2.  J.Y.  13 y/o Female  Single  Filipino  Roman Catholic  from Butuan City, Agusan del Norte

3.  Enlarged tongue

4. OB Hx Px born to a 23 y/o primigravid via NSD at a tertiary hospital (+) prenatal check-up, denies any exposure to radiation/ intake of teratogenic drugs 13 years PTA Noted by the attending physician to have enlarged tongue. No medications given, no further consultation advised. (-) Difficulty feeding, dyspnea, snoring 12 years PTA Admitted at a local hospital due to swelling and bleeding of tongue. Given unrecalled antibiotics. Advised to transfer to another hospital but px did not comply due to lack of funds. Mother noted spontaneous resolution of tongue swelling.

5. 1 year PTA Sought consult w/ ENT in Cebu Interval history (1997-2007) (+) progressive enlargement of the tongue (+) episodes of bleeding and swelling of the tongue 3-4x/ year. Px would seek consult with MD and unrecalled antibiotics were given. 3 years PTA Persistence of symptoms led to consult with a private ENT in Davao

6. 1 month PTA (+) consult at a government hospital. Opted to transfer to our institution at ENT-OPD. 2 months PTA (+) persistent bleeding and swelling of tongue (+) pain on the anterior 1/3 of the tongue. Can only tolerate minced and soft foods. Noted to be pale and weak by the mother.

7.  (-) weight loss  (-) skin rashes, changes in pigmentation  (-)blurring of vision, headache  (-) decreased hearing sensation, tinnitus, dizziness  (-)cough and colds, chest pains, palpitations  (-)abdominal pain, changes in bowel/bladder function  (-)edema, joint pains, muscle pains

8.  (-) allergies  (-)PTB  (-) hepatitis  (-) asthma  (-) previous surgeries and blood transfusions

9.  Menarche – 12 y/o  Irregular period  Duration: 4-5 days  Amount: 5 pads/day  Symptoms – dysmenorrhea

10.  (-) HPN  (-) DM  (-) Asthma  (-) PTB  (-) Ca  (-) Down’s Syndrome

11.  H – has good relations with other family members and persons at home  E – 1 st year high school, average student  A – enjoys watching TV and DVD  D – no hx of illicit drug use, smoking, intake of alcoholic beverages  S – has few friends, rarely goes out  S – no sexual activity

12.  Weight – 39 kg  Height – 144 cm  BMI – 20  BP – 100/70  PR – 84 bpm  RR – 22c pm  T – 36.7

13.  Height for age – normal; Z score below -1  BMI for age – normal; Z score 0 (median)  Conscious, coherent, ambulatory, not in cardiorespiratory distress  Warm moist skin, no rashes  Anicteric sclera, pink palpebral conjunctivae

14.  Symmetric chest expansion, clear breath sounds  Adynamic precordium, AB at 5 th LICS MCL, no murmurs, no thrills  Flat abdomen, NABS, soft, nontender  Full and equal pulses, no swelling, no edema  SMR = 3

15.  Anterior rhinoscopy: midline septum, turbinates not congested, no nasal polyps  Oral cavity: (+) enlarged reddened tongue; (+) multifocal, pebbly, vesicle like lesions on the tip, dorsal and lateral surfaces of the anterior 1/3 of the tongue; (+) blood clots on dorsal and ventral surface of anterior 1/3 of tongue; moist buccal mucosa

16.  Pharynx – nonhyperemic posterior pharyngeal wall, tonsils not enlarged  Otology: AD – no tragal tenderness, nonhyperemic EAC, intact TM; AS – no tragal tenderness, nonhyperemic EAC, intact TM  Face and neck: no facial asymmetry, neck masses, thyromegaly, palplable lymph nodes

17.  conscious, coherent, oriented to 3 spheres;  pupil 2-3 mm ERTL, EOMs full and equal  can clench teeth, can raise eyebrows, can close eyes tightly, can smile, can frown  no hearing loss, limited side to side head turning, tongue midline on protrusion  can do FTNT and APST  MMT 5/5 on all extremities  DTR ++ on all extremeties  no sensory deficits

19. SubjectiveObjective 13 y/o Bleeding Pain Enlarged tongue since birth (+) enlarged reddened tongue (+) multifocal, pebbly, vesicle like lesions on the tip, dorsal and lateral surfaces of the anterior 1/3 of the tongue (+) blood clots on dorsal and ventral surface of anterior 1/3 of tongue

20. Guide Question 1 Macroglossia Secondary to Lymphangioma of the Tongue

21.  large tongue or a tongue that protrudes beyond the teeth or alveolar ridge  most common cause of macroglossia is lymphangioma  Presents as tongue protrusion, which exposes the tongue to trauma.  Other symptoms include speech impediment, swallowing difficulties, airway obstruction, drooling, and failure to thrive. http://www.bcm.edu/oto/grand/52892.html

22.  Lymphangioma is a benign, harmatomatous tumour of lymphatic vessels with a marked predilection for the head and neck region.  the lesions present superficially as a pebbly, vesicle-like feature with so-called ‘frog-egg’ or ‘tapioca-pudding’ appearance  equal sex incidence among males and females.  The lesions can become evident at any age but they usually appear in infancy

23.  most common presentation is a soft, painless mass that may enlarge with time and Hemorrhage into the lesion can also cause sudden enlargement.  The second and third most common presenting symptoms are respiratory obstruction and problems with feeding and failure to thrive.  Grossly, the lesions are ill-defined, diffuse, and spongy, having indiscrete margins. Often, it is actually much larger than it appears to be.

24.  Physical exam demonstrates a soft, painless compressible mass often described as being doughy on palpation.  Superficial tumors may be pink to reddish blue, while deeper lesions may show no surface changes or have stretched and atrophic skin.  Regional lymph nodes are either normal or hyperplastic.  Usually these lesions are asymptomatic and patients merely have a cosmetic deformity. Pain is not common unless infection is present.

25.  not a fatal disease.  3% mortality rate which are usually due to bronchospasm, atelectasis, or airway compromise from edema.  There is no risk of malignant transformation.  The growth rate is variable but most lesions tend to progress slowly

26. Guide Question 2 Biopsy of the Tongue Thyroid assays Imaging Studies: CT Scan, MRI of the Head & Neck

27.  Biopsy of the tongue  Thyroid function test – to rule out hypothyroidism  Imaging Studies – to determine extent of lesion and pre-operative planning  CT Scan  MRI – test of choice

29. Guide Question 3 Tongue Resection and Reconstruction

30.  No proven medical care for lymphangiomas exists. This condition is not responsive to radiation therapy or steroids.