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

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

23.  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

25. Guide Question 3 Tongue Resection and Reconstruction

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