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CASE 2: ENT

CASE 2: ENT

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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 - PowerPoint PPT Presentation

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Page 1: CASE 2: ENT

CASE 2: ENT

Page 2: CASE 2: ENT

GENERAL DATA J.Y. 13 y/o Female Single Filipino Roman Catholic from Butuan City, Agusan del Norte

Page 3: CASE 2: ENT

CHIEF COMPLAINT Enlarged tongue

Page 4: CASE 2: ENT

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.

Page 5: CASE 2: ENT

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

Page 6: CASE 2: ENT

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.

Page 7: CASE 2: ENT

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

Page 8: CASE 2: ENT

PAST MEDICAL HISTORY (-) allergies (-)PTB (-) hepatitis (-) asthma (-) previous surgeries and blood

transfusions

Page 9: CASE 2: ENT

MENSTRUAL AND OBSTETRIC HISTORY Menarche – 12 y/o Irregular period Duration: 4-5 days Amount: 5 pads/day Symptoms – dysmenorrhea

Page 10: CASE 2: ENT

FAMILY HISTORY (-) HPN (-) DM (-) Asthma (-) PTB (-) Ca (-) Down’s Syndrome

Page 11: CASE 2: ENT

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

Page 12: CASE 2: ENT

PHYSICAL EXAMINATION Weight – 39 kg Height – 144 cm BMI – 20 BP – 100/70 PR – 84 bpm RR – 22c pm T – 36.7

Page 13: CASE 2: ENT

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

Page 14: CASE 2: ENT

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

Page 15: CASE 2: ENT

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

Page 16: CASE 2: ENT

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

Page 17: CASE 2: ENT

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

Page 18: CASE 2: ENT
Page 19: CASE 2: ENT

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

Page 20: CASE 2: ENT

WHAT IS YOUR IMPRESSION OF THE CASE?

Guide Question 1

Macroglossia Secondary toLymphangioma of the Tongue

Page 21: CASE 2: ENT

PUT YOUR DISCUSSION

Page 22: CASE 2: ENT

WHAT LABORATORY EXAMS WOULD YOU RECOMMEND?

Guide Question 2

Biopsy of the TongueThyroid assays

Imaging Studies: CT Scan, MRI of the Head & Neck

Page 23: CASE 2: ENT

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

Page 24: CASE 2: ENT

HISTOLOGIC FINDINGS IN BIOPSY OF THE TONGUE

Page 25: CASE 2: ENT

WHAT WILL BE SUGGESTED TREATMENT?

Guide Question 3

Tongue Resection and Reconstruction

Page 26: CASE 2: ENT

PUT YOUR DISCUSSION No proven medical care for

lymphangiomas exists. This condition is not responsive to radiation therapy or steroids.