報告組別：Intern E組 報告日期：102 / 01 / 25
指導醫師：林立民醫師、陳玉昆醫師、
王文岑醫師、陳靜怡醫師 組員：高巧宜、鄭賀夫、謝奇峰、沈恆瑋
General data
Name : XXXX
Chart no.: XXXXXXXX
Sex : Female
Age : 62
Marital status : 已婚
Attending V.S. : XXX醫師
First visit : XX/XX/2009
Chief Complaint
-101.11.26-
Swelling and tenderness over L’t submandibular area for 2 months
Present Illness
98/04/13: This 65 y/o female p’t suffered from a mass over anterior maxillary mucobuccal
fold due to improper denture, and she came to OPD for examination and biopsy.
( H-P : Mucoepidermoid carcinoma over maxillary anterior area, high grade)
Arranged OP on 98/05/29.
Regular follow up on 98/06/08 ~ 101/11/19
A Swelling and tenderness over L’t submandibular area for 2 months on 101/11/26
Past medical History
1.
Underlying disease :
HTN(+), DM(+) with medication control
2.
Denied any food or drug allergies
3.
Hospitalization (+) :
- R’t leg varicose vein (09/2010)
- Surgery for uterus myoma (10+ yrs ago),
- Oral Mucoepidermoid Ca (05/27/2009)
- Left knee fracture s/p OP
4.
Family history : denied
Past dental History
1.
Routine dental procedures
2.
Attitude to dental treatment : Cooperative
Personal History
Risk factors related to malignancy
Alcohol： (-)
Betel quid: (-)
Cigarette: (-)
Special oral habits : Denied
Bite irritation: Denied
Extraoral finding
Size：5.5 x 5 cm
Color：Normal
Surface：Normal
Tenderness：(+)
Pain : (+) throbbing pain
Induration : (+)
Consistency : Firm
Mobility : Fixed
Shape : Dome
Intraoral finding
No evidence of intra-oral tumor recurrence
Image finding- panorex 101.12.24
17
43 33
Image finding- panorex
98.05.04
Image finding- panorex
98.07.02
Image finding- panorex
98.09.17
Dental finding
Upper and lower arch with RPD
Missing teeth：
Retained abutment：
Previously endo treated：
Post and core：
Crown：
8 654321
12345678 67854 21 12
45678 7
3 3
7 3 3 7
3 3 7
3 3
Image finding- C T
Peripheral or intrabony ?
5.5 x 5cm, firm consistency, smooth surface, dome shape, normal color, fixed
Pain(+)、Tenderness(+)
No bony lesion & destruction
→ peripheral lesion
Peripheral or intrabony ?
Our case peripheral Intrabony Mucosal
lesion
+ + -
Bony
expansion
- - + / -
Cortical bone
destruction
- - + / -
→ Peripheral
Inflammation,cyst,neoplas m?
Our case Inflammation
Redness - +
Swelling + +
Local heat - +
Pain + +
Our case cyst
Fluctuation - + / -
Well + defined border
Unknown +
A mass of no local heat, firm consistency
→ neoplasm
Benign or Malignancy?
Our case Benign Malignancy
progressive 2 months Slow fast
Swelling with intact epi.
+ + -
Pain + - +
Induration + - +
lymphadenopathy Unknown - +
Malignancy
Working diagnosis
Mucoepidermoid carcinoma
Polymorphous low grade adenocarcinoma
Adenoid cystic carcinoma
Acinic cell adenocarcinoma
Mucoepidermoid carcinoma
Our case Mucoepidermoid carcinoma
Gender female Slight male
Age 62 20~70
Site L’t submandibular area Parotid gland, minor gland
Lower lip, floor of mouth, tongue, retromolar pad areas
Pain + Early stage: -
Swelling + +
Drainage - -
Shape Smooth, dome shape firm or hard
Duration 2 months slow
Polymorphous low grade adenocarcinoma
Our case PLGA
Gender Female 2/3 female
Age 62 60~90
Site L’t submandibular
area,subcutaneous Hard or soft palate
Pain + -
Ulcer - + / -
Duration 2 month Slow, indolent
Consistency Firm Firm
Shape Dome, smooth
Feature N/P Infiltrate the underlying bone
Adenoid cystic carcinoma
Our case Acinic cell carcinoma
Gender Female Equal
Age 62 Middle age adult
Site L’t submandibular area, subcutaneous
Minor salivary gland ( esp. palate)
pain + +
swelling + +
drainage - -
Numbness - + (if parotid gland)
Shape Smooth, dome shape Smooth surface
Duration unknown slow
Acinic cell adenocarcinoma
Our case Acinic cell adenocarcinoma
Gender Female Female
Age 62 40
Site L’t submandibular area,
subcutaneous Parotid gland
pain + -
swelling + +
drainage - -
Numbness - -
Shape Smooth, dome shape Smooth surface
Duration unknown slow
Clinical impression
Mucoepidermoid carcinoma over left
neck and submandibular border.
• 101 / 11 / 26
– Swelling & tenderness over L’t submandibular area
– Firm and smooth surface, dome shape,
induration(+), painful, size about 5.5 x 5 cm – Needle incisional biopsy was performed
– H-P exam
• 101 / 11 / 27
– H-P report
– Pathologic diagnosis : Oral cavity, subcutaneous , left, needle biopsy ,
mucoepidermoid carcinoma, high grade – Arranged CT scan and bone scan
– Arranged OP on 102 / 01 / 03
• 102 / 01 / 01
【Treatment plan】– Pre-operation
Consult anesthesia dept. and ENT dept.
Full mouth scaling
Require p’t NPO since midnight the day before surgery
– Operation
Wide excision + L’t radial neck dissection
– Post-operation
Oral irrigation and wound care
Check laboratory data
Oral hygiene instruction and reinforcement
Keep f/u in OPD after discharged
• 102 / 01 / 03
– Wide excision + L’t mandibular border
marginal resection + L’t radial neck dissection were performed with sacrificing SCM muscle, accessory nerve, internal jugular vein and
partial masseteric muscle
– Place a 7 mm Jackson prett over L’t neck via a stab incision
• 102 / 01 / 11
– Aseptic procedure and draping as OMS routine
– Prophylactic antibiotic：Cefazolin(1g) 1 vial + Aq-dest 20ml IV was injected
– Chylo fluid was noted as opening the neck wound
– Irrigation with N/S was performed
– Debridement and surgical packing was performed
• 102 / 01 / 17
– Aspiration of L't submandibular area and
28ml fluid was collected, then sent culture for H-P report.
– Placed another J-P tube over L't submandibular area under LA.
– BI gauze packing and elastic adhesive bandage application.
– Keep close f/u the wound condition, vital sign and general condition.
• 102 / 01 / 18 ~ 102 / 01 / 24
– Intraoral irrigation with N/S
– Generalized condition：stable
– Kept close f/u the wound condition, vital sign and general condition
Mucoepidermoid carcinoma
Etiology and pathogenesis
One of the most common salivary gland malignancies
If intra-bony lesion, may be changed from dentigerous cyst
Mucoepidermoid carcinoma
Major clinical features
No sex tendency
Wide age range (2nd-7th decades)
Most common salivary gland malignant tumor in children
Parotid gland > minor gland (palate)
Asymptomatic swelling
Sometimes blue or red color
Sometimes fluctuate
Mucoepidermoid carcinoma
Mucoepidermoid carcinoma
Histopathology features
Mucous cell
○ Foamy cytoplasm, mucin stain (+)
Epidermoid cell
○ Like squamous cell, obvious intercellular bridge
Intermediate cell
○ Like basal cell, small, round
Mucoepidermoid carcinoma
Low grade
Mucoepidermoid carcinoma
high grade
Mucoepidermoid carcinoma
Histopathologic grades
– Amount of cyst formation – Degree of cytologic atypia – Relative number of
mucous, epidermoid, and intermediate cell
Low grade:
Prominent cyst formation, minimal cellular
atypia, relatively high porportion of mucous cell High grade:
Solid island of squamous and intermediate cells, considerable pleomorphism and mitotic activity, difficult to distinguish from SCC
Mucoepidermoid carcinoma
Treatment and prognosis
Surgical excision (subtotal or total removal)
○ Location
○ Histopathologic grade
○ Clinical stage(radiation therapy may be needed)
Prognosis depends
○ Low grade: 90-98% cured
○ High grade: 30-54% surviving
○ Parotid gland > minor gland > submandibular gland >
Tongue and mouth floor
醫學倫理與病人安全
• 醫學倫理：一種道德思考、判斷和決策，以
倫理學的觀點出發，以期能做出對病人最有 利益、最能符合道德倫理規範的醫療決策
• 醫病關係的轉變：醫師中心模式轉變為病人
中心模式
• physician-centered model → patientcentered model
醫學倫理原則
由Tom Beauchamp & James Childress在1979 提出
自主原則(Autonomy)
不傷害原則(Non-maleficence)
行善原則(Beneficence)
公義原則(Justice)
自主原則(Autonomy)
原則：一位具理性思考能力的病人，在完全瞭
解醫療處置方針的利弊得失下，有權決定自己 的行為，包括決定及選擇醫療專業人員和治療 方式
臨床意義
• 病人之自主行為不應遭受他人之操控或干預
• 指醫療人員應提供充分且適當之資訊，以促成病人
針對診療方式主動作出抉擇
不傷害原則 (Non-maleficence)
源自希波克拉底之醫師誓約，即醫師之職責：「
最首要的是不傷害」
原則：
• 不殺害病人、不能侵害病人權益和福祉以及平衡利害
得失，使痛苦減到最低
臨床意義
• 醫療上是必須的，或是屬於醫療適應症範圍，因所施
行的各種檢查或治療而帶來的傷害應符合不傷害原則
• 權衡利害原則 → 兩害相權取其輕
• 保護病人的生命安全
行善原則(Beneficence)
• 原則：
– 不傷害原則的反面義務(不應該做的事)
– 確有助益的正面義務(應該做的事)
– 維護和促進病人的健康、利益和福祉，為基本
倫理原則，也是醫護人員的基本義務
• 臨床意義
– 勿施傷害：不得故意對他人施予傷害或惡行
– 預防傷害：應該預防傷害或惡行
– 移除傷害：應該移除傷害或惡行
– 維持善行：應該致力於行事或維持善行
公義原則(Justice)
原則：強調資源合理分配、賞罰分明以及合
乎正義之事。醫療上公平原則指基於正義與 公道，以公平合理的態度來對待病人、病人 家屬和受影響的社會大眾
臨床意義
公平地分配不足的資源
尊重病人的基本權利
尊重道德允許的法律，法律之前人人平等
先來先服務與急重症優先
臨床案例討論
35歲鄭女士於今年12月時因牙齒疼痛難 耐而前住大同牙科治療，當下牙醫師的診 斷為38 impaction，並安排時間拔除38，
術後幾天鄭女士持續感到臉頰有麻木感，
而且拔牙傷口沒辦法癒合並出現異味且相
當疼痛
麻藥使用
• 局部麻醉劑過量
– 一般來說，牙科用的麻醉藥為1.8ml/管 ，通常一次可 以打到8管以上都不成問題(看體重) 正常的牙科治療 大都在3管以內
• 血管收縮劑過量
– 通常局部麻醉藥裡頭含有(正)腎上腺素，有血管收縮
、降低局部末端出血量的功用 但如果總量過高，或是 打入到血管內 常有心跳加速、暈眩的副作用 ，有心 血管疾病或甲狀腺問題的病人宜少用 可以選擇低濃度 (或不含)血管收縮劑的麻藥使用
• 過敏反應
– 通常是對麻醉劑過敏(幾乎不會對血管收縮劑過敏) 症 狀有皮膚發癢、喉嚨腫脹、呼吸困難、眼鼻分泌物增 加等等
拔牙風險
一般性併發症
(1) 傷口出血(2) 傷口疼痛(3) 傷口腫脹(4) 拔
牙處對應皮膚瘀青(5) 傷口感染或癒合不良
(6) 局部或全身麻醉風險(7) 因併發症或處置
效果不如預期，必要時需再度處置。(8) 必
要時輸血導致之不適感或感染風險(如愛滋
病、肝炎等…)
拔牙風險
特殊性併發症
(1)牙根斷裂(2)乾性齒槽炎(3)鄰牙牙根暴露引發之酸痛(4) 傷害鄰牙牙周組織(5)牙齒異位(6)口鼻竇相通及鼻竇炎(7) 下顎齒槽神經或舌神經傷害，導致暫時或永久性下唇或 舌部麻木感(8)顎骨留下牙根斷片，難以取出或取出時易 造成其它後遺症。(9)造成鄰牙或其補綴物、矯正裝置鬆 脫、斷裂、喪失。(10) 鄰近軟組織撕裂傷(11)開口困難 (12)拔除牙誤吞入食道或氣管(13)臉部皮膚瘀青(14)暫時 或永久顳顎關節不適感(15)拔牙後一段時間齒槽骨窩吸收 不均，導致尖銳骨片形成，可能需再度手術修整骨頭。
(16)下顎骨斷裂(17)長期之骨內疼痛(18) 顎骨骨髓炎、顎 骨壞死、蜂窩性組織炎、壞死性筋膜炎(19)全身性感染或 敗血症(20) 術中大出血
此案例違背了哪些原則?
自主原則：
醫師並未善盡告知使用麻藥的風險、拔牙的
風險的責任
此案例違背了哪些原則?
不傷害原則：
醫師並未做好術前評估，包括病人系統性疾
病、血壓高低、是否有麻藥過敏的可能性
醫師馬上讓病人返家，未告知拔牙後的注意
事項
行善原則(預防傷害)：
術中病人感到身體不適，如有做好術前評估
，應可避免傷害發生
總結
各項治療切勿躁進，要在病人了解且同意
之下再進行侵入性治療才不會造成日後的 糾紛
