Diagnostic Information

History of Present Illness Mr. Payton is a 64-year-old male who presents with a one month history of increasing pain involving the left soft palate area. The patient complains of pain when swallowing. He also complains of “irritation” in his left eye. The patient denies skin lesions. A review of his medical history reveals: Medical History - Adverse drug effects: no known drug allergies

- Medications: felodipine, pravastatin

- Pertinent medical history: hypertension; hypercholesterolemia; prostate cancer

- Pertinent family history: paternal - deceased; maternal - deceased

- Social history: social drinker; non smoker Clinical Findings Extraoral examination is unremarkable except for an area of scar tissue formation (symblepharon) between the lateral palpebral and bulbar mucosa in the left eye (Figure 1). Intraoral examination reveals an irregular area of ulceration at the junction of the hard and soft palate on the left side. The ulceration measures approximately 1.0 x 0.5 cm and is surrounded by erythema (Figure 2). An incisional biopsy is performed of the oral lesion and the tissue is submitted for histopathologic examination.

Figure 1. Scar tissue formation (symblepharon) between the lateral palpebral and bulbar mucosa in the left eye.

Figure 2. Ulceration at the junction of the hard and soft palate on the left side.

Histopathologic Findings Histopathologic examination reveals normal appearing surface stratified squamous epithelium and underlying fibrous connective tissue. Subepithelial cleavage at the level of the basement membrane is noted. The maturation of the surface epithelium is within normal limits. The underlying connective tissue is well-vascularized and contains scattered acute and chronic inflammatory cells (Figures 3-4).

Figure 3. Low power histologic image of subepithelial cleavage at the level of the basement membrane.

Figure 4. High power histologic image of subepithelial cleavage at the level of the basement membrane. Inflammatory cells are note din the connective tissue.