A 50-year-old divorced female living on welfare was referred to our clinic, complained that pus or oil like liquid and sticky things had appeared somewhere around the inside of the right ear, neck and mouth. She also complained about trismus and pain on the right side of the throat, neck and gingiva.
She reported that these sensations occurred after she stopped using cooking oil for hair washing 5 months before the first examination. She had visited a nearby physician and dentist; however, they could not find any organic abnormalities. She was then referred to the department of oral surgery 3 months after that visit, and was diagnosed with oral cenesthopathy, based on her incomprehensible complaints and communication difficulties. They also consulted a psychiatrist and obtained a consensus. She could not take any food except puddings or jellies and had lost almost 10 kg. She visited our clinic 2 months after the referral.
Her medical history was unclear, partly confirmed by her partner. She had not smoked, but routinely consumed 2 or 3 glasses of wine. She used to work in the night entertainment business after graduating from junior high school, and she was married but divorced twice. She had given birth 4 times but lost touch with both her children, father and brothers for many years. The only family she could rely on was her mother who died 14 years ago. After that, she has been living with her partner who is 58-year-old and worked at the factory.
Her partner led her to our clinic by the hand. She gripped a dingy pink towel in her hand and covered her mouth to wipe her drooling. Her hair was grizzled and messy. She was wearing a cat-patterned smudging jacket, made of brushed fabric, over a sleeveless thin white dress with total tulip-patterned, made of cotton. Her style was messy, out of season and childish. During the medical interview, she only said a few words and pointed to the affected areas or the interview sheets. Since she could hardly talk, for the most part it was her partner who explained for her. She seemed to have some intellectual disability because without additional explanations from her partner, she hardly understood our question.
On extraoral examination, an egg-sized fixed and tender lymph node was observed on her right cervical region (Fig. 1-A). The intraoral findings were not clear because the maximum range of opening mouth was only 6 mm (Fig. 1-B). Her bad breath suggested not only poor oral hygiene but also presence of some necrotic lesion.
Panoramic radiography showed moth-eaten radiolucency and loss of radiopaque lines (Fig. 2). A malignant tumor was suspected. She was then referred to an oral surgeon in our hospital immediately. However, she denied further examinations with endoscope for the fear of pain. Computed tomography revealed that the mass with an irregular margin extended from the right oropharynx to sphenoid with multiple lymph nodes necrosis (Fig. 3).
She was clinically diagnosed with advanced oral cancer with lymph node metastasis. Radical surgery was deemed insufficient. Considering her mental capacity, she could not understand the necessity of radio chemotherapies, and could not withstand such treatments because of severe adverse effects. Then, the oral surgeon carefully explained her present condition, discussed selection of treatment. He consulted her and her partner about future treatment and prognosis. She and her partner finally decided to take palliative care, and she was referred to a nearby hospital. Six months later, we were informed about her death by her attending doctor.