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CASE 2: ENT

CASE 2: ENT. General Data. J.Y. 13 y/o Female Single Filipino Roman Catholic from Butuan City, Agusan del Norte. Chief Complaint. Enlarged tongue. Px born to a 23 y/o primigravid via NSD at a tertiary hospital

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CASE 2: ENT

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  1. CASE 2: ENT

  2. General Data • J.Y. • 13 y/o Female • Single • Filipino • Roman Catholic • from Butuan City, Agusan del Norte

  3. Chief Complaint • Enlarged tongue

  4. Px born to a 23 y/o primigravid via NSD at a tertiary hospital • (+) prenatal check-up, denies any exposure to radiation/ intake of teratogenic drugs • Admitted at a local hospital due to swelling and bleeding of tongue. • Given unrecalled antibiotics. • Advised to transfer to another hospital but px did not comply due to lack of funds. • Mother noted spontaneous resolution of tongue swelling. • Noted by the attending physician to have enlarged tongue. • No medications given, no further consultation advised. • (-) Difficulty feeding, dyspnea, snoring History of Present Illness • OB Hx • 12 years PTA • 13 years PTA

  5. Persistence of symptoms led to consult with a private ENT in Davao • (+) progressive enlargement of the tongue • (+) episodes of bleeding and swelling of the tongue 3-4x/ year. • Px would seek consult with MD and unrecalled antibiotics were given. History of Present Illness • 3 years PTA • Interval history (1997-2007)

  6. (+) persistent bleeding and swelling of tongue • (+) pain on the anterior 1/3 of the tongue. • Can only tolerate minced and soft foods. • Noted to be pale and weak by the mother. History of Present Illness • 2 months PTA ADMISSION

  7. Review of Systems • (-) weight loss • (-) skin rashes, changes in pigmentation • (-)blurring of vision, headache • (-) decreased hearing sensation, tinnitus, dizziness • (-)cough and colds, chest pains, palpitations • (-)abdominal pain, changes in bowel/bladder function • (-)edema, joint pains, muscle pains

  8. Past Medical History • (-) allergies • (-)PTB • (-) hepatitis • (-) asthma • (-) previous surgeries and blood transfusions

  9. Menstrual and Obstetric History • Menarche – 12 y/o • Irregular period • Duration: 4-5 days • Amount: 5 pads/day • Symptoms – dysmenorrhea

  10. Family History • (-) HPN • (-) DM • (-) Asthma • (-) PTB • (-) Ca • (-) Down’s Syndrome

  11. Personal and Social History • H – has good relations with other family members and persons at home • E – 1st year high school, average student • A – enjoys watching TV and DVD • D – no hx of illicit drug use, smoking, intake of alcoholic beverages • S – has few friends, rarely goes out • S – no sexual activity

  12. Physical Examination • Weight – 39 kg • Height – 144 cm • BMI – 20 • BP – 100/70 • PR – 84 bpm • RR – 22c pm • T – 36.7

  13. Physical Examination • Height for age – normal; Z score below -1 • BMI for age – normal; Z score 0 (median) • Conscious, coherent, ambulatory, not in cardiorespiratory distress • Warm moist skin, no rashes • Anicteric sclera, pink palpebral conjunctivae

  14. Physical Examination • Symmetric chest expansion, clear breath sounds • Adynamicprecordium, AB at 5th LICS MCL, no murmurs, no thrills • Flat abdomen, NABS, soft, nontender • Full and equal pulses, no swelling, no edema • SMR = 3

  15. ENT Examination • Anterior rhinoscopy: midline septum, turbinates not congested, no nasal polyps • Oral cavity: (+) enlarged reddened tongue; (+) multifocal, pebbly, vesicle like lesions on the tip, dorsal and lateral surfaces of the anterior 1/3 of the tongue; (+) blood clots on dorsal and ventral surface of anterior 1/3 of tongue; moist buccal mucosa

  16. ENT Examination • Pharynx – nonhyperemic posterior pharyngeal wall, tonsils not enlarged • Otology: AD – no tragal tenderness, nonhyperemic EAC, intact TM; AS – no tragal tenderness, nonhyperemic EAC, intact TM • Face and neck: no facial asymmetry, neck masses, thyromegaly, palplable lymph nodes

  17. Neurologic Examination • conscious, coherent, oriented to 3 spheres; • pupil 2-3 mm ERTL, EOMs full and equal • can clench teeth, can raise eyebrows, can close eyes tightly, can smile, can frown • no hearing loss, limited side to side head turning, tongue midline on protrusion • can do FTNT and APST • MMT 5/5 on all extremities • DTR ++ on all extremeties • no sensory deficits

  18. Salient Features

  19. MacroglossiaSecondary to Lymphangiomaof the Tongue Guide Question 1 What is your impression of the case?

  20. MACROGLOSSIA • large tongue or a tongue thatprotrudes beyond the teeth or alveolar ridge • most common cause of macroglossia is lymphangioma • Presents as tongue protrusion, which exposes the tongue to trauma. • Other symptoms include speech impediment, swallowing difficulties, airway obstruction, drooling, and failure to thrive. http://www.bcm.edu/oto/grand/52892.html

  21. LYMPHANGIOMA • Lymphangioma is a benign, harmatomatoustumour  of lymphatic vessels with a marked predilection for the head and neck region . • the lesions present superficially as a pebbly, vesicle-like feature with so-called ‘frog-egg’ or ‘tapioca-pudding’ appearance • equal sex incidence among males and females. • The lesions can become evident at any age but they usually appear in infancy

  22. most common presentation is a soft, painless mass that may enlarge with time and Hemorrhage into the lesion can also cause sudden enlargement. • The second and third most common presenting symptoms are respiratory obstruction and problems with feeding and failure to thrive. • Grossly, the lesions are ill-defined, diffuse, and spongy, having indiscrete margins. Often, it is actually much larger than it appears to be.

  23. Physical exam demonstrates a soft, painless compressible mass often described as being doughy on palpation. • Superficial tumors may be pink to reddish blue, while deeper lesions may show no surface changes or have stretched and atrophic skin. • Regional lymph nodes are either normal or hyperplastic. • Usually these lesions are asymptomatic and patients merely have a cosmetic deformity. Pain is not common unless infection is present.

  24. not a fatal disease. • 3% mortality rate which are usually due to bronchospasm, atelectasis, or airway compromise from edema. • There is no risk of malignant transformation. • The growth rate is variable but most lesions tend to progress slowly

  25. Biopsy of the Tongue Thyroid assays Imaging Studies: CT Scan, MRI of the Head & Neck Guide Question 2 What laboratory exams would you recommend?

  26. Biopsy of the tongue • Thyroid function test – to rule out hypothyroidism • Imaging Studies – to determine extent of lesion and pre-operative planning • CT Scan • MRI – test of choice

  27. Histologic Findings in Biopsy of the Tongue

  28. Tongue Resection and Reconstruction Guide Question 3 What will be suggested treatment?

  29. PUT YOUR DISCUSSION • No proven medical care for lymphangiomasexists. This condition is not responsive to radiation therapy or steroids.

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