Chronic lingual ulceration caused by lipoma of the oral cavity.
Case report

DEL CASTILLO-PARDO DE VERA JL , CEBRIÁN-CARRETERO JL, GÓMEZ-GARCÍA E. CHRONIC LINGUAL ULCERATION CAUSED BY LIPOMA OF THE ORAL CAVITY. CASE REPORT. MED ORAL 2004;9:163-7.

SUMMARY

Although lipomas are among the most frequent tumors in the human body, their presentation in the oral cavity is not common. Oral cavity lipomas usually show a slow painless and assymptomatic growing. When these tumors reach big sizes, they can cause compressive symptons and deformities.
In this paper we present the case of a patient in whom oral lipoma was the final finding in the differential diagnosis of a chronic mucosal ulcer. CT scan and MRI images and microscopical examination after fine-needle aspiration were the clue for the final diagnosis. The surgical excision of the tumor was the basis for the healing of the ulcer.
We also review the most relevant and recent literature about clinic, diagnosis and treatment for these tumors.

Key words: Oral lipoma, oral cavity tumors, chronic lingual ulcer.

INTRODUCTION

Oral lipoma is a bening tumor made of mature fat tissue which main characteristic is its slow and assymptomatic growing. Sometimes it shows a progressive growing pattern which causes compressive symptons and orofacial deformities.

Although it is one of the most frequent tumor of the body, the oral location is a rarity. In this sense, international literature references are mainly case reports in which lipomas of the buccal mucosa and the tongue are the cause of orofacial deformities (1)

In this work, we show the case of an oral lipoma which clinical presentation was a chronic and persistent lingual and floor of the mouth ulcer. This ulcer didn't heal after the supression of traumatic and irritant factors. We focus on the diagnosis procedures and surgical treatment, and we also review the international literature concerning about the clinical presentation, microscopical characteristics, diferential diagnosis and treatment of oral lipomas.

CASE REPORT

We show the case of a 74 years old male referred to our Department of Oral and Maxillofacial Surgery for the evaluation of a lingual and floor of the mouth chronic ulcer which hadn't showed regression after the elimination of irritative agents -alcohol, smoke and sharp teeth cuspids-.

Medical history included allergy to b-lactamics and risk factors, smoking and mil alcohol use, which had been iabandoned in the last few months.

Intraoral examination showed a deficient oral hygiene and partial edentulism. The right lateral border of the tongue and the right lateral floor of the mouth showed a 2 cm painful ulcer with ill defined margins placed in the region of friction of the mandibular first molar. Nevertheless, the most relevant finding was the diffuse swelling of the floor of the mouth that pushed the tongue to the palate. That swelling had not been notice by the patient or his family even when he had difficulties to pronounce some words. The patient didn't show dysphagya or disnea. .

There were not cervical masses or salivary gland alterations.

Intraoral X-rays didn't show dental or oral hard tissues alterations.

The patient was included in our protocol for the treatment of chronic oral cavity ulcer and the following exams were performed.

First at all incisional biopsy was performed under local anestesia. The histologic exam revealed chronic inflamation without malignant cells.

We also performed a CT scan and a MRI of the neck and the face. The images were informed as a well defined encapsulated tumor placed into the tongue intrinsic muscles with radiological density and intensity of fat tissue (figure 1).

Finally, an aspiration-needle biopsy of the mass was performed, and the result was adult fat tissue without histological alterations.

We decided the surgical treatment of the mass (figure 2) that was performed under general anestesia with endotracheal intubation. The fat tissue mass was excised using a linear incisión in the ventral raphe of the tongue that allowed the access to the intrinsic muscles that were released using blunt dissection (figure 3 and 4). The incisión was closed using reabsorbable sutures with a Z-shaped plasty in the raphe incisión.

Postoperative course was uneventful, and the patient was discharged a few hours after surgery.

The histologic exam of the surgical specimen showed a capsulated lipoma (figure 5).

The excision of the tumor and the repositioning of the tongue in its bed allowed the resolution of the ulcer. Thanks to the Z-plasty and the midline approach the patient didn't show neurological sequelae or tongue motility disturbances.

DISCUSSION

The case here presented is of special interest for the oral surgeon due to two facts.

- First at all, it open the discusión to the differential diagnosis of the chronic ulcer of the oral mucossa.

- And it shows an infrequent oral cavity tumor, the lipoma, as the cause of this ulcer.

In this discusión we foccused on this last aspect, because it gives the peculiarity to the case. Nevertheless, it is very important to remember that any ulcer of an evolution of more than 2 or 3 weeks, that shows no remmission after the solution of local irritant factors must be evaluated and eventually biopsied by an oral surgeon (2, 3).

Lipomas are very frequent tumors in the human body, but their aparition in the oral cavity is exceptional (2), being no more of 4% of the tumors in this region in different studies (1, 4, 5). Buccal mucossa, floor of the mouth and tongue are the most frequent locations inside the oral cavity. Usually they are lonely lessions, covered by a thin layer of mucosa (6). Sometimes they are múltiple in some síndromes as Gardner's or Bourneville's (7).

They are usually slow growing lession that appear in the fourth and fifth decade without sexual predilection (8,9).

Their ethiology is unknown, but some risk factors, like trauma, infection, chronic irritation and hormonal alterations (10).

The clinical course is usually assymptomatic until they get a big size. If they come from the subcutaneous tissue they cross the mylohyoid muscle to appear in the floor of the mouth (7). In other cases they can cause pain due to infections caused by accidental trauma (e.g. bad fitted dentures). They seldom masticatory or deglutory alterations and dentofacial deformities with anterior open bite (1).

The radiological appearance is characteristic. CT scan shows a density from 83 to 143 Hamsfield units with well or bad defined margins deppending on the capsule. In the ecography, they hypoecoic lessions, and in the MRI they are hyperintense tumors in T1 and T2 (11)

Differential diagnosis includes ranula, dermoid cyst, tyroglosal duct cyst, pleomorphus adenoma and mucoepidermoid carcinoma (2). The definitive diagnosis is microscopical, showing adult fat tissue cells (9) embebed in a stroma of connective tissue and surrounded by a fibrous capsule (1, 9). In this sense there are two different microscopical cases: a circunscribed superficial form and a invasive intramuscular one. Although sometimes they can show atypia, malignant transformation is exceptional (7)

The malignant counterpart for the lipoma is the liposarcoma. Sometimes they are undishtinguible, nd the only posible dinstiction is inmunohistochemistry against protein apAhor-2 (9).

The treatment of the lipoma is surgical excision including a little cuff of surrounding tissue to prevent local recurrences (12) but being conservative to the neighbourgh structures.

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