Case Report

Maxillary carcinoma
A wolf in sheep’s clothing
Patrick Mehanna BDS MB BS FRACDS(OMS) FDSRCS  Graham Smith BDS MB BS FRCS(OMFS) FRCS(Eng)

O ral squamous cell carcinoma (SCC) represents 90%

to 95% of all malignant neoplasms of the oral cavity.
It is classically regarded as an adult disease entity and
presented to the Accident and Emergency Department
in March. The maxillofacial surgery junior resident
suspected an underlying pathology, and the man was
has a high correlation with alcohol and tobacco con- booked for the consultant review, at which left-sided
sumption.1 Oral SCC occurs in several well established facial pain, cheek paresthesia, and left-sided nasal
intraoral sites, including the floor of mouth, tongue (most obstruction were documented. Intraoral examination
common), gingiva, lips, and buccal mucosa. It might revealed a 4- to 5-cm ulcerated area in the left maxil-
also present in the tooth-bearing segment of either the lary alveolus (Figure 1).
maxilla or the mandible, with bony involvement. We
present a case of a maxillary carcinoma presenting with Figure 1. Left maxillary lesion in a patient with
signs suggestive of trigeminal neuralgia (TN), initially maxillary carcinoma
seen and treated in general practice, and discuss its pre-
sentation and management. This case emphasizes that
a careful history, with extraoral and intraoral examina-
tion, should be taken before definitive diagnosis of TN
and that, if in doubt, early specialist referral is necessary
to exclude an alternative underlying pathology.

Case description
In March 2008, a 59-year-old man presented to the
Accident and Emergency Department at St George’s
Hospital in London, UK, complaining of persistent
pain in the left side of the maxilla following a tooth
extraction 1 week earlier. He was booked for a con-
sultant review appointment at an outpatient clinic;
results of an urgent biopsy confirmed invasive SCC of
the maxilla.
The patient had initially presented to his general
medical practitioner in December 2007 with left-sided Investigations included an incisional biopsy of the
facial pain. His medical history included medically lesion under local anesthetic, an orthopantomogram,
controlled hypertension and hypercholesterolemia, and a computed tomography (CT) scan of the thorax,
substantial alcohol intake of 60 to 70 units a week, neck, and mandible. A well-differentiated SCC was
and a habit of smoking 5 to 6 cigarettes a day since diagnosed. The CT scan showed an extensive left-
the age of 16 (a habit he broke in 2007). A diagnosis maxillary SCC with gross invasion and destruction of
of TN was made, and the patient’s condition was the maxillary sinus, lateral nose, orbits, and ethmoid
reviewed weekly by his general practitioner. The sinus (Figure 2). Over the next few weeks the patient
medications he was prescribed to treat TN consisted developed marked restriction and hyperglobus of the
of carbamazepine, pregabalin, and regular analgesics left eyeball, with ophthalmoplegia and diplopia con-
to help alleviate the pain. sistent with the disease progression (Figure 3).
His symptoms continued throughout January and, The case was discussed at the Multi­disciplinary Head
upon consulting a dentist in February, his left, upper- and Neck Clinic at St George’s Hospital. The tumour
mobile wisdom tooth was extracted, as it was thought was deemed to be surgically unresectable and palliative
to be contributing to his symptoms. Because of the chemoradiotherapy was instigated.
increasing pain following the extraction, the man
Discussion
This article has been peer reviewed. Oral SCC is a disease entity with well established risk
Cet article a fait l’objet d’une révision par des pairs. factors, including smoking and alcohol use. It can
Can Fam Physician 2009;55:262-4 present on the tongue (most common), floor of the

262  Canadian Family Physician • Le Médecin de famille canadien  Vol 55:  march • mars 2009
 Case Report
facial pain syndromes, including TN. In the early stages
Figure 2. Coronal computed tomography scan showing of the disease, the patient will first complain of localized
extensive invasion by squamous cell carcinoma of the maxillary pain; later, symptoms might progress to mobil-
maxilla ity of teeth. This was noted in the discussed case. As the
tumour invades the maxilla and infiltrates the maxillary
sinus, the patient will experience nasal congestion due
to direct-obstruction symptoms. The infraorbital nerve
(branch of the maxillary division of the trigeminal nerve)
will also be affected, resulting in sensory disturbances
of the cheek. Our patient complained of both paresthe-
sia and nasal obstruction. Superimposed pain due to the
direct infiltrative behaviour of the tumour will also be
reported.
As the tumour progresses superiorly, the orbital floor—
only a few millimetres thick—will be encountered and
will provide minimal resistance to orbital infiltration. This
will result in restriction of ocular mobility and alteration
of eyeball positioning, secondary to direct infiltration of
the periorbita and extraocular muscles. Next will be eth-
moidal involvement. The management of head and neck
Figure 3. Facial photograph showing marked alteration cancers involves accurately staging the extent of the dis-
of eyeball positioning due to orbital invasion ease (with the aid of investigations such as CT or mag-
netic resonance imaging), in accordance with the TNM
Classification of Malignant Tumours,2 and determining if
surgical resection is feasible. Early diagnosis is, therefore,
paramount to favourable prognosis. The management
of maxillary oral SCC involves radial surgical resection
(hemimaxillectomy or maxillectomy), which might also
include orbital exenteration and combined neurosurgi-
cal access procedures followed by adjuvant radiotherapy.
Depending on the stage of the disease, the odds of 5-year
survival can range from 40% to 60%. Although the man-
agement of a node-negative neck remains controver-
sial,3 the presence of cervical nodal metastasis decreases
survival by 50% and warrants therapeutic neck dissec-
tion followed by adjuvant radiotherapy.4 Reconstructive
options range from a
nonbiologic obturator
Signs and symptoms suggestive
(a modified denture
of invasive oral squamous cell
that extends to replace
carcinoma
the resected tissue) to
complex, microvascu-
• Unremitting progressive pain
lar, free-tissue trans-
• Paresthesia
fer (composite fibula,
• Localized mobility of teeth or
mouth, buccal mucosa, or gingiva and commonly pres- scapula, deep circum-
 recent extractions
ents as a nonhealing, exophytic or endophytic ulcer with flex iliac artery, or soft-
• Intraoral gingival lesion
associated local and regional pain. Otalgia, dysphagia, tissue rectus transfer),
• Palatal lesion
mobile teeth, and weight loss might also be present. A depending on the
• Halitosis
MEDLINE search was performed using the term max- extent of resection as
• Cheek swelling
illary carcinoma, with the subheadings maxillary neo- well as patient fac-
• Nasal obstruction
plasms and squamous cell carcinoma. Other relevant tors.5-7
• Nasal discharge and epistaxis
papers were also examined.
• Ophthalmoplegia and diplopia
Oral SCC is typically associated with the mandible or Conclusion • Proptosis
the maxilla but will slowly invade the underlying tissues Invasive SCC can be
• Lymphadenopathy
after onset. Invasive maxillary SCC will exhibit a multi- difficult to diagnose
• Recent weight loss
tude of clinical signs and symptoms, which might mimic in its early stages and

Vol 55:  march • mars 2009  Canadian Family Physician • Le Médecin de famille canadien  263
Case Report
might be misdiagnosed as facial pain syndromes (such
EDITOR’s KEY POINTS
as TN), which often present as a unilateral shooting
• Signs and symptoms of maxillary carcinoma can
pain and commonly affect branches of the trigeminal
resemble those of facial pain syndromes, particularly
nerve. Treatment of TN is initially effective in up to 90% trigeminal neuralgia (TN). Extraoral and intraoral exam-
of patients but will dampen neural impulses,8 disguis- ination and a complete history should be undertaken
ing any alternate pathology. This case confirms that a before definitively diagnosing TN and, if in doubt, early
careful history and extraoral and intraoral examination specialist referral with biopsy is necessary to exclude
as well as appropriate investigations, such as a CT scan, underlying pathology.
should be undertaken before definitively diagnosing TN. • In the early stages, patients will present with localized
If in doubt, early specialist referral to exclude an under-
maxillary pain and teeth mobility. As tumours invade
the maxilla and infiltrate the maxillary sinus, patients
lying malignancy is absolutely necessary. 
will experience nasal congestion, sensory disturbances
Dr Mehanna was a Fellow in Maxillofacial Head and Neck Surgery at St
of the cheek, and other superimposed pain caused by
George’s Hospital in London, UK, at the time of writing. Dr Smith is a con-
sultant in the Department of Oral and Maxillofacial Surgery at St George’s infiltrate behaviour.
Hospital. • Managing head and neck cancers primarily involves
Competing interests accurately staging the disease, with computed tomog-
None declared raphy scans or magnetic resonance imaging, and deter-
Correspondence mining if surgical resection of the tumour is possible;
Dr Patrick Mehanna, Oral and Maxillofacial Surgery, John Hunter Hospital,  
Lookout Rd, New Lambton, NSW 2305; e-mail [email protected]
early diagnosis is paramount to favourable outcome.
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ments sensoriels à la joue et d’autres douleurs superpo-
sées causées par le comportement de l’infiltrat.
• La prise en charge des cancers à la tête et au cou
comporte principalement d’établir l’avancement de
la maladie au moyen d’études tomographiques ou de
l’imagerie par résonance magnétique et de déterminer
s’il est possible de faire l’ablation chirurgicale de la
tumeur; le diagnostic précoce est donc d’une impor-
tance primordiale pour des résultats favorables.

264  Canadian Family Physician • Le Médecin de famille canadien  Vol 55:  march • mars 2009