CHILDHOOD DEVELOPMENTAL SCREENING 2020 https://doi.org/10.33591/sfp.46.5.up1

FINDING A MASS WITHIN THE ORAL CAVITY: WHAT ARE THE COMMON CAUSES AND 4-7 GAINING INSIGHT: WHAT ARE THE ISSUES? In Figure 2 below, a list of masses that could arise from each site Figure 3. Most common oral masses What are the common salivary gland pathologies Salivary gland tumours (Figure 7) commonly present as channel referrals to appropriate specialists who are better HOW SHOULD A GP MANAGE THEM? of the oral cavity is given and elaborated briey. Among the that a GP should be aware of? painless growing masses which are usually benign. ey can equipped in centres to accurately diagnose and treat these Mr Tan Tai Joum, Dr Marie Stella P Cruz CDR had a slow-growing mass in the oral cavity over one year more common oral masses are: torus palatinus, torus occur in both major and minor salivary glands but are most patients, which usually involves surgical excision. but sought treatment only when he experienced a sudden acute mandibularis, pyogenic granuloma, mucocele, broma, ere are three pairs of major salivary glands (parotid, commonly found occurring in the parotid glands. e most 3) Salivary gland pathology may be primary or secondary to submandibular and sublingual) as well as hundreds of minor ABSTRACT onset of severe pain and numbness. He was fortunate to have leukoplakia and squamous cell carcinoma – photographs of common type of salivary gland tumour is the pleomorphic systemic causes. ese dierent diseases may present with not sought treatment as it had not caused any pain. been timely referred and the malignant sublingual salivary salivary glands (Figure 5). 11 A 24-year-old male presented with worsening right these are shown in Figure 3. It is to be highlighted that adenoma, which classically presents with an outward very similar symptoms. When "red ag" symptoms and signs gland removed while it was still localised. buccal pain and numbness of the anterior right tip of the squamous cell carcinoma may present in various subsites of the deection of the ear. e gender distribution for salivary gland are encountered, prompt referral to a head and neck clinic to On physical examination, CDR was alert, with a blood pressure Figure 5. Anatomy of major salivary glands9 tongue. A fixed, hard, non-tender mass was found on oral cavity. tumours is equal, and they often present in the age range of rule out malignancy is warranted. of 130/66 mmHg, pulse rate of 70 beats per minute and was In a GP setting, patients may present acutely or be incidentally 12 the right floor of the mouth. Subsequently, maxillofacial 50-59 years old. 4) When in doubt, refer to a specialist. Malignancy should be afebrile. He was in signicant pain, with a pain score of 8/10. found to have a mass in the oral cavity during a routine Figure 2. Types of oral masses by site3 surgery evaluation, MRI scan of the head and neck, and ruled out. Examination of the oral cavity revealed a 3.6 cm xed hard mass examination. Hence, this clinical encounter serves as an Figure 7. Types of salivary gland tumours10 biopsy confirmed a low-grade hyalinising clear cell centred on the mid and posterior sublingual space located just excellent lesson and brings about a search for answers to the carcinoma, likely of salivary gland origin. This clinical deep to the mucosa of the right oor of mouth and close to the following questions: REFERENCES encounter led to a review for the variety of masses that lingual cortex of the right mandible more superiorly (Figure 1). 1. Milchgrub S, Gnepp DR, Vuitch F, Delgado R, Albores-Saavedra J. can occur in each site in the oral cavity and the common e mass could be palpated from the submental triangle of the 1. What are the dierent masses that can be found within the Hyalinizing clear cell carcinoma of salivary gland. The American journal masses that may present to a GP. A suggested neck. Medially, the mass bulged across the midline without oral cavity? of surgical pathology. 1994 Jan;18(1):74-82. management approach is presented. In addition, extension across the midline raphe, causing the tongue to 2. Barber B, Côté D, Seikaly H. Clearing up clear cell tumours of the common salivary gland pathologies are highlighted, and deviate to the right. 2. What is an appropriate management approach to masses in head and neck: differentiation of hyalinising and odontogenic varieties. salivary gland tumours as was present in this patient are the oral cavity by a GP? Journal of Otolaryngology-Head and Neck Surgery. 2010 Oct further discussed. Figure 1. CDR's mass within the oral cavity 1;39(5):E56. 3. What are the common salivary gland pathologies that a GP 3. Michael G. Stewart, Samuel H. Selesnick. Differential Diagnosis in Keywords: Masses in oral cavity, numbness of the should be aware of? Signs and symptoms suggesting malignancy and conditions Otolaryngology: Head and Neck Surgery. Stuttgart, Germany: Thieme; tongue, jaw pain, buccal pain, floor of mouth, salivary 2011. 520 p. gland pathology, salivary gland tumour, hyalinising clear that may predispose to malignancy are listed below (Figure 8). STUDYING THE MANAGEMENT: HOW DO 4. User:DRosenbach - Wikipedia [internet]. 2006 Aug 22 - [cited 2019 cell carcinoma In any case, any form of salivary gland swelling that is present WE APPLY IN OUR CLINICAL PRACTICE? for more than a month should be removed for assessment.10 May 26]. Available from: https://en.wikipedia.org/wiki/User:DRosenbach. Patients with salivary gland pathologies (Figure 6) commonly 5. Khaitan T, Sinha R, Sarkar S, Kabiraj A, Ramani D, Sharma M. SFP2020; 46(5): 58-61 PET CT scan abdomen and pelvis: Indications & advantage present with palpable masses and complain of swelling and/or Figure 8. Indications for urgent referral13 Conservative approach in the management of oral pyogenic granuloma over CT scan thorax, abdomen & pelvis by sclerotherapy. Journal of Indian Academy of Oral Medicine and PATIENT'S REVELATION: WHAT HAPPENED? pain related to food intake. During clinical examination, it is important to note any external swelling, presence of secretions, Radiology. 2018 Jan 1;30(1):46. PET CT scan was performed in CDR. is imaging study to carry out bimanual palpation for stones, and a thorough 6. John Doran. Fibro-Epithelial Polyps and Oral Fibromata (Irritation CDR, a 24-year-old Chinese male, presented with worsening Fibromas, Focal Fibrous Hyperplasia and Fibrous Epulides) [internet]. serves two purposes: to look for primary renal tumour, and to examination of the facial (VII) nerve and regional lymph nodes. right buccal pain and numbness of the anterior right tip of the [updated 2011 Oct 13; cited 2019 May 26]. Available from: look for distant metastases from the salivary gland tumour, i.e. e dierential diagnosis for the presence of masses within the tongue. e right buccal pain of one-week duration was http://www.exodontia.info/FEPs.html to stage the disease. Metastatic renal cell carcinoma is the most oral cavity associated with buccal pain such as in CDR is intermittent, dull and throbbing in nature, was also felt in the 7. Wikimedia Commons contributors. File:Leukoplakiaaitor.jpg [image commonly included dierential diagnosis in previous studies of extensive. Careful history-taking and clinical examination will sublingual region and associated with numbness of the anterior on internet]. Wikimedia Commons, the free media repository; 2013 clear cell carcinoma of the salivary glands. provide clues to an underlying salivary gland pathology. From tip of the tongue. It was exacerbated by talking and eating but [updated 2013 Sep 5; cited 2019 May 26]. Available from: the table below, it is of note that attention must be paid to the did not aect speech or swallowing. Each episode of pain would https://commons.wikimedia.org/w/index.php?title=File:Leukoplakiaaitor.j Given the high cost of PET CT scan, a reasonable alternative MANAGEMENT APPROACH TO MASSES IN onset, duration and pattern of symptoms, the presence of induce a headache. ere was no history of trauma or chronic During deep palpation, the mass bled slightly. It was pg&oldid=103513217 would be a CT scan of thorax, abdomen & pelvis; the latter also THE ORAL CAVITY IN THE GP SETTING associated symptoms as well as the site at which symptoms mechanical irritation to the region. He did not have any dental non-tender, xed and could not be displaced in the horizontal 8. Gonsalves WC, Chi AC, Neville BW. Common oral lesions: Part II. serves both purposes of looking for a renal primary and staging occur to improve diagnosis of salivary gland pathologies. CDR was diagnosed with having a hyalinising clear cell implants, had good dentition, and all his wisdom teeth removed plane. When displaced superiorly, the severity of jaw pain and Masses and neoplasia. American family physician. 2007 Feb of the disease. e indications for referral to a head and neck surgeon are tumour, a rare salivary gland tumour that encompasses a broad six months earlier. is was his rst episode of buccal pain with numbness was reported as lessened, suggesting lingual nerve 15;75(4):509-12. shown in gure 4. All oral masses suspected of being malignant Figure 6. Salivary gland pathologies10 age range.14 Although it was a rare diagnosis that was made even numbness of the tongue. proximity. 9. WikiJournal of Medicine/Medical gallery of Blausen Medical 2014. e advantage of the PET-CT scan over the CT TAP scan is should be referred expeditiously to a head and neck surgeon, more uncommon owing to his young age, his GP considered [internet]. Wikiversity. 2019 Jan 1 - [cited 2019 May 26]. Available from: that the former is a functional scan that measures the metabolic who will then manage the patient with input from a radiologist the possibility of a salivary gland tumour and correctly directed CDR reported that he had become aware of a slow-growing A salivary gland tumour was suspected, and he was referred to a https://en.wikiversity.org/w/index.php?title=WikiJournal_of_Medicine/Me activity of the tumour, which may provide insights into the and a pathologist. him towards denitive treatment from the beginning. e mass in the right sublingual region in the past year, but he had head and neck surgeon. Contrast-enhanced CT scan, MRI scan dical_gallery_of_Blausen_Medical_2014&oldid=1961451 biological aggressiveness of the tumour. It may also indicate presence of ulceration of the mucosa, xation of overlying of the head and neck, and ultrasound-guided ne needle 10. Ian B. Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona metastases where the size of lymph nodes involved are not Figure 4. Management of oral masses in the adult mucosa, paraesthesia of lingual nerve and intermittent pain Hall, and Harriet O'Neill. Oxford Handbook of Clinical Medicine. 10th aspiration biopsy conrmed the diagnosis of a salivary gland 8 enlarged by MRI criteria. patient with increasing severity raised the suspicion of malignancy, tumour without evidence of local invasion or metastasis. Core ed. Oxford University Press; 2017. 894 p. prompting urgent referral to the head and neck clinic. biopsy showed clear cell carcinoma, likely of salivary gland 11. To VS, Chan JY, Tsang RK, Wei WI. Review of salivary gland e surgeon had felt in this instance that PET-CT scan would origin, with low mitotic activity. A PET-CT scan of the neoplasms. ISRN otolaryngology. 2012 Feb 16;2012. TAN TAI JOUM give more information than the CT TAP scan. CONCLUSION 12. Licitra L, Grandi C, Prott FJ, Schornagel JH, Bruzzi P, Molinari R. Year 4,UCL Medical School abdomen and pelvis ruled out a metastatic renal cell carcinoma, which is the most commonly included dierential diagnosis in Major and minor salivary glands tumours. Critical reviews in University College London, UK CAUSES OF MASSES WITHIN THE ORAL Important takeaway lessons from this clinical encounter previous studies on clear cell carcinoma of the salivary glands.1,2 oncology/hematology. 2003 Feb 1;45(2):215-25. CAVITY include: 13. Mehanna H, McQueen A, Robinson M, Paleri V. Salivary gland MARIE STELLA P CRUZ 1) When faced with patients presenting with an oral cavity swellings. Bmj. 2012 Oct 23;345:e6794. A right modied neck dissection which included resection of Consultant Family Physician, MSP Cruz Long-Term & Home e oral cavity is the space which extends from the lips mass, it may be quite challenging for a family physician to 14. Weinreb I. Hyalinizing clear cell carcinoma of salivary gland: a review the primary tumour, ve levels of lymph nodes, the inner Medical Services; Visiting Consultant Family Physician, NUH anteriorly, towards the junction of the hard and soft palates as produce the right diagnosis due to the lack of diagnostic and update. Head and neck pathology. 2013 Jul 1;7(1):20-9. temple of the right mandible, and reconstruction using a right well as the circumvallate papillae posteriorly and is anked tools. However, family physicians should be familiar with the Department of Medicine sternocleidomastoid muscle ap was performed. laterally by the cheeks. Within this area, a variety of benign or major symptoms and signs that can aid in making the right malignant masses may present. ese masses can arise from any diagnosis as they are frequently the rst point of contact in Final pathology conrmed a malignant hyalinising clear cell tissue type found within the oral cavity, which is linked to the the medical setting. (HCC) tumour which was seen to arise from the sublingual occurrence of each diagnosis. 2) Being familiar with common causes of oral masses can help gland.

T H E S I N G A P O R E F A M I L Y P H Y S I C I A N V O L 4 6(5) J ULY -S EPTEMBER 2 0 2 0 : 58 FINDING A MASS WITHIN THE ORAL CAVITY: WHAT ARE THE COMMON CAUSES AND HOW SHOULD A GP MANAGE THEM?

GAINING INSIGHT: WHAT ARE THE ISSUES? In Figure 2 below, a list of masses that could arise from each site Figure 3. Most common oral masses4-7 What are the common salivary gland pathologies Salivary gland tumours (Figure 7) commonly present as channel referrals to appropriate specialists who are better of the oral cavity is given and elaborated briey. Among the that a GP should be aware of? painless growing masses which are usually benign. ey can equipped in centres to accurately diagnose and treat these CDR had a slow-growing mass in the oral cavity over one year more common oral masses are: torus palatinus, torus occur in both major and minor salivary glands but are most patients, which usually involves surgical excision. but sought treatment only when he experienced a sudden acute mandibularis, pyogenic granuloma, mucocele, broma, ere are three pairs of major salivary glands (parotid, commonly found occurring in the parotid glands. e most 3) Salivary gland pathology may be primary or secondary to submandibular and sublingual) as well as hundreds of minor ABSTRACT onset of severe pain and numbness. He was fortunate to have leukoplakia and squamous cell carcinoma – photographs of common type of salivary gland tumour is the pleomorphic systemic causes. ese dierent diseases may present with not sought treatment as it had not caused any pain. been timely referred and the malignant sublingual salivary salivary glands (Figure 5). 11 A 24-year-old male presented with worsening right these are shown in Figure 3. It is to be highlighted that adenoma, which classically presents with an outward very similar symptoms. When "red ag" symptoms and signs gland removed while it was still localised. buccal pain and numbness of the anterior right tip of the squamous cell carcinoma may present in various subsites of the deection of the ear. e gender distribution for salivary gland are encountered, prompt referral to a head and neck clinic to On physical examination, CDR was alert, with a blood pressure Figure 5. Anatomy of major salivary glands9 tongue. A fixed, hard, non-tender mass was found on oral cavity. tumours is equal, and they often present in the age range of rule out malignancy is warranted. of 130/66 mmHg, pulse rate of 70 beats per minute and was In a GP setting, patients may present acutely or be incidentally 12 the right floor of the mouth. Subsequently, maxillofacial 50-59 years old. 4) When in doubt, refer to a specialist. Malignancy should be afebrile. He was in signicant pain, with a pain score of 8/10. found to have a mass in the oral cavity during a routine Figure 2. Types of oral masses by site3 surgery evaluation, MRI scan of the head and neck, and ruled out. Examination of the oral cavity revealed a 3.6 cm xed hard mass examination. Hence, this clinical encounter serves as an Figure 7. Types of salivary gland tumours10 biopsy confirmed a low-grade hyalinising clear cell centred on the mid and posterior sublingual space located just excellent lesson and brings about a search for answers to the Types of oral masses by site carcinoma, likely of salivary gland origin. This clinical deep to the mucosa of the right oor of mouth and close to the following questions: 1) Lip REFERENCES encounter led to a review for the variety of masses that lingual cortex of the right mandible more superiorly (Figure 1). • Mucus retention cysts – Obstructed salivary duct resulting in epithelial proliferation 1. Milchgrub S, Gnepp DR, Vuitch F, Delgado R, Albores-Saavedra J. can occur in each site in the oral cavity and the common e mass could be palpated from the submental triangle of the • Mucocele – Extravasation of mucin from ruptured salivary duct into oral soft 1. What are the dierent masses that can be found within the tissues Hyalinizing clear cell carcinoma of salivary gland. The American journal masses that may present to a GP. A suggested neck. Medially, the mass bulged across the midline without • oral cavity? Squamous cell carcinoma (SCC) – Accounts for 90% of lip cancers of surgical pathology. 1994 Jan;18(1):74-82. management approach is presented. In addition, extension across the midline raphe, causing the tongue to 2. Barber B, Côté D, Seikaly H. Clearing up clear cell tumours of the common salivary gland pathologies are highlighted, and deviate to the right. 2) Tongue 2. What is an appropriate management approach to masses in • Granular cell tumour – Submucosal mass found most commonly on the tongue head and neck: differentiation of hyalinising and odontogenic varieties. salivary gland tumours as was present in this patient are • Papilloma – Benign squamous proliferation due to human papillomavirus (HPV) the oral cavity by a GP? Journal of Otolaryngology-Head and Neck Surgery. 2010 Oct further discussed. Figure 1. CDR's mass within the oral cavity infection • Leukoplakia – Premalignant white plaque that does not wipe off 1;39(5):E56. • Erythroplakia – Premalignant red mucosal plaque 3. Michael G. Stewart, Samuel H. Selesnick. Differential Diagnosis in 3. What are the common salivary gland pathologies that a GP • Fibroma – Reactive response to local irritation or masticatory trauma Keywords: Masses in oral cavity, numbness of the Otolaryngology: Head and Neck Surgery. Stuttgart, Germany: Thieme; should be aware of? • SCC tongue, jaw pain, buccal pain, floor of mouth, salivary Signs and symptoms suggesting malignancy and conditions that may predispose to malignancy are listed below (Figure 8). 2011. 520 p. gland pathology, salivary gland tumour, hyalinising clear 3) Floor of mouth STUDYING THE MANAGEMENT: HOW DO • 4. User:DRosenbach - Wikipedia [internet]. 2006 Aug 22 - [cited 2019 cell carcinoma Wharton duct – Main salivary duct of the submandibular gland; easily mistaken for In any case, any form of salivary gland swelling that is present WE APPLY IN OUR CLINICAL PRACTICE? mass for more than a month should be removed for assessment.10 May 26]. Available from: https://en.wikipedia.org/wiki/User:DRosenbach. • Ranula – Mucocele associated with the sublingual gland 5. Khaitan T, Sinha R, Sarkar S, Kabiraj A, Ramani D, Sharma M. • Patients with salivary gland pathologies (Figure 6) commonly SFP2020; 46(5): 58-61 Sialolithiasis – Salivary gland stones within the salivary duct PET CT scan abdomen and pelvis: Indications & advantage • Dermoid cyst – Secondary to the entrapment of the midline epithelium during present with palpable masses and complain of swelling and/or Figure 8. Indications for urgent referral13 Conservative approach in the management of oral pyogenic granuloma closure of the mandibular and hyoid branchial arches by sclerotherapy. Journal of Indian Academy of Oral Medicine and over CT scan thorax, abdomen & pelvis • pain related to food intake. During clinical examination, it is PATIENT'S REVELATION: WHAT HAPPENED? Torus mandibularis – Bony protuberances on lingual surface of anterior mandible; Radiology. 2018 Jan 1;30(1):46. Usually bilateral important to note any external swelling, presence of secretions, PET CT scan was performed in CDR. is imaging study • SCC to carry out bimanual palpation for stones, and a thorough 6. John Doran. Fibro-Epithelial Polyps and Oral Fibromata (Irritation CDR, a 24-year-old Chinese male, presented with worsening Fibromas, Focal Fibrous Hyperplasia and Fibrous Epulides) [internet]. serves two purposes: to look for primary renal tumour, and to 4) Buccal mucosa examination of the facial (VII) nerve and regional lymph nodes. right buccal pain and numbness of the anterior right tip of the • [updated 2011 Oct 13; cited 2019 May 26]. Available from: look for distant metastases from the salivary gland tumour, i.e. Stensen duct – Main salivary duct of the parotid gland; easily mistaken for mass e dierential diagnosis for the presence of masses within the tongue. e right buccal pain of one-week duration was • Fibroma http://www.exodontia.info/FEPs.html to stage the disease. Metastatic renal cell carcinoma is the most • Verrucous carcinoma – Wartlike; Well-differentiated squamous cell neoplasm oral cavity associated with buccal pain such as in CDR is intermittent, dull and throbbing in nature, was also felt in the 7. Wikimedia Commons contributors. File:Leukoplakiaaitor.jpg [image commonly included dierential diagnosis in previous studies of • SCC extensive. Careful history-taking and clinical examination will sublingual region and associated with numbness of the anterior on internet]. Wikimedia Commons, the free media repository; 2013 clear cell carcinoma of the salivary glands. provide clues to an underlying salivary gland pathology. From tip of the tongue. It was exacerbated by talking and eating but 5) Palate [updated 2013 Sep 5; cited 2019 May 26]. Available from: • Torus palatinus – Bony protuberance on hard palate; Usually found in mid-line the table below, it is of note that attention must be paid to the did not aect speech or swallowing. Each episode of pain would • Necrotizing sialometaplasia https://commons.wikimedia.org/w/index.php?title=File:Leukoplakiaaitor.j Given the high cost of PET CT scan, a reasonable alternative MANAGEMENT APPROACH TO MASSES IN onset, duration and pattern of symptoms, the presence of induce a headache. ere was no history of trauma or chronic During deep palpation, the mass bled slightly. It was • Nasopalatine duct pg&oldid=103513217 would be a CT scan of thorax, abdomen & pelvis; the latter also • Melanoma THE ORAL CAVITY IN THE GP SETTING associated symptoms as well as the site at which symptoms mechanical irritation to the region. He did not have any dental non-tender, xed and could not be displaced in the horizontal • 8. Gonsalves WC, Chi AC, Neville BW. Common oral lesions: Part II. serves both purposes of looking for a renal primary and staging Minor salivary gland tumours occur to improve diagnosis of salivary gland pathologies. CDR was diagnosed with having a hyalinising clear cell implants, had good dentition, and all his wisdom teeth removed plane. When displaced superiorly, the severity of jaw pain and • SCC Masses and neoplasia. American family physician. 2007 Feb of the disease. e indications for referral to a head and neck surgeon are tumour, a rare salivary gland tumour that encompasses a broad six months earlier. is was his rst episode of buccal pain with numbness was reported as lessened, suggesting lingual nerve 15;75(4):509-12. 6) Alveolar ridge shown in gure 4. All oral masses suspected of being malignant Figure 6. Salivary gland pathologies10 age range.14 Although it was a rare diagnosis that was made even numbness of the tongue. proximity. • Pyogenic granuloma – Erythematous and commonly ulcerative gingival nodule 9. WikiJournal of Medicine/Medical gallery of Blausen Medical 2014. e advantage of the PET-CT scan over the CT TAP scan is should be referred expeditiously to a head and neck surgeon, more uncommon owing to his young age, his GP considered [internet]. Wikiversity. 2019 Jan 1 - [cited 2019 May 26]. Available from: that the former is a functional scan that measures the metabolic 7) Odontogenic who will then manage the patient with input from a radiologist the possibility of a salivary gland tumour and correctly directed CDR reported that he had become aware of a slow-growing A salivary gland tumour was suspected, and he was referred to a • Periapical cyst – Cyst of the jaws developing at the apex of a nonvital tooth https://en.wikiversity.org/w/index.php?title=WikiJournal_of_Medicine/Me activity of the tumour, which may provide insights into the and a pathologist. him towards denitive treatment from the beginning. e mass in the right sublingual region in the past year, but he had head and neck surgeon. Contrast-enhanced CT scan, MRI scan dical_gallery_of_Blausen_Medical_2014&oldid=1961451 biological aggressiveness of the tumour. It may also indicate presence of ulceration of the mucosa, xation of overlying of the head and neck, and ultrasound-guided ne needle 10. Ian B. Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona metastases where the size of lymph nodes involved are not Figure 4. Management of oral masses in the adult mucosa, paraesthesia of lingual nerve and intermittent pain Hall, and Harriet O'Neill. Oxford Handbook of Clinical Medicine. 10th aspiration biopsy conrmed the diagnosis of a salivary gland 8 enlarged by MRI criteria. patient with increasing severity raised the suspicion of malignancy, tumour without evidence of local invasion or metastasis. Core ed. Oxford University Press; 2017. 894 p. prompting urgent referral to the head and neck clinic. biopsy showed clear cell carcinoma, likely of salivary gland 11. To VS, Chan JY, Tsang RK, Wei WI. Review of salivary gland e surgeon had felt in this instance that PET-CT scan would origin, with low mitotic activity. A PET-CT scan of the neoplasms. ISRN otolaryngology. 2012 Feb 16;2012. give more information than the CT TAP scan. CONCLUSION abdomen and pelvis ruled out a metastatic renal cell carcinoma, 12. Licitra L, Grandi C, Prott FJ, Schornagel JH, Bruzzi P, Molinari R. which is the most commonly included dierential diagnosis in Major and minor salivary glands tumours. Critical reviews in CAUSES OF MASSES WITHIN THE ORAL Important takeaway lessons from this clinical encounter previous studies on clear cell carcinoma of the salivary glands.1,2 oncology/hematology. 2003 Feb 1;45(2):215-25. CAVITY include: 13. Mehanna H, McQueen A, Robinson M, Paleri V. Salivary gland 1) When faced with patients presenting with an oral cavity swellings. Bmj. 2012 Oct 23;345:e6794. A right modied neck dissection which included resection of e oral cavity is the space which extends from the lips mass, it may be quite challenging for a family physician to 14. Weinreb I. Hyalinizing clear cell carcinoma of salivary gland: a review the primary tumour, ve levels of lymph nodes, the inner anteriorly, towards the junction of the hard and soft palates as produce the right diagnosis due to the lack of diagnostic and update. Head and neck pathology. 2013 Jul 1;7(1):20-9. temple of the right mandible, and reconstruction using a right well as the circumvallate papillae posteriorly and is anked tools. However, family physicians should be familiar with the sternocleidomastoid muscle ap was performed. laterally by the cheeks. Within this area, a variety of benign or major symptoms and signs that can aid in making the right malignant masses may present. ese masses can arise from any diagnosis as they are frequently the rst point of contact in Final pathology conrmed a malignant hyalinising clear cell tissue type found within the oral cavity, which is linked to the the medical setting. (HCC) tumour which was seen to arise from the sublingual occurrence of each diagnosis. 2) Being familiar with common causes of oral masses can help gland.

T H E S I N G A P O R E F A M I L Y P H Y S I C I A N V O L V O L 4 6(5) J ULY -S EPTEMBER 2 0 2 0 : 59 FINDING A MASS WITHIN THE ORAL CAVITY: WHAT ARE THE COMMON CAUSES AND HOW SHOULD A GP MANAGE THEM?

GAINING INSIGHT: WHAT ARE THE ISSUES? In Figure 2 below, a list of masses that could arise from each site Figure 3. Most common oral masses4-7 What are the common salivary gland pathologies Salivary gland tumours (Figure 7) commonly present as channel referrals to appropriate specialists who are better of the oral cavity is given and elaborated briey. Among the that a GP should be aware of? painless growing masses which are usually benign. ey can equipped in centres to accurately diagnose and treat these CDR had a slow-growing mass in the oral cavity over one year more common oral masses are: torus palatinus, torus occur in both major and minor salivary glands but are most patients, which usually involves surgical excision. but sought treatment only when he experienced a sudden acute mandibularis, pyogenic granuloma, mucocele, broma, ere are three pairs of major salivary glands (parotid, commonly found occurring in the parotid glands. e most 3) Salivary gland pathology may be primary or secondary to submandibular and sublingual) as well as hundreds of minor ABSTRACT onset of severe pain and numbness. He was fortunate to have leukoplakia and squamous cell carcinoma – photographs of common type of salivary gland tumour is the pleomorphic systemic causes. ese dierent diseases may present with not sought treatment as it had not caused any pain. been timely referred and the malignant sublingual salivary salivary glands (Figure 5). 11 A 24-year-old male presented with worsening right these are shown in Figure 3. It is to be highlighted that adenoma, which classically presents with an outward very similar symptoms. When "red ag" symptoms and signs gland removed while it was still localised. buccal pain and numbness of the anterior right tip of the squamous cell carcinoma may present in various subsites of the deection of the ear. e gender distribution for salivary gland are encountered, prompt referral to a head and neck clinic to On physical examination, CDR was alert, with a blood pressure Figure 5. Anatomy of major salivary glands9 tongue. A fixed, hard, non-tender mass was found on oral cavity. tumours is equal, and they often present in the age range of rule out malignancy is warranted. of 130/66 mmHg, pulse rate of 70 beats per minute and was In a GP setting, patients may present acutely or be incidentally 12 the right floor of the mouth. Subsequently, maxillofacial 50-59 years old. 4) When in doubt, refer to a specialist. Malignancy should be afebrile. He was in signicant pain, with a pain score of 8/10. found to have a mass in the oral cavity during a routine Figure 2. Types of oral masses by site3 surgery evaluation, MRI scan of the head and neck, and ruled out. Examination of the oral cavity revealed a 3.6 cm xed hard mass examination. Hence, this clinical encounter serves as an Figure 7. Types of salivary gland tumours10 biopsy confirmed a low-grade hyalinising clear cell centred on the mid and posterior sublingual space located just excellent lesson and brings about a search for answers to the carcinoma, likely of salivary gland origin. This clinical deep to the mucosa of the right oor of mouth and close to the following questions: REFERENCES encounter led to a review for the variety of masses that lingual cortex of the right mandible more superiorly (Figure 1). 1. Milchgrub S, Gnepp DR, Vuitch F, Delgado R, Albores-Saavedra J. can occur in each site in the oral cavity and the common e mass could be palpated from the submental triangle of the 1. What are the dierent masses that can be found within the Hyalinizing clear cell carcinoma of salivary gland. The American journal masses that may present to a GP. A suggested neck. Medially, the mass bulged across the midline without oral cavity? of surgical pathology. 1994 Jan;18(1):74-82. management approach is presented. In addition, extension across the midline raphe, causing the tongue to 2. Barber B, Côté D, Seikaly H. Clearing up clear cell tumours of the common salivary gland pathologies are highlighted, and deviate to the right. 2. What is an appropriate management approach to masses in head and neck: differentiation of hyalinising and odontogenic varieties. salivary gland tumours as was present in this patient are the oral cavity by a GP? Journal of Otolaryngology-Head and Neck Surgery. 2010 Oct further discussed. Figure 1. CDR's mass within the oral cavity 1;39(5):E56. 3. What are the common salivary gland pathologies that a GP 3. Michael G. Stewart, Samuel H. Selesnick. Differential Diagnosis in Keywords: Masses in oral cavity, numbness of the should be aware of? Signs and symptoms suggesting malignancy and conditions Otolaryngology: Head and Neck Surgery. Stuttgart, Germany: Thieme; tongue, jaw pain, buccal pain, floor of mouth, salivary 2011. 520 p. gland pathology, salivary gland tumour, hyalinising clear that may predispose to malignancy are listed below (Figure 8). STUDYING THE MANAGEMENT: HOW DO 4. User:DRosenbach - Wikipedia [internet]. 2006 Aug 22 - [cited 2019 cell carcinoma In any case, any form of salivary gland swelling that is present WE APPLY IN OUR CLINICAL PRACTICE? for more than a month should be removed for assessment.10 May 26]. Available from: https://en.wikipedia.org/wiki/User:DRosenbach. Patients with salivary gland pathologies (Figure 6) commonly 5. Khaitan T, Sinha R, Sarkar S, Kabiraj A, Ramani D, Sharma M. SFP2020; 46(5): 58-61 PET CT scan abdomen and pelvis: Indications & advantage present with palpable masses and complain of swelling and/or Figure 8. Indications for urgent referral13 Conservative approach in the management of oral pyogenic granuloma over CT scan thorax, abdomen & pelvis by sclerotherapy. Journal of Indian Academy of Oral Medicine and PATIENT'S REVELATION: WHAT HAPPENED? pain related to food intake. During clinical examination, it is important to note any external swelling, presence of secretions, Radiology. 2018 Jan 1;30(1):46. PET CT scan was performed in CDR. is imaging study to carry out bimanual palpation for stones, and a thorough 6. John Doran. Fibro-Epithelial Polyps and Oral Fibromata (Irritation CDR, a 24-year-old Chinese male, presented with worsening Fibromas, Focal Fibrous Hyperplasia and Fibrous Epulides) [internet]. serves two purposes: to look for primary renal tumour, and to examination of the facial (VII) nerve and regional lymph nodes. right buccal pain and numbness of the anterior right tip of the [updated 2011 Oct 13; cited 2019 May 26]. Available from: look for distant metastases from the salivary gland tumour, i.e. e dierential diagnosis for the presence of masses within the tongue. e right buccal pain of one-week duration was http://www.exodontia.info/FEPs.html to stage the disease. Metastatic renal cell carcinoma is the most oral cavity associated with buccal pain such as in CDR is intermittent, dull and throbbing in nature, was also felt in the 7. Wikimedia Commons contributors. File:Leukoplakiaaitor.jpg [image commonly included dierential diagnosis in previous studies of extensive. Careful history-taking and clinical examination will sublingual region and associated with numbness of the anterior ; a – Torus palatinus; b – Torus mandibularis; c – Pyogenic granuloma; d – Ranula (a type of mucocele); on internet]. Wikimedia Commons, the free media repository; 2013 clear cell carcinoma of the salivary glands. e – Fibroma; f – Leukoplakia; g – Squamous cell carcinoma provide clues to an underlying salivary gland pathology. From tip of the tongue. It was exacerbated by talking and eating but [updated 2013 Sep 5; cited 2019 May 26]. Available from: the table below, it is of note that attention must be paid to the did not aect speech or swallowing. Each episode of pain would https://commons.wikimedia.org/w/index.php?title=File:Leukoplakiaaitor.j Given the high cost of PET CT scan, a reasonable alternative MANAGEMENT APPROACH TO MASSES IN onset, duration and pattern of symptoms, the presence of induce a headache. ere was no history of trauma or chronic During deep palpation, the mass bled slightly. It was pg&oldid=103513217 would be a CT scan of thorax, abdomen & pelvis; the latter also THE ORAL CAVITY IN THE GP SETTING associated symptoms as well as the site at which symptoms mechanical irritation to the region. He did not have any dental non-tender, xed and could not be displaced in the horizontal 8. Gonsalves WC, Chi AC, Neville BW. Common oral lesions: Part II. serves both purposes of looking for a renal primary and staging occur to improve diagnosis of salivary gland pathologies. CDR was diagnosed with having a hyalinising clear cell implants, had good dentition, and all his wisdom teeth removed plane. When displaced superiorly, the severity of jaw pain and Masses and neoplasia. American family physician. 2007 Feb of the disease. e indications for referral to a head and neck surgeon are tumour, a rare salivary gland tumour that encompasses a broad six months earlier. is was his rst episode of buccal pain with numbness was reported as lessened, suggesting lingual nerve 15;75(4):509-12. shown in gure 4. All oral masses suspected of being malignant Figure 6. Salivary gland pathologies10 age range.14 Although it was a rare diagnosis that was made even numbness of the tongue. proximity. 9. WikiJournal of Medicine/Medical gallery of Blausen Medical 2014. e advantage of the PET-CT scan over the CT TAP scan is should be referred expeditiously to a head and neck surgeon, 1. more uncommon owing to his young age, his GP considered Acute swelling and/or pain [internet]. Wikiversity. 2019 Jan 1 - [cited 2019 May 26]. Available from: that the former is a functional scan that measures the metabolic who will then manage the patient with input from a radiologist the possibility of a salivary gland tumour and correctly directed CDR reported that he had become aware of a slow-growing A salivary gland tumour was suspected, and he was referred to a o Viral sialadenitis https://en.wikiversity.org/w/index.php?title=WikiJournal_of_Medicine/Me activity of the tumour, which may provide insights into the and a pathologist. • Mumps him towards denitive treatment from the beginning. e dical_gallery_of_Blausen_Medical_2014&oldid=1961451 mass in the right sublingual region in the past year, but he had head and neck surgeon. Contrast-enhanced CT scan, MRI scan • HIV biological aggressiveness of the tumour. It may also indicate presence of ulceration of the mucosa, xation of overlying 10. Ian B. Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona of the head and neck, and ultrasound-guided ne needle o Bacterial sialadenitis metastases where the size of lymph nodes involved are not Figure 4. Management of oral masses in the adult mucosa, paraesthesia of lingual nerve and intermittent pain Hall, and Harriet O'Neill. Oxford Handbook of Clinical Medicine. 10th aspiration biopsy conrmed the diagnosis of a salivary gland 8 enlarged by MRI criteria. patient 2. Recurrent unilateral swelling and/or pain with increasing severity raised the suspicion of malignancy, ed. Oxford University Press; 2017. 894 p. tumour without evidence of local invasion or metastasis. Core o Sialolithiasis prompting urgent referral to the head and neck clinic. biopsy showed clear cell carcinoma, likely of salivary gland 11. To VS, Chan JY, Tsang RK, Wei WI. Review of salivary gland e surgeon had felt in this instance that PET-CT scan would origin, with low mitotic activity. A PET-CT scan of the 3. Chronic bilateral swelling and/or pain neoplasms. ISRN otolaryngology. 2012 Feb 16;2012. give more information than the CT TAP scan. CONCLUSION abdomen and pelvis ruled out a metastatic renal cell carcinoma, o Autoimmune diseases – may coexist with dry eyes and mouth 12. Licitra L, Grandi C, Prott FJ, Schornagel JH, Bruzzi P, Molinari R. • Hypothyroidism Major and minor salivary glands tumours. Critical reviews in which is the most commonly included dierential diagnosis in • Mikulicz syndrome 1,2 CAUSES OF MASSES WITHIN THE ORAL Important takeaway lessons from this clinical encounter oncology/hematology. 2003 Feb 1;45(2):215-25. previous studies on clear cell carcinoma of the salivary glands. CAVITY • Sjören's syndrome include: 13. Mehanna H, McQueen A, Robinson M, Paleri V. Salivary gland 1) When faced with patients presenting with an oral cavity swellings. Bmj. 2012 Oct 23;345:e6794. A right modied neck dissection which included resection of o Bulimia e oral cavity is the space which extends from the lips o Chronic alcoholism mass, it may be quite challenging for a family physician to 14. Weinreb I. Hyalinizing clear cell carcinoma of salivary gland: a review the primary tumour, ve levels of lymph nodes, the inner anteriorly, towards the junction of the hard and soft palates as produce the right diagnosis due to the lack of diagnostic and update. Head and neck pathology. 2013 Jul 1;7(1):20-9. temple of the right mandible, and reconstruction using a right 4. Fixed swelling well as the circumvallate papillae posteriorly and is anked tools. However, family physicians should be familiar with the sternocleidomastoid muscle ap was performed. o Benign/Malignant salivary gland tumours laterally by the cheeks. Within this area, a variety of benign or o Acute lymphoblastic leukaemia major symptoms and signs that can aid in making the right malignant masses may present. ese masses can arise from any Sarcoidosis diagnosis as they are frequently the rst point of contact in Final pathology conrmed a malignant hyalinising clear cell o tissue type found within the oral cavity, which is linked to the o Amyloidosis the medical setting. (HCC) tumour which was seen to arise from the sublingual o Granulomatosis with polyangiitis occurrence of each diagnosis. Idiopathic 2) Being familiar with common causes of oral masses can help gland. o

T H E S I N G A P O R E F A M I L Y P H Y S I C I A N V O L V O L 4 6(5) J ULY -S EPTEMBER 2 0 2 0 : 60 FINDING A MASS WITHIN THE ORAL CAVITY: WHAT ARE THE COMMON CAUSES AND HOW SHOULD A GP MANAGE THEM?

GAINING INSIGHT: WHAT ARE THE ISSUES? In Figure 2 below, a list of masses that could arise from each site Figure 3. Most common oral masses4-7 What are the common salivary gland pathologies Salivary gland tumours (Figure 7) commonly present as channel referrals to appropriate specialists who are better of the oral cavity is given and elaborated briey. Among the that a GP should be aware of? painless growing masses which are usually benign. ey can equipped in centres to accurately diagnose and treat these CDR had a slow-growing mass in the oral cavity over one year more common oral masses are: torus palatinus, torus occur in both major and minor salivary glands but are most patients, which usually involves surgical excision. but sought treatment only when he experienced a sudden acute mandibularis, pyogenic granuloma, mucocele, broma, ere are three pairs of major salivary glands (parotid, commonly found occurring in the parotid glands. e most 3) Salivary gland pathology may be primary or secondary to submandibular and sublingual) as well as hundreds of minor ABSTRACT onset of severe pain and numbness. He was fortunate to have leukoplakia and squamous cell carcinoma – photographs of common type of salivary gland tumour is the pleomorphic systemic causes. ese dierent diseases may present with not sought treatment as it had not caused any pain. been timely referred and the malignant sublingual salivary salivary glands (Figure 5). 11 A 24-year-old male presented with worsening right these are shown in Figure 3. It is to be highlighted that adenoma, which classically presents with an outward very similar symptoms. When "red ag" symptoms and signs gland removed while it was still localised. buccal pain and numbness of the anterior right tip of the squamous cell carcinoma may present in various subsites of the deection of the ear. e gender distribution for salivary gland are encountered, prompt referral to a head and neck clinic to On physical examination, CDR was alert, with a blood pressure Figure 5. Anatomy of major salivary glands9 tongue. A fixed, hard, non-tender mass was found on oral cavity. tumours is equal, and they often present in the age range of rule out malignancy is warranted. of 130/66 mmHg, pulse rate of 70 beats per minute and was In a GP setting, patients may present acutely or be incidentally 12 the right floor of the mouth. Subsequently, maxillofacial 50-59 years old. 4) When in doubt, refer to a specialist. Malignancy should be afebrile. He was in signicant pain, with a pain score of 8/10. found to have a mass in the oral cavity during a routine Figure 2. Types of oral masses by site3 surgery evaluation, MRI scan of the head and neck, and ruled out. Examination of the oral cavity revealed a 3.6 cm xed hard mass examination. Hence, this clinical encounter serves as an Figure 7. Types of salivary gland tumours10 biopsy confirmed a low-grade hyalinising clear cell centred on the mid and posterior sublingual space located just excellent lesson and brings about a search for answers to the carcinoma, likely of salivary gland origin. This clinical deep to the mucosa of the right oor of mouth and close to the following questions: Benign or Malignant Malignant REFERENCES encounter led to a review for the variety of masses that lingual cortex of the right mandible more superiorly (Figure 1). 1. Milchgrub S, Gnepp DR, Vuitch F, Delgado R, Albores-Saavedra J. can occur in each site in the oral cavity and the common Cystadenolymphoma Mucoepidermoid carcinoma e mass could be palpated from the submental triangle of the 1. What are the dierent masses that can be found within the Hyalinizing clear cell carcinoma of salivary gland. The American journal masses that may present to a GP. A suggested neck. Medially, the mass bulged across the midline without oral cavity? Pleomorphic adenoma Acinic cell carcinoma of surgical pathology. 1994 Jan;18(1):74-82. management approach is presented. In addition, extension across the midline raphe, causing the tongue to 2. Barber B, Côté D, Seikaly H. Clearing up clear cell tumours of the common salivary gland pathologies are highlighted, and deviate to the right. Adenoid cystic carcinoma 2. What is an appropriate management approach to masses in head and neck: differentiation of hyalinising and odontogenic varieties. salivary gland tumours as was present in this patient are the oral cavity by a GP? Journal of Otolaryngology-Head and Neck Surgery. 2010 Oct further discussed. Figure 1. CDR's mass within the oral cavity Squamous/Adenoc 1;39(5):E56. 3. What are the common salivary gland pathologies that a GP 3. Michael G. Stewart, Samuel H. Selesnick. Differential Diagnosis in Keywords: Masses in oral cavity, numbness of the should be aware of? Signs and symptoms suggesting malignancy and conditions Otolaryngology: Head and Neck Surgery. Stuttgart, Germany: Thieme; tongue, jaw pain, buccal pain, floor of mouth, salivary 2011. 520 p. gland pathology, salivary gland tumour, hyalinising clear that may predispose to malignancy are listed below (Figure 8). STUDYING THE MANAGEMENT: HOW DO 4. User:DRosenbach - Wikipedia [internet]. 2006 Aug 22 - [cited 2019 cell carcinoma In any case, any form of salivary gland swelling that is present WE APPLY IN OUR CLINICAL PRACTICE? for more than a month should be removed for assessment.10 May 26]. Available from: https://en.wikipedia.org/wiki/User:DRosenbach. Patients with salivary gland pathologies (Figure 6) commonly 5. Khaitan T, Sinha R, Sarkar S, Kabiraj A, Ramani D, Sharma M. SFP2020; 46(5): 58-61 PET CT scan abdomen and pelvis: Indications & advantage present with palpable masses and complain of swelling and/or Figure 8. Indications for urgent referral13 Conservative approach in the management of oral pyogenic granuloma over CT scan thorax, abdomen & pelvis pain related to food intake. During clinical examination, it is by sclerotherapy. Journal of Indian Academy of Oral Medicine and PATIENT'S REVELATION: WHAT HAPPENED? Radiology. 2018 Jan 1;30(1):46. important to note any external swelling, presence of secretions, Indications for urgent referral 6. John Doran. Fibro-Epithelial Polyps and Oral Fibromata (Irritation PET CT scan was performed in CDR. is imaging study to carry out bimanual palpation for stones, and a thorough • Facial nerve weakness/palsy CDR, a 24-year-old Chinese male, presented with worsening Fibromas, Focal Fibrous Hyperplasia and Fibrous Epulides) [internet]. serves two purposes: to look for primary renal tumour, and to examination of the facial (VII) nerve and regional lymph nodes. • Rapid progression in size of the mass right buccal pain and numbness of the anterior right tip of the [updated 2011 Oct 13; cited 2019 May 26]. Available from: look for distant metastases from the salivary gland tumour, i.e. e dierential diagnosis for the presence of masses within the • Ulceration and/or induration of the mucosa or skin tongue. e right buccal pain of one-week duration was http://www.exodontia.info/FEPs.html to stage the disease. Metastatic renal cell carcinoma is the most oral cavity associated with buccal pain such as in CDR is • Fixation of overlying skin intermittent, dull and throbbing in nature, was also felt in the 7. Wikimedia Commons contributors. File:Leukoplakiaaitor.jpg [image commonly included dierential diagnosis in previous studies of extensive. Careful history-taking and clinical examination will • Paraesthesia/Anaesthesia of neighbouring sensory nerves sublingual region and associated with numbness of the anterior on internet]. Wikimedia Commons, the free media repository; 2013 clear cell carcinoma of the salivary glands. provide clues to an underlying salivary gland pathology. From • Intermittent pain with increasing severity tip of the tongue. It was exacerbated by talking and eating but [updated 2013 Sep 5; cited 2019 May 26]. Available from: the table below, it is of note that attention must be paid to the • History of previous skin cancer, Sjoren’s syndrome, previous radiation to did not aect speech or swallowing. Each episode of pain would https://commons.wikimedia.org/w/index.php?title=File:Leukoplakiaaitor.j Given the high cost of PET CT scan, a reasonable alternative MANAGEMENT APPROACH TO MASSES IN onset, duration and pattern of symptoms, the presence of the head and neck region induce a headache. ere was no history of trauma or chronic During deep palpation, the mass bled slightly. It was pg&oldid=103513217 would be a CT scan of thorax, abdomen & pelvis; the latter also THE ORAL CAVITY IN THE GP SETTING associated symptoms as well as the site at which symptoms • Mass observed to be arising from minor salivary glands mechanical irritation to the region. He did not have any dental non-tender, xed and could not be displaced in the horizontal 8. Gonsalves WC, Chi AC, Neville BW. Common oral lesions: Part II. serves both purposes of looking for a renal primary and staging occur to improve diagnosis of salivary gland pathologies. CDR was diagnosed with having a hyalinising clear cell implants, had good dentition, and all his wisdom teeth removed plane. When displaced superiorly, the severity of jaw pain and Masses and neoplasia. American family physician. 2007 Feb of the disease. e indications for referral to a head and neck surgeon are tumour, a rare salivary gland tumour that encompasses a broad six months earlier. is was his rst episode of buccal pain with numbness was reported as lessened, suggesting lingual nerve 15;75(4):509-12. shown in gure 4. All oral masses suspected of being malignant Figure 6. Salivary gland pathologies10 age range.14 Although it was a rare diagnosis that was made even numbness of the tongue. proximity. 9. WikiJournal of Medicine/Medical gallery of Blausen Medical 2014. e advantage of the PET-CT scan over the CT TAP scan is should be referred expeditiously to a head and neck surgeon, more uncommon owing to his young age, his GP considered [internet]. Wikiversity. 2019 Jan 1 - [cited 2019 May 26]. Available from: that the former is a functional scan that measures the metabolic who will then manage the patient with input from a radiologist the possibility of a salivary gland tumour and correctly directed CDR reported that he had become aware of a slow-growing A salivary gland tumour was suspected, and he was referred to a https://en.wikiversity.org/w/index.php?title=WikiJournal_of_Medicine/Me activity of the tumour, which may provide insights into the and a pathologist. him towards denitive treatment from the beginning. e mass in the right sublingual region in the past year, but he had head and neck surgeon. Contrast-enhanced CT scan, MRI scan dical_gallery_of_Blausen_Medical_2014&oldid=1961451 biological aggressiveness of the tumour. It may also indicate presence of ulceration of the mucosa, xation of overlying of the head and neck, and ultrasound-guided ne needle 10. Ian B. Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona metastases where the size of lymph nodes involved are not Figure 4. Management of oral masses in the adult mucosa, paraesthesia of lingual nerve and intermittent pain Hall, and Harriet O'Neill. Oxford Handbook of Clinical Medicine. 10th aspiration biopsy conrmed the diagnosis of a salivary gland 8 enlarged by MRI criteria. patient with increasing severity raised the suspicion of malignancy, tumour without evidence of local invasion or metastasis. Core ed. Oxford University Press; 2017. 894 p. prompting urgent referral to the head and neck clinic. biopsy showed clear cell carcinoma, likely of salivary gland 11. To VS, Chan JY, Tsang RK, Wei WI. Review of salivary gland e surgeon had felt in this instance that PET-CT scan would origin, with low mitotic activity. A PET-CT scan of the neoplasms. ISRN otolaryngology. 2012 Feb 16;2012. give more information than the CT TAP scan. CONCLUSION abdomen and pelvis ruled out a metastatic renal cell carcinoma, 12. Licitra L, Grandi C, Prott FJ, Schornagel JH, Bruzzi P, Molinari R. which is the most commonly included dierential diagnosis in Major and minor salivary glands tumours. Critical reviews in CAUSES OF MASSES WITHIN THE ORAL Important takeaway lessons from this clinical encounter previous studies on clear cell carcinoma of the salivary glands.1,2 oncology/hematology. 2003 Feb 1;45(2):215-25. CAVITY include: 13. Mehanna H, McQueen A, Robinson M, Paleri V. Salivary gland 1) When faced with patients presenting with an oral cavity swellings. Bmj. 2012 Oct 23;345:e6794. A right modied neck dissection which included resection of e oral cavity is the space which extends from the lips mass, it may be quite challenging for a family physician to 14. Weinreb I. Hyalinizing clear cell carcinoma of salivary gland: a review the primary tumour, ve levels of lymph nodes, the inner anteriorly, towards the junction of the hard and soft palates as produce the right diagnosis due to the lack of diagnostic and update. Head and neck pathology. 2013 Jul 1;7(1):20-9. temple of the right mandible, and reconstruction using a right well as the circumvallate papillae posteriorly and is anked tools. However, family physicians should be familiar with the sternocleidomastoid muscle ap was performed. laterally by the cheeks. Within this area, a variety of benign or major symptoms and signs that can aid in making the right malignant masses may present. ese masses can arise from any diagnosis as they are frequently the rst point of contact in Final pathology conrmed a malignant hyalinising clear cell tissue type found within the oral cavity, which is linked to the the medical setting. (HCC) tumour which was seen to arise from the sublingual occurrence of each diagnosis. 2) Being familiar with common causes of oral masses can help gland.

T H E S I N G A P O R E F A M I L Y P H Y S I C I A N V O L V O L 4 6(5) J ULY -S EPTEMBER 2 0 2 0 : 61 G U I D E L I N E S A N D I N F O R M A T I O N F O R A U T H O R S

T H E S I N G A P O R E F A M I L Y P H Y S I C I A N

%YXLSVWEVIMRZMXIHXSWYFQMXEVXMGPIWJSVTYFPMGEXMSRMRAuthors are invited to submit articles for publication in The8LI7MRKETSVI Singapore ˆ -RGPYHIREQIEHHVIWWLERHTLSRIRYQFIVERHIQEMPEHHVIWWSJXLI *EQMP]4L]WMGMERFamily PhysicianSRXLIYRHIVWXERHMRKXLEXXLI[SVOMWSVMKMREPERHXLEX on the understanding that the work is original and that it ½VWXEYXLSVXS[LSQGSVVIWTSRHIRGIWLSYPHFIWIRX MXLEWRSXFIIRWYFQMXXIHSVTYFPMWLIHIPWI[LIVI=SYVSVMKMREPEVXMGPIhas not been submitted or published elsewhere. Your original article will ˆ -RWIVXEXXLIFSXXSQREQIERHEHHVIWWSJMRWXMXYXMSRSVTVEGXMGIJVSQ [MPPFIGSRWMHIVIHJSVTYFPMGEXMSRSRXLIYRHIVWXERHMRKXLEXXLI]LEZIbe considered for publication on the understanding that they have to be [LMGLXLI[SVOSVMKMREXIH XSFIETTVSZIHF]XLI)HMXSVMEP&SEVHZMEEHSYFPIFPMRHIHTIIVVIZMI[approved by the Editorial Board via a double‐blinded peer‐review process TVSGIWWERHWYFNIGXXSVIZMWMSR%YXLSVWEVIIRGSYVEKIHXSGSRWYPXXLIand subject to revision. Authors are encouraged to consult the recom- 8LI7YQQEV]%FWXVEGXMethods (whenever applicable e.g. original article, review VIGSQQIRHEXMSRWMRXLImendations in the Uniform9RMJSVQ6IUYMVIQIRXWJSV1ERYWGVMTXW7YFQMXXIH Requirements for Manuscripts Submitted to ˆ article):8LIWYQQEV]WLSYPHHIWGVMFI[L]XLIEVXMGPI[EW[VMXXIRERHTVIWIRX Describe the selection of the subjects clearly. Give XS&MSQIHMGEP.SYVREPWBiomedical Journals (http://www.icmje.org/index.html) LXXT[[[MGQNISVKMRHI\LXQP [LMGLXLI7*4MW which the SFP is in ReferencesXLIQEMREVKYQIRXSV½RHMRKW to established methods, including statistical methods; MREGGSVH[MXLaccord with. ˆ provide0MQMX[SVHWEWJSPPS[W[SVHWJSVQENSVEVXMGPIW [SVHWJSV references and brief descriptions of methods that have been publishedGEWIVITSVXW but are not well known. Describe new or substantially 8LIJSPPS[MRKX]TIWSJEVXMGPIWQE]FIWYMXEFPIJSVTYFPMGEXMSRGEWIVITSVXWThe following types of articles may be suitable for publication: case modified methods, giving reasons for using them and evaluate their WXYH]SVMKMREPVIWIEVGL[SVOWEYHMXWSJTEXMIRXGEVITVSXSGSPWJSVTEXMIRXreports/ study, original research works, audits of patient care, protocols /I]limitations.;SVHW Include numbers of observations and the statistical SVTVEGXMGIQEREKIQIRXERHPIXXIVWXSXLI)HMXSV8LI'1)ERHVIZMI[for patient or practice management and letters to the Editor. The CME ˆ significance%HHEXXLIIRHSJWYQQEV]MREPTLEFIXMGEPPMWXMRKOI][SVHWSJYTXS of the findings where appropriate. EVXMGPIW[MPPFITYFPMWLIHYRHIVXLITVIVSKEXMZISJXLI-RWXMXYXISJ*EQMP]and review articles will be published under the prerogative of the MRRYQFIV[LMGL[MPPFIYWIHJSVEVXMGPIMRHI\MRKERHVIXVMIZEPYRHIV 1IHMGMRI -*1 MRXLI'SPPIKISJ*EQMP]4L]WMGMERW7MRKETSVI8LIEVXMGPIInstitute of Family Medicine (IFM) in the College of Family Physicians Drugs1IHMGEP must 7YFNIGX be referred ,IEHMRKW to SVgenerically; 1I7, 1I7,all the MWusual XLI trade 201 names GSRXVSPPIH may WLSYPHFI[VMXXIRMR&VMXMWL)RKPMWLERHRSXFIQSVIXLER[SVHWSingapore. The article has no word limit and should be written in British beZSGEFYPEV] included in XLIWEYVYW parentheses. YWIH JSV MRHI\MRK EVXMGPIW JSV ;46-1 ERH MRPIRKXL8LMWQYWXFIWYFQMXXIHMRERIPIGXVSRMGJSVQERHSJEJSVQEXEnglish. This must be submitted in an electronic form and of a format that 4YF1IH4PIEWIVIJIVXS[[[RPQRMLKSZQIWLJSVHIXEMPW XLEXMWGSQTEXMFPI[MXLQENSV[SVHTVSGIWWSVETTPMGEXMSRW7YFQMWWMSRWis compatible with major word processor applications. Submissions in Dosages should be quoted in metric units. MR1MGVSWSJX;SVHMR;SVHJSVQEX HSG MWTVIJIVVIHPEXIVMicrosoft Word format is preferred. ZIVWMSRW HSG\ [MPPRSXFIEGGITXIH 8LI8I\X1ERYWGVMTX JYPPGSQTPIXI Laboratory values should be in SI units with traditional unit in 8LIXI\XWLSYPHLEZIXLIJSPPS[MRKWIUYIRGIparentheses. *VSQ  .ERYEV]  EPP EVXMGPIW WYFQMXXIH JSV TYFPMGEXMSR QYWX FI WYFQMXXIH IPIGXVSRMGEPP] XLVSYKL XLI 7*4 )HMXSVMEP 1EREKIV SYV ˆ Do-RXVSHYGXMSR not use patients’7XEXIGPIEVP]XLITYVTSWISJXLIEVXMGPI names, initials or hospital numbers to ensure 1. Title Page SRPMRI WYFQMWWMSR ERH TIIVVIZMI[ W]WXIQ [LMGL GER FI EGGIWWIH EX anonymity. 2. Summary/ Abstract [[[IHMXSVMEPQEREKIVGSQWJTHIJEYPXEWT ˆ 1IXLSHW (IWGVMFI XLI WIPIGXMSR SJ XLI WYFNIGXW GPIEVP] +MZI 3. Key Words Statistics6IJIVIRGIW (if XSapplicable): IWXEFPMWLIH Describe QIXLSHW statistical MRGPYHMRK methods WXEXMWXMGEP which QIXLSHW  can be 4. Text/ Manuscript %PP MRWXVYGXMSRW JSV VIKMWXVEXMSR ERH WYFQMWWMSR GER FI JSYRH EX XLI easilyTVSZMHIVIJIVIRGIWERHFVMIJHIWGVMTXMSRWSJQIXLSHWXLEXLEZIFIIR understood and verified by the reader. Use technical terms in its 5. Tables [IFTEKI%YXLSVWERHVIZMI[IVWGERJSPPS[GPIEVP]XLITVSKVIWWSJXLI properTYFPMWLIH place, FYX and EVI where RSX [IPPpossible ORS[R quantify (IWGVMFI readings RI[ and SV indicate WYFWXERXMEPP] errors 6. Illustrations QERYWGVMTX WYFQMWWMSR ERH VIZMI[ TVSGIWW F] PSKKMRK MRXS XLI 7*4 ofQSHM½IHQIXLSHWKMZMRKVIEWSRWJSVYWMRKXLIQERHIZEPYEXIXLIMV uncertainty and confidence intervals. 7. Learning Points )HMXSVMEP 1EREKIV%R SRPMRI YWIVW´ KYMHIEYXLSVW´ ERH VIZMI[IVW´ PMQMXEXMSRW -RGPYHI RYQFIVW SJ SFWIVZEXMSRW ERH XLI WXEXMWXMGEP MRWXVYGXMSRW EVI EPWS PSGEXIH EX XLI [IFWMXI MR GEWI SJ UYIVMIW ERH ResultsWMKRM½GERGISJXLI½RHMRKW[LIVIETTVSTVMEXI (whenever applicable e.g. original article, review HMJ½GYPXMIW%R] TVSFPIQW IRGSYRXIVIH PSKKMRK MR GER FI EHHVIWWIH XS article): Present results in logical sequence in the text, table and IHMXSVMEPSJ½GI$GJTWSVKWK  illustrations.(VYKWQYWXFIVIJIVVIHXSKIRIVMGEPP] EPPXLIYWYEPXVEHIREQIWQE] FIMRGPYHIHMRTEVIRXLIWIW Discussion (whenever applicable e.g. original article, 6)'311)2()(*361%8*368,)1%297'6-48  review(SWEKIWWLSYPHFIUYSXIHMRQIXVMGYRMXW article): Authors should summarize what they found, similarities or differences compared to existing literature and why. The 8LIWYFQMWWMSRWLSYPHGSQTVMWISJXLIJSPPS[MRK  theoretical0EFSVEXSV] or ZEPYIW clinical WLSYPH implications, FI MR 7-limitations YRMXW [MXL with XVEHMXMSREP regards to YRMX study MR  8MXPI4EKI design,TEVIRXLIWIW methods, generalizability and internal validity should be  7YQQEV]%FWXVEGX discussed.  /I];SVHW  (S RSX YWI TEXMIRXW´ REQIWMRMXMEPW SV LSWTMXEP RYQFIVW XS IRWYVI  8I\X1ERYWGVMTX ERSR]QMWIHZIVWMSR Conclusion:ERSR]QMX] Summarize your main findings and its clinical  8EFPIW implication, preferably in a single paragraph and more than 3-4  -PPYWXVEXMSRW ˆ sentences.6IWYPXW 4VIWIRX VIWYPXW MR PSKMGEP WIUYIRGI MR XLI XI\XXEFPI ERH  %YXLSVW%KVIIQIRX'ST]VMKLX%WWMKRQIRX*SVQ MPPYWXVEXMSRW  4EXMIRX´W'SRWIRX*SVQMJRIGIWWEV] MRGPYHMRKGSRWIRXJSVTLSXSKVETL References: The Vancouver style of referencing is adopted by the SVMPPYWXVEXMSRXEOIRSJLYQERWYFNIGX ˆ SFP7XEXMWXMGW Journal.  (IWGVMFI WXEXMWXMGEP QIXLSHW [LMGL GER FI IEWMP] ERHIEGLSRISJXLIWIWIGXMSRWWLSYPHWXEVXSREJVIWLTEKI YRHIVWXSSH ERH ZIVM½IH F] XLI VIEHIV 9WI XIGLRMGEP XIVQW MR MXW TheTVSTIVTPEGIERH[LIVITSWWMFPIUYERXMJ]VIEHMRKWERHMRHMGEXIIVVSVW author(s) is/ are responsible for the accuracy and completeness %YXLSVW EVI EHZMWIH XS IRWYVI XLI ERSR]QMX] SJ WXYH] WYFNIGXW ERH ofSJYRGIVXEMRX]ERHGSR½HIRGIMRXIVZEPW the references, which should be identified in the text by superscript TEXMIRXWF]VIQSZMRKER]ERHEPPMRJSVQEXMSRXLEXGSYPHGSQTVSQMWIXLIMV Arabic numerals in the order of first citation and noted in numerical TVMZEG]JVSQXLIWYFQMWWMSR ˆ order6IJIVIRGIW at the end8LIEYXLSV W MWEVIVIWTSRWMFPIJSVXLIEGGYVEG]ERH of the text. GSQTPIXIRIWWSJXLIVIJIVIRGIW[LMGLWLSYPHFIMHIRXM½IHMRXLIXI\X 8LI XI\X WLSYPH FI X]TIH MR%VMEP JSRX  TSMRX WM^I [MXL E  PMRI F]WYTIVWGVMTX%VEFMGRYQIVEPWMRXLISVHIVSJ½VWXGMXEXMSRERHRSXIH WTEGI MRRYQIVMGEPSVHIVEXXLIIRHSJXLIXI\X • Add, at the end of summary in alphabetical listing, keywords of up to  5 in number which will be used for article indexing and retrieval under  (MKMXEP3FNIGX-HIRXM½IV (3- GMXEXMSRMRJSVQEXMSRQYWXFIMRGPYHIH 8LI8MXPI4EKIMedical Subject Headings or MeSH. MeSH is the NLM controlled EW E JYPP (3- 960 F] TVITIRHMRK LXXTH\HSMSVK XS ER] (3- ˆ vocabulary8LI XMXPI WLSYPH thesaurus FI GSRGMWI used for ERH indexing LMKLPMKLX articles XLI OI] for IPIQIRXW WPRIM SJ and XLI VIJIVIRGI8SMHIRXMJ]E(3-VIJIVIRGITPIEWIZMWMX'VSWW6IJEXLXXT PubMed.EVXMGPI Please refer to www.nlm.nih.gov/mesh/ for details. [[[GVSWWVIJSVKKYIWXUYIV]ERHIRXIVMRXLIVIJIVIRGIMRJSVQEXMSR ˆ -RGPYHISRXLIXMXPITEKI½VWXREQIUYEPM½GEXMSRWTVIWIRXETTSMRXQIRXW MR XLI FS\ TVSZMHIH XS PSGEXI XLI (3- [LIVI EZEMPEFPI7YGL (3- X]TIERHTPEGISJTVEGXMGISJIEGLGSRXVMFYXSV MRJSVQEXMSR[MPPJEGMPMXEXIVIEHIVWXSXVEGIVIJIVIRGIHTETIVWIEWMP]

8,)7-2+%436)*%1-0=4,=7-'-%2:3023.%21%6 T HT ETHT HESH E IES N S I S G N I I A N GN P AG G O AP A RO P P E O RO ER FR E AEF MF AF IAM A L IMY M L I I Y PL L Y YHP Y P HP S Y H H I SYCY I S ISC I A I IC CN A I I N AVA NNO V L OV V 4 L OO 6 L L ( 54()  2 J()(  1 ULYJ)) AN AJAN-SPR-M-M-JEPTEMBERARUNAR 2 20 01 15 2 56 : 0 ::? 2 74660 : 62 G U I D E L I N E S A N D I N F O R M A T I O N F O R A U T H O R S

T H E S I N G A P O R E F A M I L Y P H Y S I C I A N

 ;LIVIXLIVIEVIQSVIXLERXLVIIEYXLSVWXLI½VWXXLVIIWLSYPHFI +EMRMRKMRWMKLX;LEXEVIXLIMWWYIW# REQIHERHXLIRJSPPS[IHF]IXEP ˆManagement 8LIMWWYI W VEMWIHF]XLITEXMIRXWLSYPHFIJVEQIHMRXSUYIWXMSR W  of the case 8LIUYIWXMSR W [MPPGSRWXMXYXIETVSFPIQPMWXERH[MPPWIVZIEWEJSGYWThis section covers the approach to the management of the case by  )\EQTPI JSVXLIQEREKIQIRXSJXLMWWYFNIGXthe author(s).  8ER ERH ,S8VIEXXSXEVKIX ETTVSEGL MR QEREKMRK QSHM½EFPI VMWO JEGXSVW SJ TEXMIRXW [MXL GSVSREV] LIEVX HMWIEWI MR TVMQEV] GEVI MR 7XYH]XLIQEREKIQIRX,S[HS[IETTP]MRSYVGPMRMGEPTVEGXMGI#Literature review on latest evidence / guidelines (related to Learning7MRKETSVI;LEXEVIXLIMWWYIW#%WME4EGM½G*EQMP]1IHMGMRI  Points (for invited Family Physician Skills ˆdiagnosis 8LMWWIGXMSRGSZIVWXLIETTVSEGLXSXLIQEREKIQIRXSJXLIWYFNIGX and / or management) CourseHSM< article): Include a minimum of 3 learning points as a F]The XLI author(s) EYXLSV W 8LI should provide EYXLSV W  a literature WLSYPH TVSZMHI review of E PMXIVEXYVIcurrent evidence VIZMI[  take-home%YXLSVW QE] message [MWL for XS readers. JEQMPMEVMWI XLIQWIPZIW [MXL XLI %1% WX]PI SJGYVVIRXIZMHIRGIMJER]SJXLIFEWMWSJXLIWYFNIGX´WQEREKIQIRX/ guidelines, if any, of the basis of the case’s diagnosis / management, or JSV XLI GMXMRK SJ VIJIVIRGIW JSV &MS1IHMGEP TYFPMGEXMSRW EX [[[ SVXSLMKLPMKLXXLIKETWSJORS[PIHKIMJWYGLIZMHIRGIMWPEGOMRK8LIto highlight the gaps of knowledge if such evidence is lacking. Tables:EQEQERYEPSJWX]PIGSQ Tables should be submitted on a separate page. Label them in EYXLSV W The author(s) [MPP WYKKIWXwill provide [E]W a XS concise ETTP] XLIsummary RI[ ORS[PIHKIof the lessons MR GPMRMGEPlearnt roman‐numeric sequence [I,II,III etc] and ensure they are clear and TVEGXMGISVXSLMKLPMKLXXLIPMQMXEXMSRWSJMXWETTPMGEXMSRWMJER]from this case study. 8EFPIWwith explanatory legends as required. 8EFPIWWLSYPHFIWYFQMXXIHSREWITEVEXITEKI0EFIPXLIQMRVSQER 'SRGPYWMSRClinical Practice pointers (up to 3) RYQIVMGIllustrations: WIUYIRGI Illustrations ?------ IXGA must ERH be IRWYVI submitted XLI] in EVIa separate GPIEV ERHpage, [MXLand ˆ 8LIEYXLSV W [MPPTVSZMHIEGSRGMWIWYQQEV]SJXLIPIWWSRWPIEVRXThe author(s) will suggest ways to apply the new knowledge in clinical I\TPEREXSV]PIKIRHWEWVIUYMVIHshould be provided whenever appropriate. Illustrations should be JVSQXLMWGEWIWXYH]practice or to highlight the limitations of its applications, if any. cited in the text. When required, it is the author’s responsibility to -PPYWXVEXMSRWobtain permission to reproduce illustrations. Authors need to ensure 8LIEVXMGPIWYFQMXXIHXSXLI46-71WIGXMSRWLSYPHFI[VMXXIRF]RECOMMENDED FORMAT FOR PRISM (Patients’ RevelationsRSX ˆ that-PPYWXVEXMSRW photographs, QYWX FIillustrations WYFQMXXIH and MR E WITEVEXIfigures do TEKI not ERH contain WLSYPH any FI QSVIXLERXLVIIEYXLSVWas Insightful Studies )EGLEVXMGPIWLSYPHRSXI\GIIH[SVHWof their Management) SECTION informationTVSZMHIH[LIRIZIVETTVSTVMEXI-PPYWXVEXMSRWWLSYPHFIGMXIHMRXLIXI\X that will reveal the identities of the patients and authors. 4LSXSKVETLW SV GLEVXW QE] FI MRGPYHIH FYX WLSYPH GSRJSVQ XS XLI From;LIRVIUYMVIHMXMWXLIEYXLSV´WVIWTSRWMFMPMX]XSSFXEMRTIVQMWWMSR 1 January 2012, all photographs and illustrations taken from any WTIGM½GMRWXVYGXMSRWJSVER]SXLIVEVXMGPIWWYFQMXXIHXS8LI7MRKETSVI humanXSVITVSHYGIMPPYWXVEXMSRW%YXLSVWRIIHXSIRWYVIXLEXTLSXSKVETLW subject must be accompanied by the respective endorsed *EQMP]4L]WMGMER consentMPPYWXVEXMSRWERH½KYVIWHSRSXGSRXEMRER]MRJSVQEXMSRXLEX[MPPVIZIEP form. Clear captions to the figures should be provided.  XLI MHIRXMXMIW SJ XLI TEXMIRXW ERH EYXLSVW*VSQ  .ERYEV] EPP 6IZMWIH1ERYWGVMTX7YFQMWWMSR TLSXSKVETLWERHMPPYWXVEXMSRWXEOIRJVSQER]LYQERWYFNIGXQYWXFI 1ERYWGVMTXW QE] FI VIXYVRIH XS XLIMV VIWTIGXMZI EYXLSVW JSV VIZMWMSR AuthorEGGSQTERMIHF]XLIVIWTIGXMZIIRHSVWIHGSRWIRXJSVQ'PIEVGETXMSRW details must be included in the relevant fields when submitting an 8LMW[MPPFIEGGSQTERMIHF]ER)HMXSV´WIQEMPJSV[LMGLGSQQIRXWERH article.XSXLI½KYVIWWLSYPHFITVSZMHIH Only those who have made substantial contributions to the study VIGSQQIRHEXMSRWQE]FIQEHI8LIEYXLSVWEVIEHZMWIHXSVIEHERH and/ or preparation of the article should be acknowledged as authors and XS XEOI RSXI SJ XLIWI GSQQIRXW GEVIJYPP] ERH XS VIZMWI XLIMV EVXMGPIW %RSR]QMWIH8I\Xnamed in full. The SFP follows the International Committee of Medical EGGSVHMRKP]8LIEYXLSVWRIIHXSVITP]XSXLIIHMXSV´WIQEMPXSSYXPMRIXLIMV %WXLISVMKMREPEVXMGPI[MPPFIWYFNIGXIHXSEHSYFPIFPMRHIHTIIVVIZMI[Journal Editors (ICMJE) criteria pertaining to authorship (refer to VIWTSRWIFIJSVIXLIVIWYFQMWWMSRSJXLIVIZMWIHQERYWGVMTX8LI]WLSYPH TVSGIWWEPPMHIRXM½GEXMSRSJREQIWERHMRWXMXYXMSRWLEZIXSFIVIQSZIHhttp://www.icmje.org/ethical_1author.html). The precise role(s) of each I\GPYHIXLIMHIRXMX]SJXLIEYXLSVWERHXLIMVMRWXMXYXMSRWEWXLIIQEMP JVSQXLMWZIVWMSRXSJEGMPMXEXIXLITIIVVIZMI[TVSGIWWauthor should be included in the ‘contributorship’ declaration. QE]FIVIHMVIGXIHXSXLIVIZMI[IVWHYVMRKXLIVIWYFQMWWMSRTVSGIWW8LI VIWYFQMXXIHQERYWGVMTXWWLSYPHMRGPYHIXLIVIZMWIHGSQTPIXIZIVWMSREW %YXLSV'SRXVMFYXSVWLMTJSV3VMKMREP%VXMGPI7YFQMWWMSR [IPPEWXLIERSR]QMWIHZIVWMSREWFIJSVI %YXLSVHIXEMPWQYWXFIMRGPYHIHMRXLIVIPIZERX½IPHW[LIRWYFQMXXMRKER EVXMGPI3RP]XLSWI[LSLEZIQEHIWYFWXERXMEPGSRXVMFYXMSRWXSXLIWXYH] 4VSSJW ERHSVTVITEVEXMSRSJXLIEVXMGPIWLSYPHFIEGORS[PIHKIHEWEYXLSVWERH 4VMSV XS TYFPMGEXMSRXLI )HMXSVMEP8IEQ[MPP GST]IHMX XLI EVXMGPI XS ½X REQIHMRJYPP8LI7*4JSPPS[WXLI-RXIVREXMSREP'SQQMXXIISJ1IHMGEP XLIJSVQEXSJXLI.SYVREP8LIEYXLSV[MPPFIWIRXXLIGST]IHMXIHTVSSJ .SYVREP)HMXSVW -'1.) GVMXIVMETIVXEMRMRKXSEYXLSVWLMT VIJIVXSLXXT SJXLIEVXMGPIERHXLIEYXLSVWLSYPHVIEHGEVIJYPP]XLITVSSJERHKMZI [[[MGQNISVKIXLMGEPCEYXLSVLXQP 8LITVIGMWIVSPI W SJIEGLEYXLSV GSQQIRXWERHSVGSR½VQEXMSR[MXLMRLSYVWSJVIGIMZMRKXLITVSSJ RECOMMENDED FORMAT FOR CASE RECORDS OF WLSYPHFIMRGPYHIHMRXLI³GSRXVMFYXSVWLMT´HIGPEVEXMSR 8LMW[MPPKVIEXP]JEGMPMXEXIXLI7*4XSTVSGIIHXSTVMRXMRK[MXLSYXHIPE]SV FAMILY MEDICINE SECTION XSLEZIXSKSXSTVMRX[MXLSYXXLIGSVVIWTSRHMRKEYXLSV´WGSQQIRXW (IGPEVEXMSRSJ'SR¾MGXWSJ-RXIVIWXThe CASE RECORDS OF FAMILY MEDICINE is newly created series to 8LI7*4VIUYMVIWXLIEYXLSV W XSTVSZMHIJYPPERHHIXEMPIHHIGPEVEXMSRWSJencourage submissions from family medicine teaching programs, family 6ITVMRXW ER]GSR¾MGXWSJMRXIVIWX;LIVIXLIVIEVIRSRITPIEWIYWIXLIJSPPS[MRKmedicine departments to submit cases of learning value to the Singapore GSQTPMQIRXEV]GST]SJXLIEVXMGPI[MPPFIKMZIRXSXLIEYXLSVW%HHMXMSREP HIGPEVEXMSRFamily Physician.±8LIEYXLSV W HIGPEVI W XLEXLIWLIXLI]LEWLEZIRSGSR¾MGXSJ Cases discussed during peer review learning, family GSTMIWGERFISVHIVIHEXEYXLSVW´VEXIWEXXMQISJTVMRXMRK MRXIVIWXMRVIPEXMSRXSXLMWEVXMGPI²medicine grand ward round teachings are just some examples that are suitable for this series. Authors planning to submit their case studies to 'SVVIWTSRHIRGI )RUYMVMIWWLSYPHFIEHHVIWWIHXS the CASE RECORDS OF FAMILY MEDICINE section should structure 8LI,SRSVEV])HMXSV8LI7MRKETSVI*EQMP]4L]WMGMER 6)'311)2()(*361%8*3646-71 4EXMIRXW´6IZIPEXMSRWtheir article according to these headings: 'SPPIKISJ*EQMP]4L]WMGMERW7MRKETSVI EW-RWMKLXJYP7XYHMIWSJXLIMV1EREKIQIRX 7)'8-32Title  'SPPIKISJ1IHMGMRI&YMPHMRK The title should define the key focus of the case study.their article 'SPPIKI6SEH %YXLSVWaccording TPERRMRK to these XS headings: WYFQMX XLIMV GEWI WXYHMIW XS XLI 46-71 WIGXMSR 7MRKETSVI WLSYPHWXVYGXYVIXLIMVEVXMGPIEGGSVHMRKXSXLIWILIEHMRKW 8IP*E\The article submitted to the PRISM section should be written by not Case Presentation: )QEMPmore IHMXSVMEPSJ½GI$GJTWSVKWKthan three authors. Each article should not exceed 2000 words. 8MXPIThe author(s) will provide a pertinent summary of the medical and / Photographs or charts may be included but should conform to the ˆ 8LIXMXPIWLSYPHFIJVEQIHMRXSEUYIWXMSRXSHI½RIXLIOI]JSGYWSJor psychosocial issue pertaining to the health or disease management 'MVGYPEXMSRspecific instructions for any other articles submitted to The Singapore XLIGEWIWXYH]of the case. It should cover the situation and relevant background of 8LIFamily 7MRKETSVI Physician. *EQMP] 4L]WMGMER MW TYFPMWLIH UYEVXIVP] -X MW GMVGYPEXIH the case. Author(s) should conceal the identity of the subject and/or XS EPP *IPPS[W 'SPPIKMEXI 1IQFIVW 3VHMREV] 1IQFIVW ERH%WWSGMEXI 4EXMIRX´WVIZIPEXMSRrelated or accompanying; LEXLETTIRIH#personnel: abbreviation should be used 1IQFIVWSJXLI'SPPIKISJ*EQMP]4L]WMGMERW7MRKETSVIERHXSTVMZEXI ˆ 8LIEYXLSV W [MPPTVSZMHIEGSRGMWIHIWGVMTXMSRSJXLIWIXXMRKSR[LMGLinstead, if necessary. ERHMRWXMXYXMSREPWYFWGVMFIVW-XMWEPWSTYFPMWLIHSRPMRIERHGERFIJSYRH XLIWYFNIGXVEMWIHLMWLIVQIHMGEPSVTW]GLSWSGMEPMWWYITIVXEMRMRKXS EX[[[GJTWSVKWK DiagnosesXLIMVLIEPXLSVHMWIEWIQEREKIQIRX-XWLSYPHGSZIVXLIFEGOKVSYRH / Problems identified IRGSYRXIVERHMRXIVEGXMSRSJTEXMIRX[MXLXLILIEPXLGEVITVSJIWWMSREPThe assessment of the diagnoses / problems identified will constitute 8LI NSYVREP MW EPWS GMVGYPEXIH XS EPP VIPIZERX KSZIVRQIRXTVSJIWWMSREP HSGXSVcase. If the RYVWI case SV was EPPMIH a diagnostic LIEPXLGEVI dilemma, TVSJIWWMSREP %YXLSV W  the author(s) should WLSYPH QIHMGEPERHEGEHIQMGSVKERMWEXMSRWMR7MRKETSVIWMWXIV'SPPIKIWSZIVWIEW GSRGIEPshowcase XLI the MHIRXMX] diagnostic SJ XLI challenges WYFNIGX and ERHSV their VIPEXIH work SVin narrowing EGGSQTER]MRK to ERHXSXLI;SVPH3VKERMWEXMSRSJ2EXMSREP'SPPIKIWERH%GEHIQMIWSJ TIVWSRRIPEFFVIZMEXMSRWLSYPHFIYWIHMRWXIEHMJRIGIWWEV]the correct diagnosis and / or differential diagnoses. +IRIVEP4VEGXMXMSRIVW*EQMP]4L]WMGMERW ;32'% 

T 8 HT , ETHT ) 7 HESH E IES - N 2S I S  G N+ I I A N G%N  P A4G G O 3AP A  RO 6P P  E O )RO * ER FR E %AEF  1 MF AF - IAM A 0L  IM=Y M L  I I Y 4PL L  Y , YHP  = Y P HP  7S Y H H -I  SY'CY I S- ISC %I A I IC C2N A :I I N AVA NNO V3 L OV 0V 4 L OO 6 L L ( 542()  2 J()3(  1 ULY.J)) AN AJAN-SPR%-M2-M-JEPTEMBERAR1UNAR 2% 260  01 15 2 56 : 0 ::? 2 75670 : 63 G U I D E L I N E S A N D I N F O R M A T I O N F O R A U T H O R S

T H E S I N G A P O R E F A M I L Y P H Y S I C I A N

 ;LIVIXLIVIEVIQSVIXLERXLVIIEYXLSVWXLI½VWXXLVIIWLSYPHFI +EMRMRKMRWMKLX;LEXEVIXLIMWWYIW# REQIHERHXLIRJSPPS[IHF]IXEP ˆ 8LIMWWYI W VEMWIHF]XLITEXMIRXWLSYPHFIJVEQIHMRXSUYIWXMSR W  8LIUYIWXMSR W [MPPGSRWXMXYXIETVSFPIQPMWXERH[MPPWIVZIEWEJSGYW  )\EQTPI JSVXLIQEREKIQIRXSJXLMWWYFNIGX  8ER ERH ,S8VIEXXSXEVKIX ETTVSEGL MR QEREKMRK QSHM½EFPI VMWO JEGXSVW SJ TEXMIRXW [MXL GSVSREV] LIEVX HMWIEWI MR TVMQEV] GEVI MR 7XYH]XLIQEREKIQIRX,S[HS[IETTP]MRSYVGPMRMGEPTVEGXMGI# 7MRKETSVI;LEXEVIXLIMWWYIW#%WME4EGM½G*EQMP]1IHMGMRI  ˆ 8LMWWIGXMSRGSZIVWXLIETTVSEGLXSXLIQEREKIQIRXSJXLIWYFNIGX HSM< F] XLI EYXLSV W 8LI EYXLSV W  WLSYPH TVSZMHI E PMXIVEXYVI VIZMI[  %YXLSVW QE] [MWL XS JEQMPMEVMWI XLIQWIPZIW [MXL XLI %1% WX]PI SJGYVVIRXIZMHIRGIMJER]SJXLIFEWMWSJXLIWYFNIGX´WQEREKIQIRX JSV XLI GMXMRK SJ VIJIVIRGIW JSV &MS1IHMGEP TYFPMGEXMSRW EX [[[ SVXSLMKLPMKLXXLIKETWSJORS[PIHKIMJWYGLIZMHIRGIMWPEGOMRK8LI EQEQERYEPSJWX]PIGSQ EYXLSV W  [MPP WYKKIWX [E]W XS ETTP] XLI RI[ ORS[PIHKI MR GPMRMGEP TVEGXMGISVXSLMKLPMKLXXLIPMQMXEXMSRWSJMXWETTPMGEXMSRWMJER] 8EFPIW 8EFPIWWLSYPHFIWYFQMXXIHSREWITEVEXITEKI0EFIPXLIQMRVSQER 'SRGPYWMSR RYQIVMG WIUYIRGI ?------ IXGA ERH IRWYVI XLI] EVI GPIEV ERH [MXL ˆ 8LIEYXLSV W [MPPTVSZMHIEGSRGMWIWYQQEV]SJXLIPIWWSRWPIEVRX I\TPEREXSV]PIKIRHWEWVIUYMVIH JVSQXLMWGEWIWXYH]

-PPYWXVEXMSRW 8LIEVXMGPIWYFQMXXIHXSXLI46-71WIGXMSRWLSYPHFI[VMXXIRF]RSX ˆ -PPYWXVEXMSRW QYWX FI WYFQMXXIH MR E WITEVEXI TEKI ERH WLSYPH FI QSVIXLERXLVIIEYXLSVW)EGLEVXMGPIWLSYPHRSXI\GIIH[SVHW TVSZMHIH[LIRIZIVETTVSTVMEXI-PPYWXVEXMSRWWLSYPHFIGMXIHMRXLIXI\X 4LSXSKVETLW SV GLEVXW QE] FI MRGPYHIH FYX WLSYPH GSRJSVQ XS XLI ;LIRVIUYMVIHMXMWXLIEYXLSV´WVIWTSRWMFMPMX]XSSFXEMRTIVQMWWMSR WTIGM½GMRWXVYGXMSRWJSVER]SXLIVEVXMGPIWWYFQMXXIHXS8LI7MRKETSVI XSVITVSHYGIMPPYWXVEXMSRW%YXLSVWRIIHXSIRWYVIXLEXTLSXSKVETLW *EQMP]4L]WMGMER MPPYWXVEXMSRWERH½KYVIWHSRSXGSRXEMRER]MRJSVQEXMSRXLEX[MPPVIZIEP  XLI MHIRXMXMIW SJ XLI TEXMIRXW ERH EYXLSVW*VSQ  .ERYEV] EPP 6IZMWIH1ERYWGVMTX7YFQMWWMSR TLSXSKVETLWERHMPPYWXVEXMSRWXEOIRJVSQER]LYQERWYFNIGXQYWXFI 1ERYWGVMTXW QE] FI VIXYVRIH XS XLIMV VIWTIGXMZI EYXLSVW JSV VIZMWMSR EGGSQTERMIHF]XLIVIWTIGXMZIIRHSVWIHGSRWIRXJSVQ'PIEVGETXMSRW 8LMW[MPPFIEGGSQTERMIHF]ER)HMXSV´WIQEMPJSV[LMGLGSQQIRXWERH TheXSXLI½KYVIWWLSYPHFITVSZMHIH Singapore Family Physician is published quarterly. It is circulated to all VIGSQQIRHEXMSRWQE]FIQEHI8LIEYXLSVWEVIEHZMWIHXSVIEHERH Fellows, Collegiate Members, Ordinary Members and Associate XS XEOI RSXI SJ XLIWI GSQQIRXW GEVIJYPP] ERH XS VIZMWI XLIMV EVXMGPIW %RSR]QMWIH8I\XMembers of the College of Family Physicians Singapore, and to private EGGSVHMRKP]8LIEYXLSVWRIIHXSVITP]XSXLIIHMXSV´WIQEMPXSSYXPMRIXLIMV %WXLISVMKMREPEVXMGPI[MPPFIWYFNIGXIHXSEHSYFPIFPMRHIHTIIVVIZMI[and institutional subscribers. It is also published online and can be found VIWTSRWIFIJSVIXLIVIWYFQMWWMSRSJXLIVIZMWIHQERYWGVMTX8LI]WLSYPH TVSGIWWEPPMHIRXM½GEXMSRSJREQIWERHMRWXMXYXMSRWLEZIXSFIVIQSZIHat www.cfps.org.sg. I\GPYHIXLIMHIRXMX]SJXLIEYXLSVWERHXLIMVMRWXMXYXMSRWEWXLIIQEMP JVSQXLMWZIVWMSRXSJEGMPMXEXIXLITIIVVIZMI[TVSGIWW QE]FIVIHMVIGXIHXSXLIVIZMI[IVWHYVMRKXLIVIWYFQMWWMSRTVSGIWW8LI The journal is also circulated to all relevant government, professional, VIWYFQMXXIHQERYWGVMTXWWLSYPHMRGPYHIXLIVIZMWIHGSQTPIXIZIVWMSREW %YXLSV'SRXVMFYXSVWLMTJSV3VMKMREP%VXMGPI7YFQMWWMSRmedical and academic organisations in Singapore, sister Colleges overseas [IPPEWXLIERSR]QMWIHZIVWMSREWFIJSVI %YXLSVHIXEMPWQYWXFIMRGPYHIHMRXLIVIPIZERX½IPHW[LIRWYFQMXXMRKERand to the World Organisation of National Colleges and Academies of EVXMGPI3RP]XLSWI[LSLEZIQEHIWYFWXERXMEPGSRXVMFYXMSRWXSXLIWXYH]General Practitioners/ Family Physicians (WONCA). 4VSSJW ERHSVTVITEVEXMSRSJXLIEVXMGPIWLSYPHFIEGORS[PIHKIHEWEYXLSVWERH 4VMSV XS TYFPMGEXMSRXLI )HMXSVMEP8IEQ[MPP GST]IHMX XLI EVXMGPI XS ½X REQIHMRJYPP8LI7*4JSPPS[WXLI-RXIVREXMSREP'SQQMXXIISJ1IHMGEP XLIJSVQEXSJXLI.SYVREP8LIEYXLSV[MPPFIWIRXXLIGST]IHMXIHTVSSJ .SYVREP)HMXSVW -'1.) GVMXIVMETIVXEMRMRKXSEYXLSVWLMT VIJIVXSLXXT SJXLIEVXMGPIERHXLIEYXLSVWLSYPHVIEHGEVIJYPP]XLITVSSJERHKMZI [[[MGQNISVKIXLMGEPCEYXLSVLXQP 8LITVIGMWIVSPI W SJIEGLEYXLSV GSQQIRXWERHSVGSR½VQEXMSR[MXLMRLSYVWSJVIGIMZMRKXLITVSSJ WLSYPHFIMRGPYHIHMRXLI³GSRXVMFYXSVWLMT´HIGPEVEXMSR 8LMW[MPPKVIEXP]JEGMPMXEXIXLI7*4XSTVSGIIHXSTVMRXMRK[MXLSYXHIPE]SV XSLEZIXSKSXSTVMRX[MXLSYXXLIGSVVIWTSRHMRKEYXLSV´WGSQQIRXW (IGPEVEXMSRSJ'SR¾MGXWSJ-RXIVIWX 8LI7*4VIUYMVIWXLIEYXLSV W XSTVSZMHIJYPPERHHIXEMPIHHIGPEVEXMSRWSJ 6ITVMRXW ER]GSR¾MGXWSJMRXIVIWX;LIVIXLIVIEVIRSRITPIEWIYWIXLIJSPPS[MRK GSQTPMQIRXEV]GST]SJXLIEVXMGPI[MPPFIKMZIRXSXLIEYXLSVW%HHMXMSREP HIGPEVEXMSR±8LIEYXLSV W HIGPEVI W XLEXLIWLIXLI]LEWLEZIRSGSR¾MGXSJ GSTMIWGERFISVHIVIHEXEYXLSVW´VEXIWEXXMQISJTVMRXMRK MRXIVIWXMRVIPEXMSRXSXLMWEVXMGPI² 'SVVIWTSRHIRGI )RUYMVMIWWLSYPHFIEHHVIWWIHXS 8LI,SRSVEV])HMXSV8LI7MRKETSVI*EQMP]4L]WMGMER 6)'311)2()(*361%8*3646-71 4EXMIRXW´6IZIPEXMSRW 'SPPIKISJ*EQMP]4L]WMGMERW7MRKETSVI EW-RWMKLXJYP7XYHMIWSJXLIMV1EREKIQIRX 7)'8-32 'SPPIKISJ1IHMGMRI&YMPHMRK 'SPPIKI6SEH %YXLSVW TPERRMRK XS WYFQMX XLIMV GEWI WXYHMIW XS XLI 46-71 WIGXMSR 7MRKETSVI WLSYPHWXVYGXYVIXLIMVEVXMGPIEGGSVHMRKXSXLIWILIEHMRKW 8IP*E\ )QEMPIHMXSVMEPSJ½GI$GJTWSVKWK 8MXPI ˆ 8LIXMXPIWLSYPHFIJVEQIHMRXSEUYIWXMSRXSHI½RIXLIOI]JSGYWSJ 'MVGYPEXMSR XLIGEWIWXYH] 8LI 7MRKETSVI *EQMP] 4L]WMGMER MW TYFPMWLIH UYEVXIVP] -X MW GMVGYPEXIH XS EPP *IPPS[W 'SPPIKMEXI 1IQFIVW 3VHMREV] 1IQFIVW ERH%WWSGMEXI 4EXMIRX´WVIZIPEXMSR;LEXLETTIRIH# 1IQFIVWSJXLI'SPPIKISJ*EQMP]4L]WMGMERW7MRKETSVIERHXSTVMZEXI ˆ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

T 8 HT , ETHT ) 7 HESH E IES - N 2S I S  G N+ I I A N G%N  P A4G G O 3AP A  RO 6P P  E O )RO * ER FR E %AEF  1 MF AF - IAM A 0L  IM=Y M L  I I Y 4PL L  Y , YHP  = Y P HP  7S Y H H -I  SY'CY I S- ISC %I A I IC C2N A :I I N AVA NNO V3 L OV 0V 4 L OO 6 L L ( 542()  2 J()3(  1 ULY.J)) AN AJAN-SPR%-M2-M-JEPTEMBERAR1UNAR 2% 260  01 15 2 56 : 0 ::? 2 75670 : 64