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Asian Journal of Oral and Maxillofacial Surgery 23 (2011) 99–101
Contents lists available at ScienceDirect
Asian Journal of Oral and Maxillofacial Surgery
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / a j o m s
Case report
Large epidermoid cyst in lateral floor of mouth and submandibular region
Emiko Tanaka Isomura a,∗, Yudai Matsuokab, Munehiro Hamaguchic, Yumi Yamamoto d, Kouji Yonemitsue
a First Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, 1-8 Yamadaoka, Suita City, Osaka, 565-0871, Japanb Department of Oral and Maxillofacial Surgery, Yao Municipal Hospital, 1-3-1 Ryugatyou, Yao City, Osaka, 581-0069, Japanc Department of Oral and Maxillofacial Surgery, Yao Municipal Hospital, 1-3-1 Ryugatyou, Yao City, Osaka, 581-0069, Japand Department of Oral and Maxillofaial Surgery, Kojima Central Hospital, 3685 Ogawatyou, Kojima, Kurashiki City, Okayama, 711-0912, Japane Department of Oral and Maxillofaial Surgery, Kojima Central Hospital, 3685 Ogawatyou, Kojima, Kurashiki City, Okayama, 711-0912, Japan
a r t i c l e i n f o
Article history:
Received 25 October 2010
Received in revised form
28 December 2010
Accepted 20 January 2011
Available online 5 March 2011
Keywords:
Epidermoid cyst
Dermoid cyst
Floor of mouth
Submandibular region
a b s t r a c t
Epidermoid cysts are infrequently found in the oral and neck region. Among the cases reported, several
noted large epidermoid cysts are located in the floor of the mouth, with a maximum size of about 8 cm.
Herein, we present a case of a large epidermoid cyst sized 11cm × 9 cm×9 cm, which was located in the
floor of the mouth and reached the submandibular area across the mylohyoid muscle.
© 2011 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights
reserved.
1. Introduction
Epidermoid cysts or dermoid cysts, which arise as a result of
failure of the surface ectoderm to separate from the underlying
structures, are filled with a keratinous sebum-like material with
the evidence of skin derivatives. They are rarely found in the oral
and neck region. Typical characteristics of epidermoid cysts or der-
moid cysts include slow growth, presentation in early adult life as
asymptomatic swelling that may occasionally cause elevation of
the tongue, interference with speech, and double-chin appearance.
There are several reports of cases of large epidermoid cysts or
dermoid cysts located in the floor of the mouth, with a maximum
size of about 8 cm [1–3]. Herein, we report a patient with a large
epidermoid cyst located in the floor of the mouth that reached to
the submandibular area.
2. Case report
A 77-year-old Japanese female was referred to Yao Municipal
Hospital forpainlessswelling in thefloor of themouthand left sub-
mandibular area on May18, 2009. The patient hadnoticed swelling
in the floor of the mouth about 10 years previously, but did not
∗ Corresponding author. Tel.: +81 6 6879 2936; fax: +81 6 6976 5298.
E-mail address: [email protected] (E.T. Isomura).
seek medical attention. The lesion had gradually increased in size,
extending to the submandibular area, and she began to have dif-
ficulties while speaking because of the elevation of tongue. We
observed a large submandibular swelling and a large mass in the
floor of the mouth, while the tongue elevation was also noticeable
(Figs. 1 and 2). The lesion was fluctuant on palpation but not ten-
der, and no lymphadenopathy was noted. The patient had no other
significant medical history.
Computed tomography (CT) revealed a cystic lesion sized about
11cm× 9 cm ×9 cm in the floor of the mouth that extended to the
submandibular area across the mylohyoid muscle (Fig. 3). An axial
CT section showed that the mass caused the airway to become nar-
rowed, a coronal CT section showed that the mass swelled greatly,
and a sagittal showed that the mylohyoid muscle could be faintly
observed. No other abnormalities were noted in clinical examina-
tions.
The cyst was removed through an extraoral approach under
general anesthesia on June 5, 2009. During the procedure, a sickle-
shaped skin incision was made two fingerbreadths inferior to the
angle of the left mandible, then the platysma was divided and the
cystic wall was located. Next, the inferior border of the cystic wall
was separated from surrounding tissue, then the anterior border
and posterior border of the wall were also separated. Once, dissec-
tion of theinferiorpole wascompleted, cysticfluid wasaspirated to
reduce the mass of the lesion and facilitate control of the superior
pole of the cyst. The cystic fibrous attachment to the mylohyoideus
0915-6992/$ – see front matter © 2011 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ajoms.2011.01.004
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100 E.T. Isomura et al. / Asian Journal of Oral and Maxillofacial Surgery 23 (2011) 99–101
Fig. 1. Pre-operative photograph showing a submental mass: (A) a view from patient’s front side; (B) a view from patient’s left side.
Fig. 2. Intraoral photograph of mass in left oral floor.
musclewas released,afterwhichthe cyst wascompletely freed and
removed. The inside of the cyst was filled with brown muddy fluid
(Fig. 4).
Histological examination findings revealed that the cyst con-
sisted of stratified squamous cell epithelium with keratin piling
Fig. 4. Photograph of surgical specimen. The inside of the cyst is full with brown
muddy fluid.
into the lumen, which were consistent with an epidermoid cyst.
The underlying connective tissue contained blood vessels, fibrous
tissue, and inflammatory cells (Fig. 5).
Following the operation,difficulty while speaking due to tongue
elevation disappeared. There was no evidence of recurrence after 1
year.
Fig. 3. Computed tomography (CT) revealed the cystic lesion whose size is 11 cm×9 cm×9 cm for both the floor of the mouth and the submandibular area across the
mylohyoid muscle: (A) an axial section at the level of the submandibular area; (B) a coronal section at the mandibular ramus (arrow shows the mylohyoid muscle); (C) a
sagittal section at the left side of oral floor.
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E.T. Isomura et al. / Asian Journal of Oral and Maxillofacial Surgery 23 (2011) 99–101 101
Fig. 5. Histological finding. The cyst is consisted of stratified squamous cell epithe-
lium with pilling of keratim into the lumen. The underlying connective tissue
contains blood vessels, fibrous tissue and inflammatory cells (HE, ×400).
3. Discussion
Among the cases reported,several noted large epidermoid cysts
that exist at midline such as submental or sublingual space, but
a lateral large epidermoid cyst like our case was not reported. In
a lateral case, it is considered that it is easy to be discovered at
the early stage before it becomes large because the face becomes
asymmetry. In the present case, the patient had noticed the mass
previously, but did not seek medical attention. Over the time, the
mass enlarged, and finally made speaking difficult and narrowed
the airway. A previous case study reported a female who noted a
cystic mass over a period of 9 years, however, its size was only
4 cm× 5 cm [4]. The present patient had noticed the swelling about
10 years prior. When considering its final size, we thought that she
should have noticed it earlier.
Classification of cysts is commonly performed based on his-tological findings or location [5,6]. Historically, the generic term
“dermoid cyst” has been used to describe 3 histologic vari-
eties, epidermoid cyst (lined with simple squamous epithelium
with a fibrous wall and no adnexal structures), true dermoid
cyst (an epithelial-lined cavity with keratinization and with skin
appendages),and teratoid cyst (linedwith a range of epithelia, from
simple squamous epithelium to ciliated respiratory type, contain-
ing derivatives of ectoderm, mesoderm, and endoderm). However,
Teszler et al. proposed a comprehensive anatomo-surgical classi-
fication: suprageniohyoid, infrageniohyoid, and sublingual, which
are 3 types of supramylohioid cysts (intraoral or sublingual),
submental and submandibular, which are 2 types of inframy-
lohyoid cysts (cervical), submental transmylohyoid, and lateral
peri-mylohyoid andtransmylohyoid, which are2 types of peri- and
transmylohyoid cysts (dual intraoral and cervical) [6].
Recently, intraoral approaches have been commonly performed
to remove a dermoid cyst, while there is also a report of a median
glossotomy technique that was found useful for cases of suprage-
niohyoid cysts [2]. However, several studies have noted that an
extraoral incision is necessary when the cyst is under the genio-
hyoid muscle or mylohyoid muscle [2,5]. The present case was alateral perimylohyoid or transmylohyoid cyst whose origin might
have been the sublingual space, and the operation was performed
under an extraoral approach. We also reduced the mass by aspi-
ration of the cystic fluid following dissection of the cyst wall, due
to its large size. This technique was reported by Di Francesco et al.
and found to make removal of such cysts easier [7].
In this case, the patient did not complain of dyspnea but CT sec-
tion showed clearly that the mass caused the airway to become
narrowed. It is necessary to remove before a cyst provokes an
episode of airway narrowing, while an extreme case like this is
rare. Additionally, epidermoid cysts and dermoid cysts are com-
mon benign lesions, though a few reports have found that they can
transform into malignant tumors [8–12]. Thus, it is important to
remove a cyst before the opportunity for malignancy.
References
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