CASE PRESENTATION. Dr Mrudula 2 nd year PG Dept. Of E.N.T.

Transcription

1 CASE PRESENTATION Dr Mrudula 2 nd year PG Dept. Of E.N.T.

2 Name : XXX Age: 47 yrs Sex : Male Occupation : Agricultural labour Date of reporting: 12/08/2017

3 Chief complaint: Non healing ulcer on right side of tongue since 6 months History of present illness: Patient was apparently asymptomatic 6 months ago, when he noticed an ulcer on right side of tongue, which was insidious in onset, increasing in size to attain the present size. Associated with pain which was pricking in nature, continuous, aggravated during consumption of hot or spicy food, relieved with analgesics.

4 No complaints of restriction in movement of tongue, no c/o change in voice, no c/o foul breath No c/o excessive salivation No history of fever. No h/o dental injury He is a known case of pulmonary TB, and is on ATT since 5 months.

5 No c/o ear pain, no c/o decreased hearing or aural fullness. No c/o nasal obstruction, bleeding from nose, no c/o headache, facial pain No other associated complaints

6 Past history: Not a known case of hypertension, diabetes, bronchial asthma, epilepsy. No past ENT surgeries Personal history: Consumes mixed diet, bowel and bladder habits are regular, sleep is undisturbed while appetite is decreased since 5 months. h/o loss of 7kgs in past 6 months He smokes beedi- 20 per day since 25 years. No h/o drug abuse

7 Family history: No similar complaints Drug history: ATT since 5 months, he was receiving medication for pain from local medical centres

8 General physical examination Patient was conscious, coherent and cooperative, moderately built & nourished. Pulse rate :-88/min BP :- 120/80 mm of Hg No Pallor, no Icterus, no Cyanosis, no Clubbing, no Pedal edema, no Generalised Lymphadenopathy

9 Local examination of oral cavity Inspection : An ulceroproliferative growth of size 2cmX1.5cm present along right ventral surface of tongue,3.5cm posterior to tip of tongue on right, 4cm anterior to posterior end of ventral surface.

10 Palpation : inspection findings confirmed. Lesion is firm in consistency with indurated margins, tender, not bleeding on touch.

11 No trismus Remaining anterior 2/3 rd of tongue: normal Buccal mucosa: hyper pigmented Teeth: plaques and nicotine pigmentation present Hard palate: normal Lips: normal Gums: normal Gingivolabial, gingivolingual, gingivobuccal sulci: normal Retromolar trigone: normal

12 OROPHAYRNX and LARYNX: Anterior pillar: Normal Posterior pillar: Normal Posterior pharyngeal wall: Normal Soft palate :Normal Uvula: Normal Visible part of posterior 1/3 of tongue: Normal Indirect laryngoscopy: normal

13 On examination of neck: No palpable lymph nodes Laryngeal crepitus present No other swellings in neck

14 O/E of nose: External framework: normal Columella: normal Vestibule : normal 0n Anterior Rhinoscopy: Deviated nasal septum to right with caudal dislocation to left Turbintes: normal Roof : normal Floor : normal Mucosa: normal Posterior rhinoscopy: normal

15 o/e of Ears Right ear Pinna:Normal Preauricular area: Normal Post auricular area: Normal External auditory canal: clear Tympanic membrane: intact. Left ear Pinna:Normal Preauricular area: Normal Post auricular area: Normal External auditory canal: clear Tympanic membrane: intact.

16 Examination of PNS: normal Cranial nerve examination: normal

17 Provisional diagnosis Non healing ulcer tongue, probably malignant Differential diagnosis: Erythroplakia Tubercular granuloma Dental ulcer Verrucous lesion Plan of treatment: Biopsy under local anesthesia and proceed

18 Blood investigations Complete Blood Picture : Hb% : gm% TLC : cu.mm Neutrophils :- 50% Lymphocytes :- 42% Eosinophils :- 04% Monocytes :- 04% Basophils :- 0% Platelet count : lakhs /cu mm Smear :- Normocytic /Normochromic

19 Blood group :- O Rh typing :- POSITIVE Bleeding time : 2 mins 30sec Clotting time :4 mins 00sec Serum electrolytes: Sodium :- 139mmol/L Potasium:- 3.7mmol/L Chloride:- 101 mmol/l RBS :- 92mg/dl Serum Creatinine :- 1.01mg /dl Serum Uric acid : mg/dl Urea : 26.4%

20 Complete Urine Examination: Normal SEROLOGY: HBsAg:- Non reactive HIV :- Non Reactive ECG :- Normal Chest X Ray :- chronic bronchitis changes Sputum for AFB: negative

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22 CECT

23

24 Investigations Wedge biopsy done under local anesthesia Squamous cell carcinoma of Tongue: Well differentiated

25 Biopsy

26 Diagnosis and staging Well differentiated Squamous cell Carcinoma tongue T1N0M0

27 SURGERY DONE ON 31/08/2017 Surgery plan: Wide local resection of ulcer tongue with selective neck dissection (levels 1-3) Position :after GA, patient was placed in supine position with extension of neck Under aseptic condition, patients painted and draped. Incision : Right upper Mc Afee Sub platysmal flaps elevated.

28 Dissection done along anterior border of sternocleidomastoid and carotid sheath exposed. Dissection done from below upwards from omohyoid. Level 3, 2, 1B, 1A were excised Lowest and highest node were sent separately. specimen sent for HPE

29 Right Upper Mc Afee incision and elevation of skin flaps Dissection of right submandibular lymph nodes

30 Ulcer over right ventral surface of tongue removed with a 1.5 cm wide resection. Cut margins taken separately from anterior, lateral and posterior surfaces. Specimens sent for HPE Tongue turned over and sutured with 2-0 silk after hemostasis was secured. Neck wound was sutured in two layers over a drain. Ryle s tube placed Patient shifted to post-op under naso-tracheal intubation

31 Tongue sutured Neck wound closed, drain and Ryle s tube placed

32 POD 0 Patient was on naso-endotracheal intubation on IPPV mode Drowsy Vitals : BP: 110/70mm Hg PR: 80/min Afebrile SpO2-99% on ET tube O/E of oral cavity: pooling of saliva, blood stained, no active bleeding, oral suctioning done Neck wound dressing present, no soakage. Drain insitu and patent.

33 Treatment NBM till further orders 100ml/hr Inj. TAXIM 1g IV BD Inj. METROGYL 100ml IV TID Inj. AMIKACIN 500mg IV BD Inj. PANTOP 40mg IV OD Inj. TRAMADOL mg IM BD Monitor vitals, I/O charting ET care and monitoring

34 POD 1 Patient was on naso-tracheal intubation, on SIMV mode Patient conscious, coherent. Vitals : BP: 120/70mm Hg PR: 72/min Afebrile SpO2 maintained at 98% on ET tube O/E of oral cavity: pooling of saliva, blood stained, tongue wound healthy. Neck wound healthy, dressing done. Drain in situ, collection=96ml serosanguinous

35 Input was 2200ml, output 1300ml Chest physiotherapy Repeat Haemogram- 14gm% Nebulisation with Budecort and Duolin, Mucomist 8 th hourly as advised by Anesthetist Patient was extubated on POD 1

36 Treatment NBM till further orders 100ml/hr RT 50ml 3 rd hourly Inj. TAXIM 1g IV BD Inj. METROGYL 100ml IV TID Inj. AMIKACIN 500mg IV BD Inj. PANTOP 40mg IV OD Inj. TRAMADOL mg IM BD Inj. Hydrocort 100mg IV TID (as advised by Anesthetist) ATT with RT feedsmonitor vitals, I/O charting ET care and monitoring

37 POD 2 Patient was on oxygen He was conscious, coherent. Dysarthria present Vitals : BP: 120/70mm Hg PR: 72/min Afebrile SpO2 maintained at 98% with O/E of oral cavity: pooling of saliva was minimal, tongue wound healthy Neck wound healthy, dressing done Drain insitu and patent, collection=67ml, serosanguinous

38 Input was 2350ml, output 2100ml Chest physiotherapy and spirometry X-ray chest PA view repeated and was same as before

39 Treatment NBM till further orders 60ml/hr RT 100ml 2 nd hourly Inj. TAXIM 1g IV BD Inj. METROGYL 100ml IV TID Inj. AMIKACIN 500mg IV BD Inj. PANTOP 40mg IV OD Inj. VOVERAN 75mg IM BD Tab CHYMEROL FORTE TID with RT feeds 4 th hourly oral suctioning Oral rinsing ATT with RT feeds Monitor vitals, I/O charting

40 POD 3 Patient conscious, coherent and comfortable at room air. Dysarthria present Vitals : BP: 120/80mm Hg PR: 75/min SpO2 maintained at 99% with room air O/E of oral cavity: mild slough present along floor of mouth which was mopped gently and removed. Neck wound healthy and healing Drain insitu, collection=20ml, serous

41 Input was 3000ml, output 2100ml

42 Treatment NBM till further orders 60ml/hr RT 100ml 2 nd hourly Inj. TAXIM 1g IV BD Inj. METROGYL 100ml IV TID Inj. AMIKACIN 500mg IV BD Inj. PANTOP 40mg IV OD Inj. VOVERAN 75mg IM BD Tab CHYMEROL FORTE TID with RT feeds Oral rinsing ATT with RT feeds Monitor vitals, I/O charting

43 POD 4 Patient conscious, coherent. Speech improving Vitals : BP:110/80mm Hg PR: 78/min O/E oral cavity: tongue wound healthy Neck wound healthy Drain in situ, collection=15ml

44 Repeat: Blood urea: 18mg/dl Serum creatinine : 0.8mg/dl Input was 2600ml, output 1100ml

45 Treatment NBM till further orders 60ml/hr RT 100ml 2 nd hourly Inj. TAXIM 1g IV BD Inj. METROGYL 100ml IV TID Inj. PANTOP 40mg IV OD Inj. VOVERAN 75mg IM BD Tab CHYMEROL FORTE TID with RT feeds Oral rinsing ATT with RT feeds Monitor vitals, I/O charting

46 POD 5 Patient conscious and coherent Speech improving Vitals : O/E oral cavity: tongue wound healthy Neck wound healthy Drain in situ, collection=9ml, drain removed

47 Treatment NBM till further orders 60ml/hr RT 200ml 2 nd hourly Inj. TAXIM 1g IV BD Inj. METROGYL 100ml IV TID Inj. PANTOP 40mg IV OD Inj. VOVERAN 75mg IM BD Tab CHYMEROL FORTE TID with RT feeds Oral rinsing ATT with RT feeds Monitor vitals, I/O charting

48 POD 6- Inj. METROGYL stopped Input was 2100ml, output 1900ml Patient encouraged to take sips of oral fluids POD 7- RT removed, patient was taking oral fluids POD 8-patient encouraged to take soft diet and oral fluids POD 9 alternate staples removed POD 10- patient s speech improved and was able to take soft diet and fluids per orally POD 11- remainder of staples removed, wound healthy POD 12- patient was discharged and asked to review after 1 week

49 Histopathology report

50 Condition at discharge

51 ptnm staging Depth of invasion <5mm (1mm) T1N0M0 Further treatment: Observation Speech and swallowing rehabilitation

52 Thank you