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1. Case presentation on Ca- Buccal mucosa Dr.Souparno Mandal 2 nd year PGT

2. History 55 yrs old lady, resident of budge budge Home maker by occupation Chief complaint Swelling in the right side of cheek inner aspect x 5-6 months Ulcer over this swelling for 1 month

3. HOPI Noticed a small swelling near right lower 1 st molar over gingival region 5- 6 months back Not associated with pain Sudden onset, rapidly progressed to current size of approx. 4x3 cm with in last 3 months Involved inner aspect of cheek and molar gingiva Swelling got visible on outer aspect of cheek for last one month An ulcer developed over swelling for last one month Took medical help one month back for same .

4. Swelling was associated with difficulty in chewing so patient developed habit of chewing from left side. H/o tobacco chewing (1 packet daily ) for last 5 years h/o use of tobacco based toothpaste 3- 4 times daily for last 10 years Non alcoholic H/o of dental caries and tooth extraction (lower molars both side) with in one year H/o recurrent trauma to cheek due sharp edges of tooth x 1yr

5. No h/o bleeding on touch No h/o Halitosis , increased salivation No h/o sensory loss or hypoesthesia over face weight loss approx. 7- 8 kgs in last 6 month Metastatic history- No neck swelling No h/o chest pain, breathing difficulty No h/o Abdominal lump / swelling, H/o sleeplessness for 6 months No H/o bone pain / headache No h/o hoarseness of voice

6. Past history Known case of hypothyroidism – taking 25 mcg eltroxin Not a k/c/o DM/ HTN/ Asthma/ TB Family history No history of cancer related deaths in family Obstetric and gynecology history Attained menopause – 19 years back , had 4 children all born by NVD , No h/o menorrhagia Dietary History Mixed diet, Nonalcoholic, tobacco chewer for past 5 years

7. CLINICAL EXAMINATION General physical examination Conscious ,co- operative, oriented to time, place and person Averagely built, adequately nourished Well hydrated Pulse rate- 80/min, regular in rhythm, normal in volume and character BP – 126 /88 mmHg , RR- 18 / min No Pallor / icterus / cyanosis / pedal edema / clubbing / lymphadenopathy Poor oral dental hygiene – nicotine stained teeth

8. Systemic examination – Respiratory system/CVS/CNS - WNL P/a – abdomen was soft, no organomegaly present

9. Local Examination

10. INSPECTION Extra oral examination Facial symmetry was distorted There was fullness present in the region of adjacent to ulcer in the mouth which was around 5x 4 cm No skin erythema, scar / sinus / fistula Mouth opening was adequate No fullness seen in neck Possible flap donor sites inspected and found adequate

11. Intra oral – an Ulcero- proliferative growth of size approx 5×4 cm irregular shape present in right vestibule involving cheek mucosa and extending to gingiva of right lower canine and premolars. extent- 3 cm below upper gingiva buccal sulcus and abutting lower GB sulcus 1.5 - 2 cm behind the right commissure uptil the 2 nd molar Ulcer - Everting edges, irregular margins, floor formed by unhealthy granulation tissue with slough present Dentition was incomplete with absent teeth Teeth absent – B/l upper and lower 2nd premolars , B/l lower 1 st molars, left lower canine Dental caries present in the remaining teeth and upper premolars had sharp edges, remaining molars were displaced

12. Poor orodental hygiene - Nicotine stained teeth and palate Patches of leucoplakia , erythroplakia present Melanoplakic patch over palate No other synchronous lesion Tongue was freely mobile Retromolar trigone free Grade 2 trismus

13. PALPATION Non- Tender swelling No increase in local temperature Ulceroproliferative growth of size 5x4 cm present In the right gingivosulcus region, irregular surface, firm in consistency, everted margin, surrounding skin of around 1 cm was indurated, lesion was fixed to underlying buccinator muscle. Masseter and pterygoid muscles were free . Cheek Skin over the swelling was pinchable and free from ulcer No fixity to underlying bone Sensation over tongue was normal , and taste sensation was preserved Mouth opening ( inter incisor distance- 3 cm) No loose teeth however the edges of teeth were pointed

14. Examination of neck Trachea appeared to be central No clinical neck lymphadenopathy Common Carotid pulsation was felt at normal site in both side Examination of cervical spine normal Examination of ear, nose ,throat and scalp was normal

15. Diagnosis 55 years old lady with ulcero- proliferative growth of lower right gingivobuccal sulcus for 6 months probably SCC of c T 3 N M of stage III without complications

16. Investigations To confirm my diagnosis To stage the disease To treat the patient

17. To confirm my diagnosis Edge / punch biopsy USG of neck then USG guided FNAC of lymph nodes to confirm neck metastasis

18. To stage the disease OPG CT contrast face and neck to evaluate precise extent of involvement CXR PA – lung metastasis Indirect laryngoscopy for synchronous malignancies USG abdomen Bone scan for possible bony involvement

19. To treat the patient PAC fitness investigations Doppler for perforators for flap

20. Management Three dimensional W ide L ocal Excision + segmental m andibulectomy + functional neck dissection and reconstruction with Free fibula bone graft with skin paddle