Oral Cancer

History-

·         45 yrs, male

·         Non smoker, non alcoholic, no addiction to tobacco

·         Low socio economic status

·         No H/O:: loss of weight/ Appetite

·         No significant past H/O similar illness

·         No significant family history

·         Patient is vegetarian, bladder/ bowel/ sleep habits normal

Presenting complaints-

·         Swelling in (left )lower side of the face- 2 months

·          Loosening of teeth (left lower jaw) – 6 weeks

H/O Present illness-

·         Swelling- 2 months

·         No H/O trauma (dentures)

·         No fever/ pain/ redness

·         No H/O contact

·         No difficulty: opening mouth

·         Difficulty in speech and chewing

·         No halitosis

·         Loosening of tooth in left lower jaw 6 weeks back

·         Tooth extracted

·         Loosening of 2 or more adjacent teeth- 3 weeks

Metastatic history-

·         No H/O breathlessness, cough, expectoration, haemoptysis

·         No H/O jaundice

·         No H/O of loss of consciousness, seizures

·         No H/O bone pains

Treatment history-

·         Mouth washes

·         Analgesics

·         Biopsy done 2 weeks back

Importance of loosening of tooth- if there is loosening of tooth then involvement of mandible occurred due to malignant tissue. If mandible is involved then whole management plan changes accordingly.  Of course loosening of teeth is also seen in caries.

H/O contact- HPV 16- it damages the DNA of mucosa. It takes away the protective element.

Tobacco- Nicotine- Nitrosamine {nitrosamine produced from nicotine by action of local bacteria or irritation}

Passive smoking-

Alcohol- it takes away the protective lining (mucosa). Alcohol potentiates the toxicities of tobacco. It causes mutation in the DNA lining of mucosal cells.

H/O pigmentation/ chronic ulceration/ patches-

Precancerous condition- Leukoplakia, Erythroplakia, Submucous fibrosis, Viral Warts, Veneral warts, hypoplastic candidiasis

H/O excessive salivation- chronic irritation

Drooling of saliva- if lesion is involving facial nerve then there will be asymmetry of face and drooping of the angle of mouth. Marginal mandibular branch of the facial nerve will be responsible for drooling of the saliva.

Summary {history}-

·         Any Precancerous condition

·         Any condition that predispose to oral cancer

·         Is patient a high risk case?

·         Is he suffering from something that could be prevented before?

·         Family history

General examination-

·         Alert, conscious, co-operative

·         Sitting comfortably

·         Averagely built, averagely nourished

·         Hydration status adequate

·         Performance status- Karnofsky’s 80

·         PR-72/min, BP- 130/80mmHG

·         RR-16/min, afebrile

Nutritional status- BMI, Mid Arm circumference, Triceps Skin fold thickness, Pallor, Pedal edema, loss of temporal fat, bald tongue- viatamin deficiency, hydration status of the patient,

Performance status – Karnofsky’s scale- patient’s capability for fighting the disease and also co-operating with the treatment.

In general exam in cancer dis special emphasis on- 1.       Performance status 2.       Nutrition status 3.       Hydration status

Local examination-

·         Inspection-

o   face is asymmetrical

o   there is visible swelling in left lower jaw

o   extending from angle of mouth to angle of mandible

o   4cm*3cm in size

o   Surface of the swelling appear to be smooth

o   Margins appear to be well defined

o   Skin overlying swelling is normal

o   No scar mark, no pigmentation mark, no venous prominence

·         Palpation-

o   Temperature over swelling not raised

o   Non tender

o   Hard in consistency

o   Fixed to the bone – it may be either arising from bone or involved the bone { if fixed to the bone- staging change to T4 & it is contraindicated for radiotherapy- Radiotherapy is not recommended why? Reason- higher doses of radiotherapy required that will produce RADIONECROSIS OF BONE that will produce osteonecrosis and produce pathological fracture}

Rest of the oral cavity to be examined under torchlight-

·         Mouth opening- adequate or not adequate (mouth opening should be at least 3cm to be called as adequate)

·         Tongue protrusion- whether patient can protrude tongue completely or is there any deviation in the tongue?  ( if there is involvement of floor of mouth then tongue protrusion would be inadequate- ankyloglossia) . if involvement of the Hypoglossal nerve will cause deviation on the same side. Why deviate to same

·         Angle of mouth-

·         Ulcer

·          

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The Karnofsky Performance Scale Index allows patients to be classified as to their functional impairment. This can be used to compare effectiveness of different therapies and to assess the prognosis in individual patients. The lower the Karnofsky score, the worse the survival for most serious illnesses.

KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA

Able to carry on normal activity and to work; no special care needed.	100	Normal no complaints; no evidence of disease.
	90	Able to carry on normal activity; minor signs or symptoms of disease.
	80	Normal activity with effort; some signs or symptoms of disease.
Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed.	70	Cares for self; unable to carry on normal activity or to do active work.
	60	Requires occasional assistance, but is able to care for most of his personal needs.
	50	Requires considerable assistance and frequent medical care.
Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly.	40	Disabled; requires special care and assistance.
	30	Severely disabled; hospital admission is indicated although death not imminent.
	20	Very sick; hospital admission necessary; active supportive treatment necessary.
	10	Moribund; fatal processes progressing rapidly.
	0	Dead