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
HISTORY OF PRESENT ILLNESS
OB Hx
• 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
13 years PTA
• Noted by the attending physician to have enlarged tongue. • No medications given, no further consultation advised. • (-) Difficulty feeding, dyspnea, snoring
12 years PTA
• 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.
HISTORY OF PRESENT ILLNESS
1 year PTA • Sought consult w/ ENT in Cebu
Interval history (1997-2007)
• (+) 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.
3 years PTA
• Persistence of symptoms led to consult with a private ENT in Davao
HISTORY OF PRESENT ILLNESS
1 month PTA • (+) consult at a government
hospital. • Opted to transfer to our institution
at ENT-OPD.
ADMISSION
2 months PTA
• (+) 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.
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
PAST MEDICAL HISTORY (-) allergies (-)PTB (-) hepatitis (-) asthma (-) previous surgeries and blood
transfusions
MENSTRUAL AND OBSTETRIC HISTORY Menarche – 12 y/o Irregular period Duration: 4-5 days Amount: 5 pads/day Symptoms – dysmenorrhea
FAMILY HISTORY (-) HPN (-) DM (-) Asthma (-) PTB (-) Ca (-) Down’s Syndrome
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
PHYSICAL EXAMINATION Weight – 39 kg Height – 144 cm BMI – 20 BP – 100/70 PR – 84 bpm RR – 22c pm T – 36.7
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
PHYSICAL EXAMINATION Symmetric chest expansion, clear
breath sounds Adynamic precordium, AB at 5th LICS
MCL, no murmurs, no thrills Flat abdomen, NABS, soft, nontender Full and equal pulses, no swelling, no
edema SMR = 3
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
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
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
SALIENT FEATURESSubjective Objective 13 y/o
Bleeding
Pain
Enlarged tongue since birth
(+) 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
WHAT IS YOUR IMPRESSION OF THE CASE?
Guide Question 1
Macroglossia Secondary toLymphangioma of the Tongue
MACROGLOSSIA large tongue or a tongue that protrudes
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
LYMPHANGIOMA Lymphangioma is a benign,
harmatomatous tumour 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
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.
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.
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
WHAT LABORATORY EXAMS WOULD YOU RECOMMEND?
Guide Question 2
Biopsy of the TongueThyroid assays
Imaging Studies: CT Scan, MRI of the Head & Neck
Biopsy of the tongue Thyroid function test – to rule out
hypothyroidism Imaging Studies – to determine extent
of lesion and pre-operative planningCT ScanMRI – test of choice
HISTOLOGIC FINDINGS IN BIOPSY OF THE TONGUE
WHAT WILL BE SUGGESTED TREATMENT?
Guide Question 3
Tongue Resection and Reconstruction
PUT YOUR DISCUSSION No proven medical care for
lymphangiomas exists. This condition is not responsive to radiation therapy or steroids.