A 50 y.o. man presents with sinus congestion and deafness in the R ear

When you look in his mouth you see what is pictured below.

you notice an ulcerated mass on the palate directly in the midline.  What is this?

Our patient had a basaloid poorly differentiated squamous cell carcinoma. The mass extended through the palate into the sinus. 

The differential for lesions of the palate is interesting and ranges  from benign to malignant.  Nicotine stomatitis is common and caused by nicotine irritation of salivary glands. It appears initially as whitish patches of hyperkeratosis and keratotic papules with red centers.  A second benign lesion is necrotizing sialometaplasia.  This is caused by ischemia of the salivary glands of the palate ( often caused by dentures or vasoconstriction from cocaine)  It is thought that long term use of salbutamol might lead to thinning of the mucosa making it more susceptible to trauma.  A biopsy is often necessary to prove this is not cancer.

nicotine stomatitis

necrotizing sialometaplasia

Lesions of the palate can also be malignant. 50% ofall hard palate cancers are squamous cell carcinoma.  In addition to squamous cell CA , sarcomas, adenoid cystic carcinoma, mucoepidermoid ca, adenocarcinoma,  melanomas and  salivary gland tumors are found in the palate. .  Lethal midline granuloma   renamed NK-T cell lymphoma is a particularly devastating form of cancer leading to destruction of the midface.  It can be treated with radiation but has a very poor prognosis.

lethal midline granuloma

Our patient is being prepared  for surgery. Clinical pearl:  Remember to look in the mouth on your patients. 

Fowler CB. Brannon RB. Subacute necrotizing sialadenitis: Report of 7 cases and a review of the literature. Oral SurgOral Pathol Oral Radiol Endod. 200:89:600-9.

Carlson DL. Necrotizing sialometaplasia: A practical approach to the diagnosis. Arch Pathol Lab Med 2009;133:692-8. 

Ghosh, SN, Dey SK, Chattergee C. Lethal Midline Granuloma.  Indian J Derm 1995;40:53-4.