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| IMC Wiki | Soft Tissue Cysts

Soft Tissue Cysts

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Introduction

The lip, floor of the mouth, throat and salivary gland areas are particularly prone to soft tissue cysts.
Soft tissue cysts represent abnormal epithelium-lined cavities, which are filled with liquid (usually glandular secretions), tissue remnants or cell products. They can arise prenatally or postnatally.

In contrast to maxillary cysts, in soft tissue cysts the emphasis is on clinical symptoms.
  • Slow-growing, generally well demarcated, painless swellings of a soft to firmly elastic consistency.
  • Occasional fluctuations.
  • It is not uncommon for soft tissue cysts to be associated with fistulae. Fistulae may also arise in isolation at typical sites.
  • Pain or other inflammation reactions only occur in the event of secondary infection of the cyst or fistula.
Aspiration, contrast visualisation procedures, standard X-ray procedures and newer imaging procedures (ultrasound, CT, NMR) are helpful in the diagnosis of soft tissue cysts. Sialography can be diagnostically useful for cysts of the large salivary glands.
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Cysts of the salivary glands

Aetiology

Cysts of the salivary glands arise as a result of obstruction of drainage ("retention cysts") or as extravasation cysts.
Retention cysts
If sacculation of a salivary gland duct occurs as a result of salivary congestion, this is referred to as a salivary retention cyst or a retention mucocele. These are true cysts with an epithelial lining.
Extravasation cysts
Extravasation mucoceles are mucus-containing cavities arising as a result of duct obstruction due to inflammation or trauma (e.g. bite injuries).
This obstruction leads to penetration of secretions into the gland interstitium and thus to the formation of a cyst.

Clinical features

These cysts are a translucent bluish colour as a result of the covering mucosa and give rise to hemispherical swellings. They may burst, releasing a colourless, mucoid liquid.

#pic# #pic#

Differential diagnosis

Salivary gland tumours

Treatment

Circumcision and excision is indicated as a treatment. The edges of the wound are stitched in the area of the mobile soft tissues. On the hard palate, the wound is allowed to heal by open granulation.
Unexcised cyst remnants will lead to recurrence.

Ranulae

Ranulae, extravasation cysts of the sublingual gland, are located in the mucosa of the anterior part of the floor of the mouth lateral to the lingual frenum.

Aetiology

Congenital atresia and/or obliteration of the duct as a result of recurrent inflammation play a role in pathogenesis.

Clinical features

  • Almost always a paramedian location
  • or above the mylohyoid muscle in the area of the sublingual plica.
  • Where they are extensive, this can give rise to swallowing problems, speech problems and reduced tongue mobility.
  • Now and again, these cysts will drain spontaneously and then refill (recurrent swelling)
#pic# #pic#

Differential diagnoses

  • Sublingual abscess
  • Obstruction of the submandibular duct by salivary calculi (Wharton's duct)
  • Dermoid cysts
  • Lymphangioma
  • Tumours of the sublingual gland
  • Congenital cystic hygroma of the neck in neonates
  • Haemangioma of the floor of the mouth

Treatment

  • Total extirpation
    CAUTION! It is important to avoid damage to the duct of the submandibular gland and the lingual nerve during extirpation, for which reason this intervention should only be performed by experienced surgeons!
  • Larger cysts can also be treated using marsupialisation. In this case the oral cyst is excised together with the covering mucosa. The wound edge of the oral mucosa is stitched to what is left of the cyst.

Retention cysts of the maxillary sinus mucosa

Mucoceles and occlusion cysts

Aetiology

Mucoceles (mucus retention cysts) of the maxillary sinus mucosa arise from chronic recurrent inflammation, often as a result of apical ostitis in an upper molar or premolar.
Mucoceles which arise in maxillary sinuses which have previously undergone surgery or have experienced trauma are known as occlusion cysts. They arise as a result of post-operative or post-traumatic cycles of inflammation leading to proliferation and formation of cysts of the epithelium enclosed within the scarred maxillary sinus mucosa.

Clinical and radiological features

Cysts are generally incidental findings, they require treatment only where they cause problems (sensation of pressure, headaches, neuralgia-like symptoms)
  • They are well demarcated and form hemispherical protrusions in the maxillary sinus without filling it completely or causing bone deformation.
  • They contain a clear, thin, yellowish liquid, which sometimes drains spontaneously through the nose.
  • Primary location: the floor and lateral walls of the maxillary sinus.
  • Radiological features: Mucoceles are well defined, domed shadows, attached to the floor of the maxillary sinus by a pedicle, generally only weakly radio-opaque and with no osseous border.

Differential diagnosis

Odontogenic cysts

Treatment and prognosis

Mucocele
  • Extirpation of the cyst with appropriate treatment of the problem tooth (apicectomy, extraction).
Occlusion cysts
  • They require treatment only where they cause problems (sensation of pressure, headaches, neuralgia-like symptoms).
  • Each repeat intervention means further scarring with the possibility of enclosed epithelium.

Epidermoid and dermoid cysts

Epidermoid cysts are lined with keratinised squamous epithelium and contain a thick keratinic liquid.
Dermoid cysts contain keratinised squamous epithelium and skin appendages (hair follicles and sebaceous glands) and contain a greasy keratinic liquid with hairs.

Aetiology

Both cysts arise from epithelial enclosures in the area of the embryonic facial furrows and clefts. They may be present at birth or develop subsequently (rarely also as a result of traumatic displacement of the epithelium downwards).

Clinical features

The main localisations are:
  • The medial line of the floor of the mouth
    Sublingual dermoid cysts are recognisable as rounded, painless swellings of the floor of the mouth. Where the mucosa is thin, a translucent yellowish appearance is seen.
    #pic# #pic#
  • Medial line of the submental area.
    A submental dermoid cyst can give the appearance of a double chin. The rounded cyst is movable along the skin of the throat and surrounding tissue.
    #pic# #pic#

Differential diagnoses

Tumours and cysts of different origin
A cysts consisting also of mesenchymal tissue (bone, teeth) is referred to as teratoma.

Treatment

Complete extirpation of the cyst (for sublingual cysts via an intraoral incision, for submental cysts via a submental incision).

Lymphoepithelial cysts

Small, squamous epithelial cysts generally at the base of the tongue, arising from enclosed epithelial remnants in lymphatic tissue.
  • Diameter < 1 cm
  • Slightly raised, firm, yellowish swelling
  • They can occur at almost any age and are more common in men.
  • Harmless, often incidental finding
  • Intraoral counterpart of the lateral cervical cyst.

Median cervical cysts (fistulae)

Aetiology

Median cervical cysts develop from remnants of the thyreoglossal duct.

Clinical features

  • Located on the median line of the throat from the foramen caecum linguae to the caudal cervical area.
  • Firm, rounded swelling or fistula,
  • generally located immediately below and attached to the hyoid.
  • The cyst slides upwards when swallowing or when the tongue is stuck out.
#pic# #pic#

Differential diagnoses

Enlarged lymph nodes
Lymph node abscesses
Suprahyoid dermoid and epidermoid cysts
Lateral cervical cysts/fistulae
Tumours of the thyreoglossal duct

Treatment

Complete extirpation of the cyst or fistula, as malignant degeneration has been described.
To avoid recurrence, a partial resection of the body of the hyoid bone may be required.

Lateral cervical cysts (fistulae)

Aetiology

Developmental abnormalities of the visceral clefts or cystic transformation of epithelium (salivary gland epithelium) enclosed in lymph nodes during embryogenesis have been discussed as possible mechanisms of pathogenesis.

Clinical features

  • Circumscribed, flexible swelling or fistula on the lateral side of the throat.
  • Main location is below the submaxillary angle on the leading edge of the sternocleidomastoid muscle.
  • Slow growth.
#pic#

Differential diagnoses

Lymph node disorders
Specific inflammations
Tumours and diseases of the submandibular gland
Cervical lymph node metastases
Carcinomas

Treatment

  • Complete extirpation
  • Practically no recurrence
  • Malignant transformation is very rare


sources

  • Bánkfalvi A, Piffkó J, Joos U (2006), Klinische Oralpathologie, Verlag MIB Gmbh, Münster