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Case Report
mouth, buccal mucosa, or gingiva and commonly pres-
ents as a nonhealing, exophytic or endophytic ulcer with
associated local and regional pain. Otalgia, dysphagia,
mobile teeth, and weight loss might also be present. A
MEDLINE search was perormed using the term max-
illary carcinoma, with the subheadings maxi llary neo-
plasms and squamous cell carcinoma. Other relevant
papers were also examined.
Oral SCC is typically associated with the mandible or
the maxilla but will slowly invade the underlying tissues
ater onset. Invasive maxillary SCC will exhibit a multi-tude o
clinical signs and symptoms, which might mimic
acial pain syndromes, including TN. In the early stages
o the disease, the patient will frst complain o localized
maxillary pain; later, symptoms might progress to mobil-
ity o teeth. This was noted in the discussed case. As the
tumour invades the maxilla and infltrates the maxillary
sinus, the patient will experience nasal congestion due
to direct-obstruction symptoms. The inraorbital nerve
(branch o the maxillary division o the trigeminal nerve)
will also be aected, resulting in sensory disturbances
o the cheek. Our patient complained o both paresthe-
sia and nasal obstruction. Superimposed pain due to the
direct infltrative behaviour o the tumour will also be
reported.
As the tumour progresses superiorly, the orbital oor
only a ew millimetres thickwill be encountered and
will provide minimal resistance to orbital infltration. This
will result in restriction o ocular mobility and alteration
o eyeball positioning, secondary to direct infltration o
the periorbita and extraocular muscles. Next will be eth-moidal
involvement. The management o head and neck
cancers involves accurately staging the extent o the dis-
ease (with the aid o investigations such as CT or mag-
netic resonance imaging), in accordance with the TNM
Classifcation o Malignant Tumours,2 and determining i
surgical resection is easible. Early diagnosis is, thereore,
paramount to avourable prognosis. The management
o maxillary oral SCC involves radial surgical resection
(hemimaxillectomy or maxillectomy), which might also
include orbital exenteration and combined neurosurgi-
cal access procedures ollowed by adjuvant radiotherapy.
Depending on the stage o the disease, the odds o 5-yearsurvival
can range rom 40% to 60%. Although the man-
agement o a node-negative neck remains controver-
sial,3 the presence o cervical nodal metastasis decreases
survival by 50% and warrants therapeutic neck dissec-
tion ollowed by adjuvant radiotherapy.4 Reconstructive
options range rom a
nonbiologic obturator
(a modiied denture
that extends to replace
the resected tissue) to
complex, microvascu-
lar, ree-tissue trans-er (composite ibula,
scapula, deep circum-
ex iliac artery, or sot-
tissue rectus transer),
depending on the
extent o resection as
well as patient ac-
tors.5-7
ConclusionInvasive SCC can be
diicult to diagnosein its early stages and
Signs and symptoms suggestiveof invasive oral squamous
cellcarcinoma
Unremitting progressive pain
Paresthesia
Localized mobility of teeth or
recent extractions
Intraoral gingival lesion
Palatal lesion
Halitosis
Cheek swelling
Nasal obstruction
Nasal discharge and epistaxis
Ophthalmoplegia and diplopia
Proptosis
Lymphadenopathy
Recent weight loss
Figure 2. Coronal computed tomography scan showingextensive
invasion by squamous cell carcinoma of themaxilla
Figure 3. Facial photograph showing marked alterationof eyeball
positioning due to orbital invasion
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264 Canadian Family PhysicianLe Mdecin de famille canadien Vol
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Case Report
might be misdiagnosed as acial pain syndromes (such
as TN), which oten present as a unilateral shooting
pain and commonly aect branches o the trigeminal
nerve. Treatment o TN is initially eective in up to 90%
o patients but will dampen neural impulses,8 disguis-
ing any alternate pathology. This case confrms that a
careul history and extraoral and intraoral examination
as well as appropriate investigations, such as a CT scan,
should be undertaken beore defnitively diagnosing TN.
I in doubt, early specialist reerral to exclude an under-
lying malignancy is absolutely necessary.
Dr Mehanna was a Fellow in Maxilloacial Head and Neck Surgery at
StGeorges Hospital in London, UK, at the time o writing. Dr Smith
is a con-sultant in the Department o Oral and Maxilloacial Surgery
at St GeorgesHospital.
competing inteestsNone declared
coespondeneDr Patrick Mehanna, Oral and Maxilloacial Surgery,
John Hunter Hospital,Lookout Rd, New Lambton, NSW 2305; e-mail
[email protected]
refeenes1. Llewellyn CD, Johnson NW, Warnakulasuriya KA. Risk
actors or squamouscell carcinoma o the oral cavity in young peoplea
comprehensive literaturereview. Oral Oncol2001;37(5):401-18.
2. Patel SG, Shah JP. TNM staging o cancers o the head and neck:
striving oruniormity among diversity. CA Cancer J Clin
2005;55(4):242-58.
3. Jeremic B, Nguyen-Tan PF, Bamberg M. Elective neck
irradiation in locallyadvanced squamous cell carcinoma o the
maxillary sinus: a review. J CancerRes Clin Oncol2002;128(5):235-8.
Epub 2002 Apr 10.
4. Shah JP, Anderson PE. Evolving role o modifcations in neck
dissections ororal squamous cell carcinoma.Br J Oral Maxillofac
Surg1995;33(1):3-8.
5. Cordeiro PG, Santamaria E. A classifcation system and
algorithm orreconstruction o maxillectomy and midacial deects.
Plast Reconstr Surg2000;105(7):2331-46.
6. Futran ND. Primary reconstruction o the maxilla ollowing
maxillectomy withor without sacrifce o the orbit. J Ora l Maxillo
fac Surg 2005;63(12):1765-9.
7. Sharma AB, Beumer J 3rd. Reconstruction o maxillary deects:
the case orprosthetic rehabilitation. J Oral Maxillofac
Surg2005;63(12):1770-3.
8. Chole R, Patil R, Degwekar SS, Bhowate RR. Drug treatment o
trigemi-nal neuralgia: a systematic review o the literature. J Oral
Maxillofac Surg2007;65(1):40-5.
EDITORS KEY POINTS
Signs and symptoms o maxillary carcinoma canresemble those o
acial pain syndromes, particularlytrigeminal neuralgia (TN).
Extraoral and intraoral exam-ination and a complete history should
be undertakenbeore defnitively diagnosing TN and, i in doubt,
earlyspecialist reerral with biopsy is necessary to
excludeunderlying pathology.
In the early stages, patients will present with
localizedmaxillary pain and teeth mobility. As tumours invadethe
maxilla and infltrate the maxillary sinus, patientswill experience
nasal congestion, sensory disturbanceso the cheek, and other
superimposed pain caused byinfltrate behaviour.
Managing head and neck cancers primarily involvesaccurately
staging the disease, with computed tomog-raphy scans or magnetic
resonance imaging, and deter-mining i surgical resection o the
tumour is possible;early diagnosis is paramount to avourable
outcome.
POINTS DE REPRE DU RDACTEUR Les signes et les symptmes dun
carcinome maxil-
laire ressemblent ceux des syndromes de douleursaciales, en
particulier la nvralgie du trijumeau (NT). Ilaut aire un examen
lextrieur et lintrieur de labouche, et prendre une anamnse complte
avant dediagnostiquer dfnitivement la NT et, dans le doute,il aut
demander sans dlai une biopsie pour excluretoute autre pathologie
sous-jacente.
Aux premiers stades, le carcinome spinocellulaire oralse prsente
par une douleur maxillaire localise et unemobilit des dents. mesure
que la tumeur envahit lemaxillaire et sinfltre dans le sinus
maxillaire, le patient
prouve de la congestion nasale, suivie de drange-ments
sensoriels la joue et dautres douleurs superpo-ses causes par le
comportement de linfltrat.
La prise en charge des cancers la tte et au coucomporte
principalement dtablir lavancement dela maladie au moyen dtudes
tomographiques ou delimagerie par rsonance magntique et de
dterminersil est possible de aire lablation chirurgicale de
latumeur; le diagnostic prcoce est donc dune impor-tance
primordiale pour des rsultats avorables.
