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Lipoma in Submandibular region -A Case Report

Lipoma in Submandibular region -A Case Report

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466Journal of Maxillofacial & Oral Surgery 2008 Vol. 7 : No. 4
Suhas Godhi
1
, Sonia Goyal
2
, ManishPandit
3
1
Professor
2
Associate Professor
3
PG studentDepartment of Oral and MaxillofacialSurgery, I.T.S Centre for Dental Studiesand Research
Address for Correspondence: 
Suhas Godhi
Department of Oral & MaxillofacialSurgeryI.T.S Centre for Dental Studies &Research, MuradnagarDelhi-Meerut RoadGhaziabad – 201 206, Uttar PradeshPh: 09899450488E-mail: drgodhi@yahoo.com
Received for publication August 2008Accepted after peer review December 2008Available online Dec. 2008 at www.jmosi.com
Lipoma in theSubmandibular Region: ACase Report
Suhas Godhi, Sonia Goyal, Manish Pandit 
 Abstract:
Lipomas in the submandibular region are relatively rare. This casereport presents a case of lipoma in submandibular region in a 35 year old Indianmale. Lipomas and its variants are common soft tissue tumors but are not commonly are in the oral and maxillofacial region. Lipoma of the oral and maxillofacial region occurs most commonly in the parotid region, followed closelyby buccal mucosa. It is composed of adult fat cells that are subdivided into lobuleby septae of fibrous connective tissue. Surgical excision is the treatment of choicewith recurrence not expected.
 Keywords:
 Lipoma and submandibular.
Case Reports - Cysts & Tumours
Introduction
Lipoma is a common, slow growing,benign, encapsulated tumor of fatty tissuethat is rare in the oral cavity. It was firstreported in 1887 by Grosch.
1
Lipomas arethe most common soft tissue mesenchymalneoplasms, with 15 to 20% of the casesinvolving the head and neck region and 1%to 4% affecting the oral cavity.
2
Geschickter
3
found only three oral tumorsin a series of 440 lipomas.The lipoma represents 0.1% to 5% of all benign tumors of the mouth. They areusually found as long standing soft nodularasymptomatic swellings covered by normalmucosa. Oral lipomas affect predominantlythe buccal mucosa, floor of mouth, tongueand lips.
4
Histologically, they can be classifiedas simple lipomas or its variants such asfibrolipomas, Spindle Cell Lipomas(SCL), intramuscular lipomas,angiolipomas, salivary gland lipomas,plemorphic lipomas, myxoid lipomas andatypical lipomas. Angiolipomas andinfiltrating lipomas are rarely found in theoral cavity.
4
According to Furlong et al lipoma of the oral and maxillofacial region occur mostcommonly in adult male in the parotidregion, followed closely by buccal mucosa.This entity is rare in children.
5
Case report
A 35 year old male patient presentedwith a painless,gradually increasing, welldefined, oval shaped extraoral swellingmeasuring, approximately 6x4 cm in leftsubmandibular region with 13 yearsduration. On palpation, a soft rubbery masscould be felt and slipping sign was present.The transillumination test was negative.Medical history was noncontributory. Theultrasonograph revealed an elliptical massin right submandibular region that washyper-echoic relative to the adjacentmuscle. Based upon the classical sign of slipping edge and ultrasonography thediagnosis of lipoma was made. The patientwas admitted for excision of the mass undergeneral anesthesia. Routine preoperativeinvestigations were within normal limits.A submandibular incision was made,and a yellowish, soft encapsulated mass wasremoved by blunt dissection. The massshelled out easily with no adhesion toadjacent structures. Postoperative recoverywas uneventful. The patient was underfollowup for 22 months and showed norecurrence.Histological investigation showed thelesion to be macroscopically solid andconsisting entirely of microscopicallyencapsulated fatty tissue with areas of fibrosis. The adipocytes are looselyarranged in large areas which showpresence of empty cytoplasm and smallnuclei.
Discussion
Lipoma presents clinically as a sessileor pedunculated mass which is slowgrowing, freely mobile, and may or maynot have a yellow hue, depending on depthof localization and degree of fibrosis.
6
De Visscher et al studied the clinicaland histological characteristics of lipomasand fibrolipomas of the oral cavity. Themale-female ratio for lipomas was 1.5:1,and for fibrolipomas 1:1.3. In most casesthe only symptom was a painless, palpabletumour. The cheek was the most favouredsite, followed by the tongue, floor of mouthand buccal sulcus and vestibule equally, lip,palate, gingiva and retromolar area.
7
The benign fatty tumor, the lipoma, iscomposed of adult fat cells that are
 
467Journal of Maxillofacial & Oral Surgery 2008 Vol. 7 : No. 4
Fig. 3: Excision of lesionFig. 1: Preoperative frontal view of the patient  photographFig. 2: Exposure of the lesionFig. 4: SpecimenFig. 5: Lipoma Photomicrograph
subdivided into lobules by septae of fibrousconnective tissue. It appears frequently inthe subcutis of adults and is histologicallyindistinguishable from normal adiposetissue. The metabolism of lipoma differsfrom that of normal adipose tissue.
8
Various variants of lipoma such aschondrolipoma
9
, osteolipoma
10
, infiltratinglipoma
11
and spindle cell lipoma
12-15
arereported in the literature. Lipomas in thesubmandibular region are relatively rare.Masaaki et al reported a case of lipoma insubmandibular region in 67 year old male.
16
Dattilo et al also reported lipomas insubmandibular space.
17
Sialolipoma is a new variant of salivarygland lipoma first described in 2001. Rameret al presented 2 cases of sialolipomainvolving the soft palate and buccal mucosaof 2 female patients.
18
Spindle cell lipoma is a distincthistological variant of lipoma. Clinically,it appears as a solitary, subcutaneous,circumscribed lesion. Spindle cell lipomaaccounts for about 1.5% of all adipocytictumours. Very few cases of intraoral SCLwere found to be reported in literature.
13
According to Piattelli et al Spindle celllipoma is a benign tumour composed by:(1) mature fat cells; (2) spindle cells; (3) amyxoid matrix separated by thick bands of birefringent collagen. Agoff et al reportedthe first case of intramuscular Spindle-celllipoma of the oral cavity. Oral SCLs arerare, and only four cases of intramuscularSCL exist in the literature.
14
According to Billings et al; Spindlecell lipoma is typically seen in the neck/ trunk region of middle aged and oldermen. Billings et al also described thelargest series of oral spindle cell lipomainvolving the tongue, buccal mucosa, floorof mouth, and lip. The patients (3M; 4F)ranged from 31 to 88 years of age.Immunohistochemical stains for CD34highlighted the bland spindle cells in allcases. Spindle cell lipoma should beconsidered in the differential diagnosis of oral cavity mesenchymal tumors.
15
Oliveros et al reported a case of a bigoral fibrolipoma in a 72 year old woman.After surgery, a mass of 13 x 8 x 6 cm wasobtained. The tumor had an implantationpedicle of 1 cm on the floor of the mouth.The microscopic evaluation showed thepresence of polygonal cells grouped intonests and separated by fibrous connectivetissue septa.
19
Lipomatous lesions of the parotid glandare rare. Lipomatous lesions accounted foronly 1.3% of parotid tumors and occurredmore frequently in males, at a ratio of 3:1.The most common presentation was that of a slowly enlarging, painless mass.
20
Kindblom et al reported 21 cases of atypical lipoma. The tumors were mainlycomposed of univacuolated fat cellswithout cellular or nuclear atypia, but alsoshowed univacuolated fat cells withenlarged, moderately polymorphic, dark nuclei. In two of the tumors a fewmultivacuolated fat cells with scallopednuclei were found. Small multinucleatedcells with overlapping, peripherallyarranged nuclei, reminiscent of so calledfloret-like cells as in pleomorphic lipoma,could occasionally be seen. Areas of generally delicate linear or patchy fibrosiswith atypical nuclei were a commonfinding.
21
To facilitate the diagnosis of a lipoma,specific imaging such as ultrasound orMagnetic Resonance Imaging (MRI) isneeded. According to Ahuja et al thecharacteristic sonographic appearance of head and neck lipomas is that of an ellipticalmass parallel to the skin surface that ishyperechoic relative to adjacent muscle.
22,23
CT scan shows a density from 83-143Hamsfield units with well or bad definedmargins depending on capsule. With MRI,it is possible to confirm the diagnosis byvisualization of fat equivalent intensityvalues.
24
Solitary lipomas and familial multiplelipomatosis are very well encapsulated.They are very slow growing and have thepotential for recurrence if incompletelyexcised and a very remote chance formalignant changes. These can be freed fromsurrounding tissue without difficulty, butbecause of the fibrous nature of the capsule,its violation is more likely to occur withthe suction technique. This may result inan inadequate resection, possibly leadingto recurrence. Al-basti and El-Khatibreported the treatment of moderate (>4-10cm) and large (>10 cm) lipomas withliposuction-assisted surgical extraction of the capsule via the same wound (1 cm inlength).
25
This capsule extraction was aimedat avoiding recurrence and evaluating the
 
468Journal of Maxillofacial & Oral Surgery 2008 Vol. 7 : No. 4
histopathological nature of these swellings.There has been no recorded recurrence insix years postoperative followup.
Bibliography
1.Grosch J: Studien ueber das Lipom.Dtsch Z Chir 1887; 26:307.2.Ghandour K, Issa M: Lipoma of thefloor of the mouth. Oral Surg Oral MedOral Pathol 1992; 73: 59-60.3.Geschickter CF: Lipoid tumors. Am JCancer 1943; 21: 617.4.Fregnani ER, Pire FR, Falzoni R, LopesMA, Vargas PA: Lipomas of the oralcavity: clinical findings, histologicalclassification and proliferative activityof 46 cases. Int J Oral Maxillofac Surg2003; 32: 49-53.5.Furlong MA, Smith JC, Childers EL:Lipoma of the oral and maxillofacialregion: site and subclassification of 125cases. Oral Surg Oral Med Oral PatholOral Radiol Endod 2004; 98: 441-450.6.Greer R, Richarson J: The nature of lipomas and their significance in the oralcavity. Oral Surg 1973; 36: 551-557.7.De Visscher JG: Lipomas andfibrolipomas of the oral cavity. JMaxillofac Surg. 1982; 10(3): 177-181.8.Epivatianos A, Markopoulous AK,Papanayotou P: Benign tumors of adipose tissue of the oral cavity: aclinicopathlogical study of 13 cases. JOral Maxillofac Surg 2000; 58: 1113-1117.9.Hietanen J, Makinen J: Chondrolipomaof the tongue: a case report. Int J OralMaxillofac Surg 1997; 26: 127-128.10.Castilho RM, Squarize CH, Nunes FD,Pinto DS: Osteolipoma: a rare lesionin the oral cavity. Br J Oral MaxillofacSurg 2004; 42: 363-364.11.Ayasaka N, Chino T, Antoh M,Kawakami: Infiltrating lipoma of themental region: report of case. Br J OralMaxillofac Surg 1993; 31: 388-390.12.Piattelli A, Rubies C, Fioroni M,Steches G: spindle-cell lipoma of thecheek: a case report. Oral Oncol 2000;3: 495-496.13.Garibaldi JA, Ragsdale BD, William K,Lopategui J: Spindle cell lipoma of theoral cavity. Journal of Maxillofacial andOral Surgery 2007; 16: 74-78.14.Piattelli A, Perrotti V, Fioroni M,Rubini C: Spindle cell lipoma of thefloor of the mouth: report of a case.Auris Nasus Larynx. 2005; 32(2):205-207.15.Billings SD, Henley JD, Summerlin DJ,vakili S, Tomich CE: Spindle celllipoma of the oral cavity. Am JDermatopathol 2006; 28(1): 28-31.16.Masaaki W, Mutsumi K, Kenichi N,Kazuyuki M, Katsuhiro, Hiroshi F,Motoyasu N: A case of lipoma in thesubmandibular region. HokkaidoJournal of Dental Science 1998; 19:227-233.17.Dattilo DJ, Ige JT, Nwana EJC:Intraoral lipoma of the tongue andsubmandibular space. J Oral MaxillofacSurg 1996; 54: 915-917.18.Ramer N, Lumerman HS, Ramer Y:Sialolipoma: report of two cases andreview of the literature. Oral Surg OralMed Oral Pathol Oral Radiol Endod.2007; 104(6): 809-813.19.Oliveros-Chaparro C, Bogarin-Rodríguez J, Sánchez-Méndez M:Giant fibrolipoma of the floor of themouth: Presentation of a clinical case.Invest Clin. 2001; 42(2): 147-152.20.Ethunandan M, Vura G, Umar T, AnandR, Pratt CA, Macpherson DW, WilsonAW: lipomatous lesions of the parotidgland. J Oral Maxillofac Surg 2006; 64:1583-1586.21.Kindblom LG, Angervall L, Fassina AS:Atypical lipoma. Acta Pathol MicrobiolImmunol Scand. 1982; 90: 27-36.22.Ahuja AT, King AD, Kew J, King W,Metreweli C: Headand neck lipomas: sonographic appearance. AmJ Neuroradiol 1998; 19: 505-508.23.Zong LP, Zhao SF, Chen GF, Ping FY:ultrasonographic appearance of lipomain the oral and maxillofacial region.Oral Surg Oral Med Oral Pathol OralRadiol Endod 2004; 98: 738-740.24.Hohlweg-Majert B, Metzger MC,Dueker J, Schupp W, Schulze D:Salivary gland lipomas:ultrasonographic and magneticresonance imaging. J Craniofac Surg.2007; 18(6):1464-1466.25.Al-basti HA, El-Khatib HA: The useof suction assisted surgical extractionof moderate and large lipomas: longterm follow-up. Anesthetic Plast Surg2002; 26: 114-117.
Source of Support:
Nil,
Conflict of interest:
None declared.

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