Famous Patients, Famous Operations, 2003 - Part 2: The Case of the Physician with An Oral Growth

Albert B. Lowenfels, MD

Disclosures

April 08, 2003

Introduction

A 67-year-old male physician presented with a growth on the right side of the roof of his mouth, near the glossopharyngeal fold. He underwent excisional biopsy of the lesion as an outpatient, but had to be hospitalized because of unexpected hemorrhage.

Following the initial surgical procedure, he received radiotherapy over a period of a few months. Six months after the initial surgery, because of pain and a persistent oral lesion, he consulted a second surgeon who believed that another operation should be performed. At this time, there was a large ulcer within his mouth close to the maxilla and a palpable mass below the right clavicle.

The second operative procedure was performed in 2 stages: (1) stage 1 consisted of partial, right-sided neck dissection and ligation of the external carotid artery; (2) 6 days later, the tumor, maxilla, and a portion of the mandible were excised. Both operations were performed under local anesthesia with intravenous sedation. A temporary prosthesis was inserted at the time of the second operation to separate the nasal and oral cavities.

The patient had smoked cigars nearly all his life, sometimes smoking as many as 20 per day, and he consumed alcohol, usually in moderate amounts. His past history included episodes of cardiac arrhythmia, and, at times, attacks of chest pain. His family history was negative for cancer. His father, a smoker, died at age 81, probably of heart failure; his mother died at age 95.

Over the next 16 years, the patient underwent approximately 20-30 additional oral procedures including multiple biopsies and frequent cauterization of suspicious tissue at the original operative site. In order to consume food or to converse, he had to use an oral prosthesis. During all these years, he continued to smoke cigars.

In the final years of his life he suffered from continuous oral pain, finally dying at age 83 after receiving an injection of morphine administered by his physician.

Who is the mystery patient?

  1. Christian Barnard

  2. Sigmund Freud

  3. Albert Schweitzer

  4. William Osler

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Why did the patient require so many oral operations?

  1. The original operation was unnecessary and led to continuous formation of exuberant scar tissue.

  2. The patient developed fungal overgrowth, which was never recognized.

  3. The continuous use of an intra-oral prosthesis led to tissue breakdown.

  4. The original operative excision of the underlying lesion was inadequate.

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What was the etiology of the original oral condition?

  1. Carcinoma of the mouth

  2. Syphilis

  3. Tuberculosis of the maxilla

  4. Actinomycosis

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Which of the patient's habits might be related to the underlying disease?

  1. Alcohol only

  2. Tobacco only

  3. Both alcohol and tobacco

  4. Neither alcohol nor tobacco

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In addition to tobacco and alcohol, what other risk factors are linked to head and neck cancer?

  1. Epstein-Barr virus

  2. High-fat diet

  3. Human papillomavirus (HPV)

  4. Consumption of large amounts of green tea

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Is ligation of the carotid artery usually necessary in a case such as Freud's?

  1. Yes

  2. No

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