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Revista Española de Cirugía Oral y Maxilofacial

On-line version ISSN 2173-9161Print version ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.30 n.4 Madrid Jul./Aug. 2008

 

PÁGINA DEL RESIDENTE

 

What’s your diagnosis?

¿Cuál es su diagnóstico?

 

 

A 60-year-old man with no personal history of other than surgical intervention for maxillary implant rehabilitation one week earlier (Figs. 1 and 2). The patient came to the clinic for intense palatal pain for a week. In the physical examination, we found two ulcerated lesions in the hard palate with irregular, painful, violaceous edges that were hard on palpation (Fig. 3). We started treatment with topical antiseptics and systemic analgesics. Two weeks later, the patient presented evident clinical improvement, with total resolution of the lesions after 7 weeks (Figs. 4 and 5).

 


 

Necrotizing sialometaplasia

Sialometaplasia necrotizante

 

 

C. Moreno García1, F. Monje Gil2, H. Serrano Gil1, O. Maestre1, L. Villanueva Alcohol1, L. Ruiz Laza3, A.J. Morillo Sánchez3, J. Mateo Arias3, R. González García3, P. Quirós Álvarez3, D. Manzano Solo de Zaldivar3

1 Médico Residente.
2 Jefe de Servicio.
3 Médico Adjunto.
Servicio de Cirugía Oral y Maxilofacial.
Hospital Infanta Cristina. Complejo Hospitalario Universitario de Badajoz. España

Correspondence

 

 

Necrotizing sialometaplasia (NS) is a self-limited, benign, inflammatory disease that affects the minor salivary glands. The etiology is not clear. Most authors suggest that a chemical, physical, or biological injury of the blood vessels produces ischemic changes that cause infarction of the glandular tissue, with necrosis, inflammation, and attempted repair. Secondarily, it induces metaplasia, with changes in the ducts and scar tissue formation.1

 

Discussion

NS was described by Abrams et al. in 1973.1,29 The most frequent location is a minor salivary gland of the oral cavity and oropharynx, especially the palate.1,2,5 Cases have been described in the larynx, paranasal sinuses, and locations in the upper airway and digestive tract. The mean age of presentation is 46 years and it is more common in men (2:1). The lesion usually occurs as a firm, erythematous nodule measuring several centimeters in diameter, which often is ulcerated.6-10,14,21 Lesions are bilateral in 20% of cases.1,28 They usually are painful and paresthesia may be associated.

Microscopically, there is coagulative necrosis of minor salivary glands and regenerative hyperplasia of the adjacent salivary ducts with squamous-cell metaplasia. The lesions cure spontaneously in a month or so, depending on their size.1,2,17

The main differential diagnoses of necrotizing sialometaplasia are squamous-cell carcinoma and mucoepidermoid carcinoma.1,2,17

The pathogenesis of NS is debated, but most authors agree that ischemia is an important mechanism.19,22-27 NS has been described in association with severe non-neoplastic conditions that produce vascular obliteration, such as injections of local anesthetic, local surgical trauma, dental prostheses, arteriosclerosis, thromboangiitis obliterans, Raynaud disease, sickle-cell anemia, and heavy alcohol and tobacco use.12,13,15,16,20 Different neoplasms have been reported in relation to NS, such as mixed tumor, monomorphic adenoma, Wartin tumor, and rhabdomyosarcoma.2

Lymphoproliferative lesions that originate in the nasal cavity, paranasal sinuses, and hard palate constitute a group of diseases known as lethal midline granuloma syndrome. Many of these lesions are malignant lymphomas. Angiocentric T-cell lymphomas in this anatomic region produce vascular necrosis as a result of vascular invasion and vessel destruction by cytotoxic cells, in addition to infiltration by inflammatory cells. This produces large areas of mucosal ulceration that can be confused clinically with several inflammatory and neoplastic diseases, so a biopsy is necessary for diagnosis. The unusual association of NS with T-cell lymphoma is thought to be due to local ischemia of the palatal salivary glands, probably as a result of vascular invasion and vascular destruction by neoplastic lymphocytes.2

A fair number of cases of eating disorders have been associated with necrotizing sialometaplasia.4,11 In 1998, NS of the hard palate was associated for the first time with chronic repeated vomiting in 2 bulimic patients.11 Another case was described by Scully and Evenson in 2004. Bulimia nervosa is an eating disorder most common among young girls and characterized by the ingestion of large amounts of foods, followed by episodes of induced vomiting or laxative abuse.

Bulimia and other conditions like gastroesophageal reflux and chronic alcoholism can cause regurgitation of the gastric content into the oral cavity. The clinical findings of the oral complications of bulimia include salivary adenosis, xerostomia, and erosion of dental pieces.

The pathogenesis of NS is related to ischemic changes; in bulimic patients, it seems to be secondary to chronic mechanical injury of the palatal mucosa caused by induced vomiting.11

The presence of palatal ulcer in an adolescent or young person with clinical signs of bulimia nervosa should suggest the diagnosis of NS.

 

Conclusions

NS is a benign inflammatory disease. It is accepted that the main cause of this injury is an acute loss of the blood supply to minor salivary glands. The main diagnosis must be made with oral carcinoma. Clinicians and pathologists must be alert to avoid diagnostic and therapeutic errors, in view of the fact that this a self-limited disease.

 

 

Correspondence:
Carlos Moreno García
c/ Fernando Sánchez Sampedro 4, Portal 8, 4ºB.
06003 Badajoz. España
Email: carlosmorenogarcia@wanadoo.es

 

 

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