History of the present illness

This is an 82-year-old white male who first presented to the UW otolaryngology clinic for ear pain, drainage and hearing loss. He was also complaining about generalized oral ulcers. He was referred to the oral medicine clinic at the UW School of Dentistry to evaluate generalized palatal and gingival painful ulcers (Figures 1-3) of at least six months duration. The ulcerated areas include the hard palate (Figure 1) and the maxillary (Figure 2) and mandibular (Figure 3) gingiva, both buccal/facial and lingual/palatal. The ulcers were mostly superficial and flat; however, in focal areas, especially on the palate, they were associated with swelling and had rolled borders. The ulcers are described as painful and persistent. The patient also complained of episodes of epistaxis and painful ears with drainage and hearing loss. The patient's first oral biopsy showed lichenoid mucositis with tissue eosinophilia but the patient did not respond to the conventional treatment for lichen planus or lichenoid drug reaction. The lesions got progressively worse.

Figure 1 This photograph was taken at first presentation where diffuse superficial to focally rolled bordered ulcers are noted involving the hard palate and palatal gingiva.

Figure 2 This photograph was taken at first presentation where diffuse superficial ulcers are noted to involve the maxillary buccal gingiva.

Figure 3 This photograph was taken at first presentation where diffuse superficial ulcers are noted to involve the mandibular buccal gingiva.