UNUSUAL EXPERIENCE IN OSMF

Kishore Sandu1, S.M. Makharia2

INTRODUCTION Oral Submucous Fibrosis (OSMF) is a distressing condition in which due to limited opening of the oral cavity, the patient is neither able to consume a normal diet nor maintain proper oral hygiene. This chronic, progressive, insidious and disabling disease not only involves the submucosa of the oral cavity and oropharynx but sometimes also the oesophagus and rarely the larynx. It may sometimes be present concomitantly with oral squamous cell carcinoma, leukoplakia, lichen planus and pemphigus. This article highlights how this concomitant presentation was missed especially in patients with severely restricted mouth opening. This could complicate the treatment options.

severe bleeding, though we were able to get the endotracheal tube into the trachea. The bilateral coronoidectomies were performed and we achieved a satisfactory mouth opening. The raw area was packed with Bismuth Iodoform Paraffin bolsters. We were inquisitive regarding the traumatic nasotracheal intubation even in the hands of a very senior and experienced anesthetist. T his prompted us to do a Direct Laryngoscopy, and we were surprised to find an exophytic growth on the base tongue, which was then biopsied and was reported as moderately differentiated squamous cell carcinoma. The patient was referred for primary radiotherapy. CASE REPORT 2 Mrs DK , a chronic tobacco chewer had similar complaints and presentation as the previous case. Similar surgical procedure was planned. The awake nasotracheal intubation was uneventful and after the surgery we had a satisfactory mouth opening. After the mouth opening we noticed that the patient had an ulcerative lesion on the lateral border of the mobile tongue going onto the gingivolingual sulcus. The biopsy of the ulcer revealed poorly differentiated squamous cell carcinoma. CONCLUSIONS l. The treating Otolaryngologist must always suspect an underlying concomitant malignancy while treating oral submucus fibrosis. One must keep in mind that the carcinogenic substances are the same as those causing OSMF and Oral cancers. This may be difficult at times, especially when the patient has associated restricted mouth opening and no neck metastasis. It may be necessary to perform a bilateral coronoidectomy get a good mouth opening, to actually diagnose, stage and even to take the biopsy from such a lesion. 2. Flexible Endo Laryngoscopy would be diagnostic in lesions involving the oropharynx and below, and also in nasotracheal intubations, though this still does not help in

CASE REPORT 1
Mr BS was a 50 year old security personnel, a regular guthka, paan, tobacco chewer presented with features suggestive of Oral Submucus Fibrosis. He had trismus and mouth opening was restricted to l cm. The general ENT examination was normal with no neck lymphadenopathy. We planned to do an intra oral resection of the fibrotic strands on both the retromolar trigone and extending it to the buccal mucosa, followed by a wide temporalis muscle myotomy and a bilateral coronoid process excision. The patient was to undergo this procedure under general anesthesia with a blind awake nasotracheal intubation. We preoperatively give the patient Lignocaine nebulisation, an external Glossopharyngeal Nerve, Superior Larygeal Nerve blocks and a transtracheal instillation of 2% Lognocaine. The patient was given Lignocaine viscous to be held in the throat for 15 minutes prior to the procedure. The nasal cavity is lubricated with lignocaine jelly and an awake nasotracheal intubation was attempted. There was severe bleeding and when the anesthetist repeatedly failed we had to abandon the procedure, as the patient had refused a tracheostomy. We planned the procedure with a senior anesthetist who was well experienced in this procedure. The intubation had
1

Lecturer, Department of ENT & Head Neck Surgery, K. E. M Hospital and Seth G.S Medical College, 2Honorary, Seth A. J B. Municipal Ear Nose & Throat Hospital, Mumbai, India.

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An Unusual Experience in OSMF

diagnosing lesions of the mobile anterior tongue. Also Flexible Laryngoscopes may not be available at all centers, which means these patients require greater caution. 3 . P r e o p e r a t i v e B a r i u m s wa l l o w a n d a n Orthopantomogram (or X ray mandible) have now become a part of our routine work up of these patients. This helps us, though a submucosal lesion may still be difficult to diagnose. 4.Once we achieve a satisfactory mouth opening, a thorough examination under anesthesia to pick up any underlying induration / submucosal lesion now completes our entire ENT examination.

5. Role of MRI in OSMF with severe trismus needs attention and this investigation would be important in our diagnostic armamentarium.

REFERENCES
1. 2. Kavrana N. M., Bathena H. M. (1987) : Surgery for severe trismus in SMF, Brit J. of Plastic Surgery. 40 : 407-409. Khanna J.N., Andrade N.N.(1995) : Oral submucous fibrosis a new concept in surgical management. Int J. of Oral Maxillofac. Surgery. 24:433-439.

Address for Correspondence : Dr. Kishore Sandu, 5, Krishna Bhuvan, 7th Cross Road Chembur, Mumbai - 400071, India.

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 56 No. 1, January - March 2004