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Case report: Painful tongue—A diagnostic challenge
OOOOE Volume 99, Number 4 that the resorption of the left condyle may have been due to hemarthrosis with possible thrombosis of the microvasculature of the synovial tissues and/or condyle, precipitated by the arthroscopic procedure. Alternatively, the resorptive process may have been initiated with jaw manipulation during the abdominal surgery, and progressed during the observed time period. Based upon this experience, it would appear that surgical procedures involving the TMJ in a patient with thrombocythemia should be undertaken with caution. Conversely, maximal management of the underlying pathology may have given improved results.
TRIGEMINAL NERVE NEUROSENSORY CHANGES FOLLOWING ACUTE AND CHRONIC PARANASAL SINUSITIS. S. Quek, A. Biron, E. Eliav, O. Nahlieli, and R. Benoliel, University of Medicine and Dentistry of New Jersey, Newark, NJ; Hadassah-Hebrew University Faculty of Dentistry, Jerusalem, Israel; and Barzilai Medical Center, Ashkelon, Israel. Objectives. To document sensory changes in the supraraorbital, infraorbital, and mental nerve distributions following acute and chronic maxillary and frontal sinusitis. Study design. Seven patients with a total of 16 infected sinuses were included in the study. Neurosensory function was evaluated by measuring the electrical detection threshold for large myelinated nerve fibers, and for the assessment of the thinly myelinated nerve fibers the heat detection thresholds were measured. The sensory tests were conducted in the region of the infraorbital, supraorbital, and mental nerve distributions. Evaluation included clinical examination and tomographic imaging of the sinuses. Sinusitis symptoms that lasted up to 1 month were considered an acute sinusitis, and symptoms that persisted for more than 3 months were considered chronic. Eight healthy volunteers’ detection thresholds served as a control group. Results. Ten acute and 6 chronic sinusitis were diagnosed. The acute sinusitis cohort consisted of 7 maxillary and 3 frontal sinuses. The chronic sinusitis cohort consisted of 2 maxillary and 4 frontal sinuses. Acute sinusitis produced bilateral large myelinated nerve hypersensitivity compared to healthy controls (ANOVA, F8,59 P \ .05), with no significant change in the thin unmyelinated nerve fibers’ detection threshold. Chronic sinusitis resulted in large myelinated fiber hyposensitivity and thin myelinated fiber ipsilateral hyposensitivity compared to healthy controls (ANOVA, F8,59 P \ .05). Conclusions. This study concurs with previous studies in finding that early inflammatory neuritis can produce large myelinated nerve fiber hypersensitivity and a long-lasting process, presumably accompanied with nerve damage, may result in hyposensitivity.
BRAIN TUMOR SYMPTOMS THAT MIMIC FACIAL PAIN CONDITIONS: A POPULATION-BASED STUDY. M. T. Drangsholt, B. C. Custer, and W. T. Longstreth Jr, University of Washington, Seattle, Wash; and Blood Centers of the Pacific, San Francisco, Calif. Objectives. Dentists are often concerned that brain tumors may masquerade as orofacial pain conditions. However, little work has been done describing the usual symptoms of common benign brain tumors and how frequently these symptoms may mimic orofacial pain problems in a community-based popula-
Abstracts 445 tion. The specific aims of this study were as follows. (1) What are the types and the frequency of primary symptom complexes associated with intracranial meningioma? (2) What orofacial pain conditions are initially reported in people with intracranial meningioma symptoms? Study design. A population-based case-control study of the risk factors for intracranial meningioma was conducted in western Washington state. Eligible subjects were patients diagnosed with histologically confirmed intracranial meningioma tumors from January 1, 1995, to June 30, 1998, age 18 or older;, a resident of King, Pierce, or Snohomish counties, and English-speaking. Two hundred thirty-eight patients were identified using the Cancer Surveillance System, 24 refused participation, and 14 were lost to follow-up, leaving 200 participants who consented to participate in the study. Enrolled patients completed a structured in-person interview about symptoms associated with their tumor and possible risk factors. For a subsample of 74 subjects, dental records were retrieved. Descriptive statistical analyses were done using Excel 2003 and Stata 7.0. Results. Of the 200 subjects with intracranial meningomas, 72% were female and the average age was 56.4 (range 18 to 86). The median time from first symptom to first physician visit was 2 months (range 0 to 72). The most common single presenting symptom was headache (48%), followed by memory difficulties (33%), incoordination (33%), and vision symptoms (32%). The number of symptoms reported were 1 (26%), 2 (22%), and 3 or more (50%). Although many combinations of first symptoms were present, headaches, dizziness, and vision problems were the most common group of problems reported together. Some orofacial pain conditions were initially reported by cases associated with their tumor; these included jaw pain or pain with chewing (3.5%), toothache (1.0%), and facial numbness without pain (6.5%). There were no cases of facial numbness with pain. All of these orofacial conditions were reported in combination with other symptoms such as dizziness or difficulty swallowing. Other commonly experienced symptoms were migraine-like headaches with nausea or vomiting. There was no evidence in the subset of cases with recent dental records that dentists were first consulted for their meningioma associated symptoms. Conclusions. In this population-based sample of benign brain tumors, few subjects reported symptom complexes that could commonly be confused with orofacial pain conditions. Most symptoms reported by cases included 3 or more focal neurological problems, most commonly including headaches, dizziness, and vision problems. Few diagnostic problems with orofacial pain conditions appear to have occurred. Funded by NIH CA60710 and DE14069.
CASE REPORT: PAINFUL TONGUE—A DIAGNOSTIC CHALLENGE. N. Narayana, University of Nebraska Medical Center College of Dentistry, Lincoln, Neb. Background. Unilateral submucosal swelling of the dorsal tongue involving the base of the tongue in an elderly patient with the history of lung cancer and metastasis to the adrenals resulted in a diagnostic dilemma. We were unable to arrive at a definitive diagnosis prior to his death 3 months later. Case report. This 76-year-old male Caucasian with a chief complaint of sore tongue and hoarseness of 3 months duration was seen at the University of Nebraska Medical Center College of Dentistry, Lincoln, Neb. He had been treated with a course of antibiotic, antifungal, and antiviral therapy. His pain was
446 Abstracts debilitating with difficulty in swallowing and sleeping. His past medical history included prostatic cancer treated with irradiation, a coronary artery bypass, and back surgery. He was currently undergoing treatment for lung cancer with metastasis to the adrenal glands. His current medications included chemotherapy, Tiazac, aspirin, Protonix, a multivitamin, and Percocet. He was a pipe smoker with no history of alcohol use. He had no known drug allergies. Oral examination revealed a diffusely firm, almost nodular swelling on the right dorsum of the tongue. The posterior extent of the lesion could not be ascertained clinically. The overlying mucosa was slightly erythematous. A clinical diagnosis of metastatic tumor was considered. CT scans were not helpful in determining either the nature or the extent of the lesion owing to artifacts from many metallic restorations on his teeth. An incisional biopsy was performed following consultation with his oncologist. Intramuscular hemangioma was considered
OOOOE April 2005 histopathologically with no evidence of a metastatic tumor. The patient was seen 1.5 months later by an otolaryngologist. At this time weakness of his hypoglossal nerve was noted. Deeper incisional biopsies done under direct laryngoscopy resulted in a diagnosis of ‘‘hyalinizing subepithelial fibrosis.’’ Special stains revealed no amyloid or any infiltrating tumor. Conclusions. The main reason for presenting this case is to discuss the differential diagnosis of a tongue mass with incapacitating pain and problems associated with patient care. No definitive histological diagnosis was ever established though no infiltrating tumor was diagnosed. In treating his primary tumor his physicians overlooked the patient’s main concern, painful tongue. Surgical excision may have been curative but was not considered owing to his medical status. The patient was sedated and placed on narcotics to control his pain. We are unable to explain the etiology of the pain in this case.
TRIGEMINAL NERVE NEUROSENSORY CHANGES FOLLOWING ACUTE AND CHRONIC PARANASAL SINUSITIS. S. Quek, A. Biron, E. Eliav, O. Nahlieli, and R. Benoliel, University of Medicine and Dentistry of New Jersey, Newark, NJ; Hadassah-Hebrew University Faculty of Dentistry, Jerusalem, Israel; and Barzilai Medical Center, Ashkelon, Israel. Objectives. To document sensory changes in the supraraorbital, infraorbital, and mental nerve distributions following acute and chronic maxillary and frontal sinusitis. Study design. Seven patients with a total of 16 infected sinuses were included in the study. Neurosensory function was evaluated by measuring the electrical detection threshold for large myelinated nerve fibers, and for the assessment of the thinly myelinated nerve fibers the heat detection thresholds were measured. The sensory tests were conducted in the region of the infraorbital, supraorbital, and mental nerve distributions. Evaluation included clinical examination and tomographic imaging of the sinuses. Sinusitis symptoms that lasted up to 1 month were considered an acute sinusitis, and symptoms that persisted for more than 3 months were considered chronic. Eight healthy volunteers’ detection thresholds served as a control group. Results. Ten acute and 6 chronic sinusitis were diagnosed. The acute sinusitis cohort consisted of 7 maxillary and 3 frontal sinuses. The chronic sinusitis cohort consisted of 2 maxillary and 4 frontal sinuses. Acute sinusitis produced bilateral large myelinated nerve hypersensitivity compared to healthy controls (ANOVA, F8,59 P \ .05), with no significant change in the thin unmyelinated nerve fibers’ detection threshold. Chronic sinusitis resulted in large myelinated fiber hyposensitivity and thin myelinated fiber ipsilateral hyposensitivity compared to healthy controls (ANOVA, F8,59 P \ .05). Conclusions. This study concurs with previous studies in finding that early inflammatory neuritis can produce large myelinated nerve fiber hypersensitivity and a long-lasting process, presumably accompanied with nerve damage, may result in hyposensitivity.
BRAIN TUMOR SYMPTOMS THAT MIMIC FACIAL PAIN CONDITIONS: A POPULATION-BASED STUDY. M. T. Drangsholt, B. C. Custer, and W. T. Longstreth Jr, University of Washington, Seattle, Wash; and Blood Centers of the Pacific, San Francisco, Calif. Objectives. Dentists are often concerned that brain tumors may masquerade as orofacial pain conditions. However, little work has been done describing the usual symptoms of common benign brain tumors and how frequently these symptoms may mimic orofacial pain problems in a community-based popula-
Abstracts 445 tion. The specific aims of this study were as follows. (1) What are the types and the frequency of primary symptom complexes associated with intracranial meningioma? (2) What orofacial pain conditions are initially reported in people with intracranial meningioma symptoms? Study design. A population-based case-control study of the risk factors for intracranial meningioma was conducted in western Washington state. Eligible subjects were patients diagnosed with histologically confirmed intracranial meningioma tumors from January 1, 1995, to June 30, 1998, age 18 or older;, a resident of King, Pierce, or Snohomish counties, and English-speaking. Two hundred thirty-eight patients were identified using the Cancer Surveillance System, 24 refused participation, and 14 were lost to follow-up, leaving 200 participants who consented to participate in the study. Enrolled patients completed a structured in-person interview about symptoms associated with their tumor and possible risk factors. For a subsample of 74 subjects, dental records were retrieved. Descriptive statistical analyses were done using Excel 2003 and Stata 7.0. Results. Of the 200 subjects with intracranial meningomas, 72% were female and the average age was 56.4 (range 18 to 86). The median time from first symptom to first physician visit was 2 months (range 0 to 72). The most common single presenting symptom was headache (48%), followed by memory difficulties (33%), incoordination (33%), and vision symptoms (32%). The number of symptoms reported were 1 (26%), 2 (22%), and 3 or more (50%). Although many combinations of first symptoms were present, headaches, dizziness, and vision problems were the most common group of problems reported together. Some orofacial pain conditions were initially reported by cases associated with their tumor; these included jaw pain or pain with chewing (3.5%), toothache (1.0%), and facial numbness without pain (6.5%). There were no cases of facial numbness with pain. All of these orofacial conditions were reported in combination with other symptoms such as dizziness or difficulty swallowing. Other commonly experienced symptoms were migraine-like headaches with nausea or vomiting. There was no evidence in the subset of cases with recent dental records that dentists were first consulted for their meningioma associated symptoms. Conclusions. In this population-based sample of benign brain tumors, few subjects reported symptom complexes that could commonly be confused with orofacial pain conditions. Most symptoms reported by cases included 3 or more focal neurological problems, most commonly including headaches, dizziness, and vision problems. Few diagnostic problems with orofacial pain conditions appear to have occurred. Funded by NIH CA60710 and DE14069.
CASE REPORT: PAINFUL TONGUE—A DIAGNOSTIC CHALLENGE. N. Narayana, University of Nebraska Medical Center College of Dentistry, Lincoln, Neb. Background. Unilateral submucosal swelling of the dorsal tongue involving the base of the tongue in an elderly patient with the history of lung cancer and metastasis to the adrenals resulted in a diagnostic dilemma. We were unable to arrive at a definitive diagnosis prior to his death 3 months later. Case report. This 76-year-old male Caucasian with a chief complaint of sore tongue and hoarseness of 3 months duration was seen at the University of Nebraska Medical Center College of Dentistry, Lincoln, Neb. He had been treated with a course of antibiotic, antifungal, and antiviral therapy. His pain was
446 Abstracts debilitating with difficulty in swallowing and sleeping. His past medical history included prostatic cancer treated with irradiation, a coronary artery bypass, and back surgery. He was currently undergoing treatment for lung cancer with metastasis to the adrenal glands. His current medications included chemotherapy, Tiazac, aspirin, Protonix, a multivitamin, and Percocet. He was a pipe smoker with no history of alcohol use. He had no known drug allergies. Oral examination revealed a diffusely firm, almost nodular swelling on the right dorsum of the tongue. The posterior extent of the lesion could not be ascertained clinically. The overlying mucosa was slightly erythematous. A clinical diagnosis of metastatic tumor was considered. CT scans were not helpful in determining either the nature or the extent of the lesion owing to artifacts from many metallic restorations on his teeth. An incisional biopsy was performed following consultation with his oncologist. Intramuscular hemangioma was considered
OOOOE April 2005 histopathologically with no evidence of a metastatic tumor. The patient was seen 1.5 months later by an otolaryngologist. At this time weakness of his hypoglossal nerve was noted. Deeper incisional biopsies done under direct laryngoscopy resulted in a diagnosis of ‘‘hyalinizing subepithelial fibrosis.’’ Special stains revealed no amyloid or any infiltrating tumor. Conclusions. The main reason for presenting this case is to discuss the differential diagnosis of a tongue mass with incapacitating pain and problems associated with patient care. No definitive histological diagnosis was ever established though no infiltrating tumor was diagnosed. In treating his primary tumor his physicians overlooked the patient’s main concern, painful tongue. Surgical excision may have been curative but was not considered owing to his medical status. The patient was sedated and placed on narcotics to control his pain. We are unable to explain the etiology of the pain in this case.