Tuberculosis of the mouth

TUBERCULOSIS

OF THE MOUTH*

BENJAMIN L. FEUERSTEIN, M.D. Assistant Visiting Radiation Therapist, Bellevue Hospital NEW YORK CITY

I

N the war against cancer, the reahzation that in earIy diagnosis and treatment lies our onIy hope for cure has made the examining physician regard with suspicion that group of casua1 symptoms which may possibIy signify cancer. Prominent among these is the presence of a persistent uIceration in the mouth. This cancer suspicion is ampIy justified because cancer of the mouth accounts for 20 per cent of a11 deaths from cancer, and is by far the commonest cause of chronic uIceration of the mouth. by the Such cases, upon discovery dentist or physician, are usuaIIy treated for cancer even before the diagnosis has been confirmed by biopsy. In the anxiety to controI cancer, another disease which may produce a lesion cIinicaIIy simiIar to cancer, but whose treatment and prognosis is totally different, may fai1 of consideration. This disease is tubercuIosis. Carmody, in 1915, coIIected from the Iiterature 534 cases of ora tubercuIosis. Because of the vigorous pubIic health campaign being waged against tubercuIosis today, tubercuIosis of the mouth is not a common condition. Tuberculosis of the mouth is aImost aIways secondary to puImonary tubercuIosis. Carmody described 17 cases in his paper, a11 of which had definite histories of puImonary Iesions. Levy described 8 cases, a11 of which had known lung invoIvement of from one to fifteen years. The diffrcuIty in diagnosis arises in those cases in which the patient has no knowIedge and gives no cIear history of pulmonary invoIvement. Ivy and AppIeton reported 3 cases of

ora tubercuIosis in which the patient gave no history of Iung tuberculosis. The discovery of a simiIar group of cases in our clinic has prompted the writing of this paper. These 6 cases were originaIIy referred as carcinomata of the mouth. None gave a history of pulmonary tubercuIosis. In addition to these cases, this report incIudes 4 cases of ora tubercuIosis in which tubercuIosis eIsewhere in the body to exist previous to the was known patient’s first visits to the clinic. In the examination of these cases, severa points of diagnostic vaIue were noted: the superficial nature of the uIceration, the multipie foci, and the pin-head, yellowish spots have been described by other investigators. In addition, we have noted that the uIceration was usuaIIy more irreguIar than in carcinoma, with smaI1, tongue-Iike areas radiating out into the surrounding tissue. The surrounding area showed a pecuIiar puffiness, which on palpation feIt soft in contrast to the hard induration of carcinoma. This absence of hardness was striking in a Iesion seemingIy maIignant. The uIceration itseIf was often crossed by fissures, a finding usuaIIy absent in carcinoma. The area might, or might not, be tender, and enIargement of the regiona Iymph nodes, if present, was due to secondary infection. CASE I. J. C., white male, aged thirty-eight, Iaborer, entered the hospital in August, 193 I, camp aining of a swollen, tender Iower Lip of five years’ duration. The Iesion began as a small “cold sore” and since then had slowly, progressively spread over the entire lower lip. A Wassermann test at that time was reported 4 PIUS, but antiIuetic treatment failed to give

*From the Radiation 7 herapy Service, BeIIevue Hospital, Ira I. KupIan, M.D., Director. 313

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Feuerstein-TubercuIosis

any improvement, aIthough it did cause the Wassermann to become negative. Because the Iesion persisted, the patient was referred to

FIG.

IA.

FG.

,935

of the surrounding tissues, and, in addition, there was a smaI1, reddened area on the hard paIate. TubercuIosis was suspected, which was

IB.

Case I. Edematous lip with fissure through center. Fissure was of a purplish-grayish coIor. FIG. IB. Case I, after radium therapy and pIastic operation. Lesion compIeteIy heaIed. FIG.

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IA.

the Radiation Therapy Department with a tentative diagnosis of carcinoma of the lip. Examination at this time reveaIed a diffuseIy swollen lower Iip, with a hard, noduIar mass extending from side to side, deep in the lip tissue. The mucous membrane was fissured at the center of the Iip. The surrounding areas had the characteristic induration which we have found in carcinoma cases. Because the lesion seemed to be marignant, a biopsy was taken and immediate irradiation administered, A wax moId containing 6-5 mg. tubes of radium was appIied to the lip and a dosage of 2 I 60 mg. hours given over a period of three days. (The pathoIogica1 report at this time showed a chronic, productive inffammatory Iesion with definite epithelioid tubercles.) The condition was partiaIIy improved foIIowed by a pIastic operation producing an exceIIent resuIt. The patient has remained we11 to date. (Fig. IA and B.) CASE II. J. B., forty-eight-year old laborer, was referred to the cIinic as a case of maIignancy of the mouth. He gave a history of a rapidliy growing sore in the right corner of the mouth. The Iesion began as a smaI1 ulcer six months previousIy and had been growing rapidly. The patient gave a history of a chronic cough for the past eleven years, though his genera1 condition seemingly was exceIIent. He had not Iost weight and had been working steadiIy. Examination of the mouth showed an uIcer invoIving the entire angle of the mouth on the right side, extending out on the skin for about 0.5 cm. There was a good dea1 of edema

FIG. 2. Case II. Six month uIcer with surrounding edema and numerous fissures. History and x-ray were positive for pulmonary tuberculosis.

confirmed by biopsy, which showed miIiary tubercuIosis; and an x-ray of the chest showed cavitation in both apices. Because of the puImonary disease the patient was referred to the tubercuIosis service for treatment. (Fig. 2.) J. S., a city fireman, thirty-one CASE III. years of age, gave a history of a sore mouth of six months’ duration. He gave no history suggestive of tubercuIosis, except for a cough of three weeks’ duration. Examination reveared that the entire bucca1 mucosa on the right side was studded with smaI1 yeIIowish granuIes. There was a superficia1 crusting of the skin at the right corner of the mouth. In addition, the entire right side of the face was markedIy swoIIen. (Fig. 3.) X-ray of the chest showed signs of extensive tubercuIosis. WhiIe this case was cIinicaIIy the most characteristic of the group, severa biopsies faiIed to show histoIogicaI signs of tubercuIosis. The patient was referred to the tubercuIosis service for treatment, but because of the severity of his condition, death rapidIy ensued. oId tailor, CASE IV. A. H., a forty-nine-year gave a history of an uIceration in the mouth of three months’ duration. Examination reveaIed on the Ieft bucca1 mucous membrane a raised area, about 2 inches in diameter, grayish-white in coIor, and fissured throughout. It was moderateIy tender, but firm, and the surrounding area was moderateIy swolIen. There were no bIeeding areas and no paIpabIe cervical gIands. A provisiona diagnosis of IeucopIakia was

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made and a biopsy taken. It was reported as a On this basis, squamous-ceII epithelioma. radium needIes were inserted into the lesion

lower lip of five months’ duration. Tuberculosis was suspected aIthough there was no history of puImonary tuhercuIosis and confirmation by

FIG. 3. Case III. Edematous right cheek with superficial fissured ulceration. Check mucosa was simiIarly diffusety involved. Chest x-ray was positive for phthisis.

and a dose of I ISO mg. hours administered. The condition improved, but faiIed to clear up compIeteIy. Further radiation was given six months Iater but because the condition faiIed to heal compIeteIy, or extend further, or invoIve the regiona gIands, another biopsy was taken. This showed tubercuIosis. Re-examination of the origina sIide demonstrated the previous error, for the origina diagnosis, too, shouId have been tuberculosis. An x-ray of the chest showed evidences of tuberculosis and the patient was referred to the tubercuIosis service where, under sanitorium treatment, he improved iemarkabIy. CASE v. E. B., white maIe, aged thirty-two years, entered the cIinic with a history of a sore on Iip of two months’ duration. He gave no history of puImonary tubercuIosis. Examination reveaIed a smaI1, indurated uIcer, 35 inch in diameter, on the right side of the upper Iip. The ulcer was covered by a brown scab and the surrounding area of the lip was thickened, but felt soft and unIike the hard induration characteristic of maIignancy. The cIinica1 appearance of the Iesion, and the unusua1 Iocation on the upper lip, suggested a benign condition. Examination of the microscopic section showed the condition to be tuberculosis. Radon needIes were inserted into the Iesion and a dosage of 700 mc. hours was given. The lesion healed compIeteIy, and at the Iast return visit to the cIinic, six months later, the patient’s condition was excellent. CASE \-I. H. L., a twenty-five-year oId gir1, was referred for treatment of a smaI1 sore on

FIG. 4. Case IV. Photomicrograph of bucca1 mucosa. Section shows numerous characteristically appearing tubercles.

pathological

examination

could

not

be

ob-

tained. She was treated with surface appIication of radium, a dosage of $52 mg. hours being given. The Iesion healed, recurred six months later, was treated again, and again recurred. The patient developed paraIysis of the fifth, seventh, and eighth nerves and was referred to the neuroIogica1 service. She went rapidIy downhiI1, and died a year Iater. Autopsy showed tuberculosis with extension to the centra1 nervous system. CASE VII. E. T., male, forty years of age, with a history of pulmonary tuberculosis of known duration of one year, reported to the clinic with a smaI1 ulcer on the Ieft side of the tongue of six weeks’ duration. The lesion was about 0.5 cm. in diameter and rested against a broken, jagged tooth, and n-as soft, not indurated. It was excised with the endotherm under IocaI anesthesia. Pathologica report of the specimen was tuberculosis. Subsequent history is Iacking for the patient failed to return for folIo\v-up examinations.

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CASE VIII. J. M., thirty-five-year oId man, was referred to the clinic for treatment of a fissure on the tongue. Examination reveaIed a fissure on the dorsum of the tongue, about 3 cm. Iong and I cm. deep. The edges were sIightIy thickened but there was no induration present. The patient’s mother and brother had tubercuIosis, and he, himseIf, had aIso been treated for puImonary tubercuIosis for the past three years. Radium, in the form of pIatinum tubes, was appIied to the lesion on the tongue. Four appIications of IOO mg. hours each were given over a period of two months. The patient faiIed to return for foIIow-up examination. CASE IX. J. S., forty-two years of age, white, male, was referred from the DentaI CIinic for treatment of an uIcer of the gum. The patient had had several teeth extracted six months previousIy and the present Iesion had deveIoped at the site of the extractions. Examination reveaIed an uIceration of the gum, 3 cm. by 3 cm. with a sharp edge, not hard nor indurated, but quite tender. A biopsy was taken and examination of the specimen microscopic showed a coIIection of epithelioid ceIIs and occasiona muItinucIeated giant ceIIs resembIing tubercIes. x-ray examination of the chest reveaIed extensive nodular i&Itration of the Iungs. Three years previousIy the patient had had a tubercuIous kidney removed. No radium treatment was given for the mouth Iesion. He was referred to the tubercuIosis service but his

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genera1 condition as we11 as the IocaI Iesion in the mouth became progressiveIy worse. CASE X. L. s., a twenty-seven-year oId housewife, with a Iong-standing history of puImonary and IaryngeaI tubercuIosis, was referred for treatment of an uIcer of the pharynx. Examination revealed a smaI1 shaIIow uIcer on the posterior pharyngea1 waI1, about I cm. in diameter, with fairIy weII-defined edges, but no induration. The patient’s genera1 condition was very poor and she died before any radiation couId be given. SUMMARY I. TubercuIosis of the mouth shouId be considered as a possibIe diagnosis in cases of chronic uIceration of the mouth. 2. WhiIe aIways secondary to puImonary tubercuIosis, the Iung Iesion may give few, or no, symptoms. It is in this group of cases in which errors in diagnosis are most IikeIy to occur. 3. Radiation therapy may be of some vaIue in the treatment of these cases. REFERENCES I.

IVY and APPLETON. J. A. M. A.,

81: 1483 (Nov. 3)

1923.

2. LEVY, R. Denver M. Times (Dec.) IgoT. 3. CARMODY, T. E. Ann. Oto-Rhino-Laryngol.

‘915.

(June)