Lumps and swellings

Prepared by :Jamal Q Ahmed

Supervised by: Prof. Ali Al.Zubaidi

Lumps and swellings Swelling and lumps in the mouth are common,

and the tongue often detects even very small swellings or patients may notice a lump because it is sore. Some individuals discover worry about normal anatomical features such as parotid papilla, foliate papillae on the tongue, or the pterygoid hamulus. Many oral cancers may be diagnosed far too late, often after being present several months , because the patient ignores swelling. Some lumps become ulcerated as in various bullous lesions or malignant neoplasms.

Causes The mouth’s normal anatomy

Pterygoid hamulus Parotid papillae Foliate papillae

Developmental Maxillary and mandibular tori Unerupted teeth Heamangioma Lymphangioma Hereditary gingival fibromatosis Von Recklinghausen’s neurofibromatosis

CONTD Inflammatory

Abscess Pyogenic granuloma Crohn’s disease Sarcoidosis Wegener’s granulomatosis Infections Insect bites

Traumatic

Heamatoma / epulis / epithelial polyp / denture granuloma

CONTD Cystic

Eruption cyst Developmental cysts Cyst of infective origin

Hormonal Pregnancy epulis Oral contraceptive ( pill gingivitis )

Drugs Phenytoin Ciclosporin Calcium channel blockers

CONTD Blood dyscriasis

Leukemia and lymphoma Benign neoplasms

Viral lesions like papillomas, common warts, genital warts ( condyloma acuminatum ), heck’s disease

Fibro-osseous lesions like fibrous dysplasia, paget’s disease

Malignant neoplasms Others

Angioedema / Amyloidosis

Diagnosis Position: the anatomic position should be defined

as accurately as possible. The proximity of the lumps other structures ( e.g. teeth, dentures) should be noted. Does the swelling has an orifice, or sinus? If fluid is draining from the opening, is it clear, cloudy or purulent? Other similar or relevant changes elsewhere in the oral cavity should be noted. Midline lesions tend to be developmental e.g. Torus

palatinus Determine whether the lump is bilateral, Since most

neoplastic lumps are unilateral

CONTD Number of swellings, particularly with regard to whether the

lesion is bilaterally symmetrical and thus possibly anatomical. Multiple lesions suggest an infective or occasionally developmental origin

Size: The size should always be measured and recorded. Thus, significant changes which may occur later can be recognized.

Shape: many swellings have characteristic shapes which point towards the diagnosis. Thus swelling of the parotid gland often fills in the space, between the posterior border of the mandible and the mastoid process.

CONTD Color and temperature: brown or black

pigmentation may be due to a variety causes such as melanoma. Purple or red lesions may be due to an angioma or Kaposi sarcoma. Is the lump pale in color suggesting underlying fibrosis, or soft tissues stretched over bony enlargement :red ( suggesting inflammation ) : or deep red ( suggesting heamangioma or giant cell epulis )? Any variation in color with in the lump e.g. a pointing abcess should be observed. The skin and mucosa overlying acute inflammatory lesion, such an abscess, is frequently red and warm

CONTD Tenderness: inflammatory swellings such as an

abscess are characteristically tender, although clearly palpation must be gentle to avoid excessive discomfort to the patient

Discharge: note any discharge from the lesion ( clear fluid, pus, blood)

Movement: the mobility of any swelling should be tested to determine if it is fixed to adjacent structures or the overlying skin/ mucosa such as a neoplasm

CONTD Consistency: this may vary from soft and

fluctuant to hard. Fluctuation refers to the presence of fluid within a swelling such as a cyst. This sign is elicited by directing movement of fluid when the swelling is compressed. Palpation may then help assessment of it’s contents and these can be put into such categories as fluid ( fluctuant because of cyst fluid, mucus, pus or blood), soft, firm, or hard like a carcinoma ( indurant).

CONTD Palpation may cause release of fluid ( e.g. pus from an

abscess) or cause the lesion to blanch ( vascular) or occasionally cause a blister to appear or expand ( Nikolsky sign). some times palpation cause the patient pain ( suggesting an inflammatory lesion). The swelling overlying a bony cyst may crackle ( like an egg-shell) when palpated. Palpation may disclose an underlying structure (e.g. the crown of a tooth under an eruption cyst) or show that the actual swelling is in deeper structures ( e.g. submandibular calculus). Bimanual manual palpation should be used when investigating lesions in the floor of the mouth, cheek, and occasionally the tongue

CONTD Surface texture; the surface texture may

vary from uniform smooth texture of many fibrous lumps to the grossly irregular. Papillomas have an anemone-like appearance. Carcinomas tend to have a nodular surface and

may ulcerate. Ulceration: the character of edge of ulcer,

ulcer base appearance should be noted. Also induration of ulcer should be noted.

CONTD Margin: the margins of the swelling may be well

defined or poorly defined. This may give some indication of the underlying pathology. Ill defined margin are frequently associated with malignancy, where as clearly defined margins are suggestive of benign growth.

Associated swelling: some conditions are associated with multiple swellings of a similar nature ( e.g. neurofibromatosis).

Investigation Any teeth adjacent to a lump involving the jaw should be

tested for vitality, and any caries or suspect restorations investigated

The periodontal status of any involved teeth should also be determined.

Imaging is required whenever lumps involve the jaws, and should show the full extent of the lesion and possibly other areas. Special radiograph ( e.g. the skull, sinuses, salivary gland function), CT, MRI or Ultrasonography may be indicated.

The medical history should be fully reviewed as systemic disorders may be associated with intraoral or facial swellins. Blood tests or endocrine function test may be needed.