in our case ˇ?)
2. 誠信原則 (Veractity): 醫師對其病人有「以誠信相對待」的義務。
>>>>> ( in our case ˇ)
3. 自主原則 (Autonomy): 病患對其己身之診療決定的自主權必須得到 醫師的尊重。 >>>>> ( in our case ˇ)
4. 不傷害原則 (Nonmaleficence): 醫師要盡其所能避免病人承受不必 要的身心傷害。 >>>>> ( in our case ˇ)
5. 保密原則 (Confidentiality): 醫師對病人的病情負有保密的責任。
>>>>> ( in our case ˇ?)
6. 公義原則 (Justice): 醫師在面對有限的醫療資源時，應以社會公 平、正義的考量來協助合理分配此醫療資源給真正最需要它的人。
>>>>> ( in our case ˇ)
