Difficulties in Diagnosing Lesions

in the Floor of the Mouth Report of Two Rare Cases

MS Tan, BDS, MDS and Singh, BDS, MDS
Ann Acad Med Singapore 2004; 33 (Suppl): 72S 76S

Presented by :
Gatot Widyatmo P
Supervisor :
drg. Masykur Rakhmat, Sp.BM (K)

Introduction
The floor of the mouth: 4th week of gestation
downward growth and subsequent
degeneration of ectoderm surrounding the
peripheral of the tongue forming lingual
sulcus.
The anterior boundary: 6th week of gestation
formation of Merkels cartilage ossify to
form mandible.

 Thickening of oral epithelium:

ectomesenchyme proliferation buds,
morphogenise and cytodifferentiate
salivary gland, entwine with a network of
nerve, blood vessel and lymphatic system.
Association of the floor of the mouth and
mediastinum layers of neck muscles bridge
two anatomical space infection from the
floor of the mouth will tract along these
muscle planes down to the vital structure in
the mediastinum.

 Lesions of the floor of the mouth confined

structures in anatomical space, except
thyroglossal tract cyst.
Table 1 list of possible lesions of the floor of
the mouth, but often manifest with a swelling
that mimics
another clinically.
Inflammatory/trauma
Mucus retention (Ranula)

Developmental

Dermoid cyst

Epidermoid cyst

Lymphoepithelial cyst

Neoplasm

Lipoma

Salivary gland tumour

Benign mesenchymal
tumours

Case Reports
Case 1
A chinese man, 55 years old, fluctuant swelling on
the right floor of the mouth, asymptomatic,
unaware of its presence. The lesion resembled a
bulk of excess soft tissue at the floor of the mouth
herniating through edentulous ridge and became
more obvious when he raised his tongue.
Bimanual palpation delineated a fluctuant mass
measuring approximately 15 mm in diameter. In
October 2000, from the clinical signs and
symptoms, the diagnosis made was ranula. Local
anaesthesia marsupialisation was performed by
incision and dissection via the mucosa directly
over the crest of the mass yielded a soft,
yellowish lobulated mass.

 The classical sight of an adipose tissue coupled

with a capsule surrounding its peripheral lipoma.
Excision was performed instead and careful
dissection to segregate the lipoma from the
sublingual gland, other associated structures were
not exposed. The lesion measured 20x14x10 mm,
separated in two part, one displace into water to
differentiate its relative density and as a speciment
sent for histopathology. Buoyancy in water
reaffirmed the presence of fatty tissue.
Histopathological examination revealed a benign
tumour composed of several lobules of adipose
tissue lipoma.

 Case 2
A woman, 54 years old, large lump below the left
side of the tongue about 4 months, speech and
masticatory efficiency were affected. The lesion
was asymptomatic and no neurosensory deficit,
firm and non-tender on palpation and measured
4 cm clinically. The differential diagnosis made
included ranula, dermoid cyst and salivary gland
tumour. A CT scan was performed and the
findings indicated a slightly heterogeneous soft
tissue mass measuring 1.8x3.6 cm. No
significant lymphadenopathy was noted.
Excision of the left sublingual mass and the
associated gland was performed under general
anaesthesia.

 The submandibular duct was cannulated and the lingual

nerve protected. The mass and sublingual gland were
excised and sent for histopathological examination. The
biopsy revealed adenoid cystic carcinoma with
characteristic cribiform epithelial nests forming
cylindromatous growth pattern in a fibrous stroma,
occasional solid mass, no neural invasion, the tumour
intact within the capsule and negative for any malignancy
of sublingual gland.
The case was discussed at the multidisciplinary tumour
board and decision was made to give radiation therapy
(60 Gy over 30 fraction) in view of the high risk of local
relapse.
The patient has been on regular follow-up with clinical
and radiographic examination and no evidence of
recurrence.

Discussion
The floor of the mouth lesions can be very
challenging and the common diagnosis of a
ranula for the swelling can be misleading.
Lipoma is a slow growing benign tumour and
intra oral incidence range from 1 - 4.4 %.
Lipid unavailable for metabolism coupled
with the autonomous growth of a lipoma a
true benign neoplasm. The site of occurence
in the intra oral cavity depend on quantity of
fat deposit, the most is cheek, followed by
tongue, the floor of the mouth, buccal sulcus
and vestibule, palate, lips and gingival.

 Intra oral lipomas can be grouped into 2 forms:

- diffuse form affecting the deep tissues
- superficial, encapsulated form
Infiltrating lipoma: encapsulated and invade
into the deep soft tissue, 62.5% of its
recurrence after surgical excision.
Spindle cell lipoma: able to transform to
liposarcoma or fibrosarcoma.
CT scan, USG and MRI are useful adjuvants in
the investigation of lesions of the floor of the
mouth. CT scan has specific range of unit
values which tabulated for lipoma. In USG,
lipoma often appears hypoechoic.

 MRI with soft tissue contrast enables a lipoma to

be isolated and its multiplanar images are
particularly useful in observing infiltration into the
oral floor.
Table 2. Possible Aetiologies of Lipoma
1. Lipoblastic embryonic cell nest in
origin
2. Metaphase of muscle cells
3. Fatty degeneration
4. Hereditary
5. Hormonal cause
6. Trauma induced
7. Infection
8. Chronic irritation
9. Infarction

Lipoma are treated by surgical excision and must

be cautioned as the lesion maybe in contiguous
with vital structures such as the salivary glands
with ducts and the lingual nerve.

 Adenoid cystic carcinoma or cylindroma is the

second most common malignant epithelial tumour,
4 - 8% of all salivary gland tumours, 50 - 70% occur
in minor salivary glands, the submandibular gland
is the most common, slightly higher incidence in
females, presents as a slow growing enlarging mass
with severe pain in 50% of cases, facial nerve
paralysis in 25% of cases and neurosensory deficit
in late stage, able to invade through bone marrow.
Adenoid cystic carcinoma has a history of relentless
recurrences, systemic spread and more progressive
after surgical resection. Histologically, it has
infiltrative capacity and distinct propensity for
perineural invasion by expressing the Brain Derived
Neurotrophic Factor (BDNF).

 The origin of adenoid cystic carcinoma is from the

intercalated duct reserve cell or terminal tube
complex.
3 histological types of adenoid cystic carcinoma with
peripheral nerve invasion:
- Cribiform type, classic histology of nest of cell with
neatly
punched out spaces. Cystic-like spaces are not
true ductal
or glandular lumina but are in continuity with
supporting
connective tissue stroma.
- Tubular type, the tumour cells are arranged in
small nests
separated from one another. True duct lumens
surrounded by

 There is no strong correlation between histologic

type and behaviour of the tumour, but some
argue that the cribiform and tubular types have a
better prognosis, such as size, anatomical
location, facial nerve involvement, presence of
metastases (blood borne 40 60%, lung 40%,
bone, liver, lymph node) and gross residual tumor
after surgery.
Treatment of choice for adenoid cystic carcinoma
is wide to radical excision with postoperative
radiation therapy. Neutron radiotherapy is
considered because of their ability to repair
radiation damage and resistant to conventional
forms of radiotherapy (photons/x-rays, or
electrons). Neutrons deposit 20 100 times more
energy along their path length and so inflict

 Neutron radiotherapy is utilised for patients with

inoperable, recurrent diseases, multiple positive
margins (residual), perineural invasion, spread to
regional lymph nodes and recurrence which
previously treated by conventional forms of
radiotherapy.
Neutron radiotherapy need 16 treatments over 4
weeks period, in otherwise conventional
radiotherapy need 7 8 weeks.
Survival rate if there is distant metastasis: 5 14
years (20%), 2 years (33%), 5 years (80 90%)
and 15 years (10%).

Conclusion
The floor of the mouth lesions: clinically and
surgically, superficial ranula and sialoliths
often simplify as the possible diagnosis.
Lesions range from the most benign ranula to
the sinister carcinoma, investigated by CT
scan, MRI or USG.
Deeply seated lesions of the floor of the
mouth has possible surgical complications,
such as contiguity with vital structures and
resultant infection which could tract down to
the mediastinum.