Hold your tongue!

March 1, 2015

Clinical Vignette

A healthy 11-year-old girl complained of a lump on her tongue for 3 weeks. It felt funny when she was eating or talking but did not interfere with swallowing. Although it seemed to be growing for the first 2 weeks, it was unchanged for the last week. (Fig. 1) What's the diagnosis?

Diagnosis and Clinical Presentation

Diagnosis: mucocele of the tongue Mucoceles are cystic lesions that may occur on the mucosal surfaces of the oral cavity where underlying accessory salivary glands are normally present. The most common location is the lower lip and less frequently the floor of mouth, buccal mucosa and upper lip (1). Mucoceles of the tongue are unusual, constituting only a small percentage of all reported oral mucoceles. In one large series spanning 15 years, only 36 cases of oral mucoceles were reported, of which only 3 were on tongue (2). The mucocele mass is very variable ranging from just a few mm in diameter to lesions as large as 20 mm in diameter3 and the surface appearance varies according to size and depth of the lesions. The lesion is usually a round, nontender mass appearing and palpably cyst like. In the course of the mucocele development the size may decrease or increase (3,4). Mucoceles when superficial could rupture easily and even involute spontaneously. The females are predominant affected.

Epidemiology and pathogenesis

The human tongue contains 3 groups of minor salivary glands: glands of Weber along the border of lateral tongue, the glands of von Ebner surrounding the circumvallated papillae, and glands of Blandin and Nuhn embedded with in the musculature of the anterior tongue ventrum. The glands of Blandin and Nuhn, are mixed mucus and serous salivary glands and they extend laterally and posteriorly from the midline, forming a mass resembling a horseshoe with its opening pointing towards the root of the tongue (1). There are two reported types of mucoceles, extravasation and retention mucoceles (3). Extravasation mucoceles are formed by leakage of mucus into connective tissues and are usually caused by trauma, such as accidental biting or surgery. Inflammatory and tissue repair response occurs with subsequent formation of a granulation tissue wall. Most of the mucoceles of the tongue involve the salivary glands of Blandin-Nuhn and are of the extravasation type. Vascular and granulation tissue elements may be pronounced. Retention mucoceles occur from obstruction of the salivary gland ducts due to inspissated debris or calculi or from kinking of a tortuous duct, resulting in dilatation. These lesions are also termed salivary duct cysts and are more common in older people as compared to the extravasation type (3,5).

Differential Diagnosis

Extravasation mucoceles seen in children may be difficult to distinguish visually from vascular lesions, pyogenic granuloma, polyps or squamous cell papillomas.1 Retention mucocele especially in older patients must be must be distinguished from neoplasms of minor salivary gland origin, such as mucoepidermoid carcinoma (MEC), inverted ductal papilloma, sialadenoma papilliferum, intraductal papilloma and cystadenoma.

Treatment

For superficial and small mucoceles, no treatment is recommended since they can heal spontaneously with in 2 -3 wks (4). For those lesions that persist or are larger, the treatment of choice is surgical excision of the mucocele as well as the immediate surrounding minor salivary glands (5). The mucocele may recur if involved glands are not completely resected. Alternative treatment options include corticosteroid injection and cryotherapy.

Our Patient

Our patient was referred to pediatric otolaryngology for treatment. Although the lesion decreased somewhat in size before the visit, it was excised uneventfully. Histopathology showed the typical findings of a mucocele. At followup 2 months later there was no evidence of recurrence. Of interest she also was noted to have a small pigmented nevus on the tip of the tongue that had been present since infancy (Fig. 2).

Conclusion

A mucocele should be considered in a patient who develops an asymptomatic glistening cyst on the inner aspect of the lips or tongue.

References

  1. Jinbu Y, Kusama M. Mucocele of the glands of Blandin- Nuhn: clinical and histopathological analysis of 26 cases. Oral Surgery Oral Medicine Oral Pathology 2003; 95: 467-70
  2. Nico MMS, Park JH. Mucocele in Pediatric Pateints: Analysis of 36 children. Pediatric Dermatology 2008; 25(3): 308 – 311
  3. Andiran N, Sarikayalar F. Mucocele of the anterior lingual salivary glands: from extravasation to an alarming mass with a benign course. International Journal of Otorhinolaryngology 2001; 61: 143-147
  4. Oda D, Bansal S. AAOMP CASE CHALLENGE: Smooth- surfaced Nodule on the Ventral Tongue. Journal of Contemporary Dental Pract 2007;(8)7: 114 – 118
  5. Guimaraes MS, Hebling J. Extravasation mucocele involving the ventral surface of the tongue(glands of Blandin – Nuhn). International Journal of Paediatric Dentistry 2000;16: 435 - 439

Diagnosis and Clinical Presentation Tags

Pattern

Morphology

Pigmentation

Anatomic Depth