Tuesday, 16 August 2011

Excision of maxillary (possible) chondrosarcoma

The specimen was a 47 year old male who turned up in the clinic this morning with a complaint of a swelling in his right upper jaw that had (according to him) developed over the last month. (I'll tell you in just a moment why I don't believe that). Apparently he had the four teeth in that part of the jaw (the premolars and the first and second molar) extracted between November of 2010 and March of this year because they were "loose". He - implicitly if not in so many words - blamed his former dentist for the swelling.

This man had no significant medical history but was a tobacco chewer. This is what I saw in his mouth:



The swelling extended from the attachment of the gum to the cheek (the buccal fornix) to close to the midline of the palate. It was firm to the touch, not soft and yielding to pressure as it would have if it was filled with fluids (cyst contents or pus). I couldn't see any sign of broken roots or other remnants of the extracted teeth.

I took an intraoral X ray, but it showed nothing identifiable - the entire plate was filled with an amorphous radiopaque mass that could have been pretty much anything. More significant was what I couldn't  see, and what I should have:

- I couldn't see the bone of the jaw;
- I couldn't see the maxillary sinus;
- I couldn't see any broken tooth roots, or indeed any sign that the teeth had ever existed; I couldn't even see the sockets.

All of this - along with the tobacco-chewing habit and the history of "loose" teeth - led me to believe that the swelling was some kind of tumour which had invaded the jawbone and pushed the teeth out of their sockets. I decided on excising as much of the tumour as I could, and having a biopsy performed.

When I cut the gum (under local anaesthetic) and raised a flap, this is what I saw:



Note the large, granular object. That's the upper surface of the growth, whatever it is. I had a very difficult time separating it from the mucous membrane of the palate, which adhered to it tightly, and from the deeper tissues, to which it was also adhering (I finally found the eroded bone, far below its normal position). The final structure I removed was about the size of a large olive, and of the texture of cartilage.

The reason I don't believe the specimen's contention is that nothing that large and hard can possibly grow in just one month. It's evident he was frightened sick of what was going on in his mouth and only persuaded himself (or was persuaded) to see a dentist when his lower teeth, as I saw, began biting on the mucous membrane covering the swelling.

I don't know what the growth is, but from the consistency I think it might be a neoplasm of cartilaginous origin, a chondrosarcoma or chondromyxoid fibroma. Let's see what the biopsy report says.

After removal of the tissue (which was too large to pop into the biopsy bottle until I cut, or rather, given its consistency, hacked it into two), I was left with a gaping wound in the jaw and a smaller one in the palate. I managed to close them with two black silk sutures:



Now let's see what the biopsy report says. I'll decide on future treatment after I see it.



This was the second of three surgeries I've done so far today. The other two were much more mundane.

3 comments:

  1. so...what was the result?

    i found this interesting.

    ReplyDelete
  2. It turned out to be a mixed cartilaginous and glandular tissue-origin benign tumour, which (despite being benign) had destroyed most of the cheek bone and the maxillary sinus. He's going to require major surgery. Well beyond my area of expertise.

    ReplyDelete
  3. robindro waikhom30/11/2012 06:43

    I really wish case reports written similarly are accepted for publication in scientific journals.what is the harm when the style of writing makes the topic more intersting.I seriously would love Bill to author all my intersting cases and display them beautifully in this blog

    ReplyDelete

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