Review of Imaging Anatomy and Pathology of The Floor of The Mouth

Review of imaging anatomy and pathology of the floor of the
mouth
Poster No.: C-1245

Congress: ECR 2012
Type: Scientific Exhibit
Authors: I. Alba de Caceres, A. Paniagua Bravo, L. Ibañez, J. A. Blanco
Cabellos, E. Roa, A. I. Fernández Martín, M. I. Diaz Vacas;
Madrid/ES
Keywords: Head and neck, Salivary glands, CT, MR, Ultrasound, Education,
Neoplasia, Abscess, Congenital
DOI: 10.1594/ecr2012/C-1245
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Page 1 of 40
Purpose
1-The floor of the mouth is an anatomical area of the neck.The boundaries and content
are not always well known by everybody, therefore, our purpose is to explain the findings
to recognize MRI and CT scan.
2-The pathology that affects the floor of the mouth is varied and dependent on its various
organs. Our goal is to outline the different etiologies and imaging study that show it eith
more sensitivity and specificity for each one.
3- Conclude which is the most common injury that damages the floor of the mouth and
the kind of population are the most affected.
Methods and Materials
Our study included all patients whose clinical pathology focuses on any of the various
organs of the floor of the mouth, seen in our hospital during the past three years. The
disease has been divided into three main sections: congenital, infectious and tumoral.
Page 2 of 40
Fig. 1: Pathology of the floor of the mouth
References: I. Alba de Caceres; Madrid, SPAIN
60 patients are included 22 women and 38 men, aged between 3 and 92,a wide range,
because the variety of pathology that is designed for the study.
Patients with low suspect of tumor pathology , firstly ultrasonography was performed and
subsequently CT.
Patients with high suspicion of tumor pathology underwent CT and later MRI.
The benign and malignant tumor disease was confirmed histologically after surgical
removal.
Abscesses, cellulitis and infectious non-obstructive submandibular sialadenitis , stopped

after appropriate medical treatment.
Page 3 of 40
Most congenital lesions were confirmed histologically, despite radiologic findings were
so specific on some of them , that it were enough for classifying.
First, we have made a reminder of the complex anatomy of the floor of the mouth with
the three imaging techniques.
• The floor of the mouth is a U-shaped area covered by squamous mucosa.

• Anteriorly is bounded by the gingiva of the mandible and posteriorly by the
anterior faucial pillar.
• The mylohyoid muscle and the anterior belly of the digastric muscle combine
with geniohyoid muscle to form the floor of the mouth.
• The pair mylohyoid muscles are joined by a fibrous median raphe and
form a diaphragm between the mandible and hyoid bone ,supporting the
structures of the floor of the mouth.
• The sublingual space is a fatty connective tissue space within the floor of the
mouth without well-defined fascial margins.
• Sublingual space contains the sublingual salivary glands, the submandibular
duct ( warthon duct), the lingual artery, vein and nerve (a branch of the Vc
C.N.) and the hypoglossal nerve (XII C.N.).
• The submandibular salivary glands have a superficial portion, and a deep
portion which is contained in the sublingual space
Page 4 of 40
Fig. 2: CT anatomy
Page 5 of 40
Fig. 3: CT anatomy
Page 6 of 40
Fig. 4: CT anatomy
Page 7 of 40
Fig. 5: MR i anatomy
Page 8 of 40
Page 9 of 40
Page 10 of 40
Page 11 of 40
Page 12 of 40
Fig. 10: US anatomy
FLOOR OF THE MOUTH; CONGENITAL PATHOLOGY
Vascular lesions
1-Hemangiomas
Hemangiomas are neoplastics that demonstrate cellular hyperplasia , proliferation and

rapid enlargement, as well as spontaneous involution during childhood.
Often, these lesions are superficial ( cutaneous), but they may extend deeply and infiltrate
underlying muscles.
On T1WI are isointense o hypointense to muscle. They are moderately hyperintense

on T2 W sequences with flow voids identified. The intense enhancement seen with the
Page 13 of 40
administration of contrast material may help differentiate infantile hemangiomas from
other masses.
Fig. 11: Hemangioma

2-Vascular Malformations
They are not tumors and display a rate of cell turn-over that is proportional to the rate
of growth of the child.
They are congenital vascular anomalies that are present at birth and do not involute.
They are classified based on their predominant anomalous vessel into:
• Arterial
They are high -flow lesions that result from abnormal vessel morphogenesis and include
arteriovenous malformations (AVMs) and arteriovenous fistulas. AVMs involving a nidus
Page 14 of 40
of abnormal feeding arteries and draining veins that grows proportionately with the child,
although may enlarge acutely because of trauma, surgery, infection or thrombosis and
in puberty and pregnancy. MR imaging reveals multiple flow voids indicating a high-flow
lesion
• Capillary
Low-flow lesions, including port-wine stains (as a component of a syndrome such as

Sturge-Weber) and telangiectasias. They are also clinically visible portion of a combined
low-flow vascular malformation, such as Klippel-Trenaunay syndrom
• Venous
They are low-flow lesions and the most common vascular malformations involving the
oral cavity.
These lesions consist of varicosities of venous channels. The channels may contain
phleboliths (the presence is diagnostic), which can be identified on all imaging modalities.
Mixed lymphaticovenous malformations share characteristics of both types on MR

imaging, with enhancement of the venous component with the administration of
gadolinium .
Page 15 of 40
Fig. 12
• Lymphatic
They are low-flow lesions composed of multiple dilated cystic spaces. Most contain
chylous fluid.
Usually grow proportionately with the child, the growth is due to continued production of
lymph fluid by endothelium. Regression is rare.
The lesions may be localized or diffuse. They are infiltrative and do not respect facial
planes.
Lymphangiomas in the head are usually centered in the posterior triangle or in the
submandibular space.
Page 16 of 40
On Ultrasound are multiloculated cystic masses with septae of variable thickness. Fluid-
fluid levels can be seen and may be related to recent hemorrhage.
On CT scanning are poorly circumscribed , multiloculated hypoattenuating masses with

homogeneous fluid attenuation. The CT density of the fluid depends on the lipid content
and the presence of hemorrhage.
On T1MRI the lesion has low or intermediate signal intensity. High signal implies
hemorrhage or high lipid content. On T2MRI has multiple well-defined cysts with signal
intensity greater than muscle. Administration of contrast material reveals either no
enhancement or peripheral rim enhancement of lymphatic malformations.
Fig. 13: Cystic lymphangioma

Lingual artery aneurism
Page 17 of 40
Digastric muscle anomalies
It is an uncommon congenital lesion, but it is important to recognize them to not to

confuse them with an actual pathology. Bilateral or unilateral accessory anterior digastric
muscle can be confused with masses in the floor of the mouth or enlarged lymph nodes.
Hipoplasia or aplasia may be mistaken for denervation atrophy.
Fig. 14: Dygastric muscle anomaly

Thyroglossal duct cyst
The primitive thyroid originates at the foramen cecum (posterior third of the tongue)
descends in the neck, penetrates through the tongue and the floor of the mouth and
passes anterior to the hyoid bone and laryngeal cartilages.
If any of its portions persists, secretions may give rise to cystic lesions. Inflammation is
the most likely cause of thyroglossal duct cyst.
Page 18 of 40
Thyroglossal duct cysts are located in the midline or in a paramedian location in the
anterior neck. Approximately 80% are either at or below the level of the hyoid bone and
20% are above. Rarely may manifest as a mass in the floor of the mouth.
On all radiologic images manifests as a cystlike mass in the midline of the anterior neck
at the level of the hyoid bone.
At ultrasound as an anechoic mass with a thin outer wall.
On CT appears as a smooth well-circumscribed hypodense mass with thin wall, and

peripheral rim enhancement , are usually unilocular but septations may be seen.
On MRI use to be hypointense on T1 and hyprintense on T2 but it may be variable due

to the presence of the protein content.
Fig. 15: Persistent thyroglossal duct and cyst

Page 19 of 40
Lingual Thyroid
Solid thyroid rests, also referred to as lingual thyroid, are embryonic rests of thyroid tissue
which remain along the tract of the thyroglossal duct.
The great majority occur in the midline dorsum of the tongue near the foramen cecum,
but they may occur anywhere along this tract.
Usually detected incidentally on CT scans, due to their affinity for iodine, they appear as
foci with high attenuation both before and after intravenous contrast administration.
Although they are usually asymptomatic, they are subject to all forms of thyroid pathology
and as such may enlarge to compress the airway or produce dysphagia.
Fig. 19: Lingual thyroid

Page 20 of 40
Dermoid cyst
Dermoid cysts refer collectively to three histologically different processes. Epidermal

cysts are simple cystic structures lined by squamous epithelium surrounded by a fibrous
tissue capsule. Dermoid cysts are like epidermoids with the additional presence of skin
appendages.
Teratoid cysts contain skin appendagesas as well as mesenchymal connective tissue

derivatives .
In head and neck, the most common locations of dermoid tumors are in the orbit, the
oral cavity and the nasal regions. In the oral cavity are more commonly located in the
sublingual space.
They are not detected until second to third decade. They are generally midline or
paramedian in location and are usually asymptomatic.
Epidermoids tend to be fluid density without enhancement on CT and without invasion of

surrounding structures , they are typically similar in signal intensity to free water on T1
and T2 images . Fat and calcification can be identified in both dermoids and teratomas ,
the presence of intra-lesional fat will cause hyperintensity on T1 and T2 images.
FLOOR OF THE MOUTH
INFLAMMATORY/INFECTION PATHOLOGY
Cellulitis
It is a diffuse infection that involves cutaneous and subcutaneous tissues.
In the floor of the mouth, infections generally arise from glandular inflammations or dental
infections.
On imaging studies cellulites may be seen as thickening of the skin, reticulation or

edematous fat, and enhancement of the fascial planes.
Abscesses
Page 21 of 40
They are single or multiloculated collections that usually conform to the fascial planes.
Floor of the mouth abscesses may result from a variety of infectious etiologies
including tonsillar or salivary gland infections, dental procedures, inadequately treated
inflammatory adenopathy etc…
Postoperative abscesses may occur in any patient who undergoes head and neck
resection or cervical spine surgery.
On CT they are low-density collections with peripheral rim enhancement. On MRI they
are hypointense to isointense on T1WI and hyperintense on T2 WI.
Fig. 16: Acute abscess

Ludwig´s Angina
Page 22 of 40
Represents intense form of cellulitis in the submandibular and sublingual space caused
by streptococcal and staphylococcal bacteria related to recent extraction of the lower
second and third molars.
Extension of the infection into the mediastinum may occur, resulting in angina-like chest
pain, it spreads by contiguity not by lymphatic and spares glandular structures.
Imaging methods may be used in defining the presence and site of any drainable
abscess, determine airway patency and detect any underlying dental infection
Fig. 17: Ludwig´s angina

Ranula
Page 23 of 40
Is a cystic mass found in the floor of the mouth or the tongue that results from obstruction
of minor salivary glands or the sublingual gland. These may result from trauma or ductal
anomaly.
Ranulas can be classified as simple or diving based on their extension in relationship to

the mylohyoid muscle.
Simple ranulas are epithelial cystic masses confined to the sublingual space.
Diving or plunging ranulas are the simple ranulas with extravasation of mucous below
the mylohyoid muscle.
US, CT and MR show the cystic nature of these lesion. On CT show a low
attenuation, sharply marginated, thin -walled masses. On MRI are hypointense on T1
and hyperintense on T1.
Fig. 24: Simple ranula

Page 24 of 40
Fig. 30: Simple Ranula
Submandibular sialoadenitis
Bacterial and viral infections are among the most common causes of sialoadenitis.
Bacterial infections commonly ascend from the oral cavity because of decreased salivary
flow due to a wide variety of entities ; trauma, surgery, radiaton and Sjögren syndrome.
Poor dental hygiene may contribute to the development of infections.
Sialolithiasis can contribute to sialoadenitis and it is predominantly a disease of the

submandibular gland (80-85%).
Chronic inflammation of the salivary gland can result from infections, obstruction and
autoimmune diseases. Signs of acute inflammation are generally absent.
Page 25 of 40
Sonography can show an enlarged well-defined hyper to hypoechoic gland in acute
adenitis. Sialolithiasis are echogenic with posterior acoustic shadowing. Cervical nodes
can be found.
CT findings in acute sialoadenitis include glandular enlargement and excessive

enhancement, inflammatory changes (skin and platysmal thickening and reticulation of
subcutaneous fat), ductal dilatation and calculi may be observed.
On MRI, glandular enlargement with variable but abnormal signal intensity on T2WI and
excessive enhancement on fat-suppressed postcontrast T1 WI.
Fig. 18: Sialoadenitis secondary sialolithiasis

FLOOR OF THE MOUTH
PATHOLOGY BENIGN TUMORS.
Page 26 of 40
Pleomorphic adenoma
It is the most common salivary gland tumor and benign salivary gland tumor
15 % occur in submandibular and sublingual glands. Pleomorphic adenomas are almost
always solitary.
On sonography , the tumor is usually a single well-defined round hypoechoic lesion with
a lobulated contour. There may be associated posterior acoustic enhancement.
On CT, they are usually round, homogeneous and well-circumscribed, may contain fat
or calcium , and enhancement is usually absent or minimal.
On MR, pleomorphic adenomas are hypointense on T1WI, enhance inhomogeneously

after gadolinium and are hyperintense on T2WI.
Lipoma
Lipomas are benign encapsulations of mature adipose tissue. These are the most
common parenchymal origin neoplasms.
They are uncommon in the head and neck (approximately 13 %), most commonly these
occur in the posterior triangle, but may occur elsewhere.
They are hypodense masses ( -65 to -125 U.H.) with no clearly identificable capsule on
CT and isointense to adjacent fat on MRI. Rarely they may be infiltrative.
Page 27 of 40
Fig. 20: Lipoma
Osteochondroma
Page 28 of 40
Fig. 29: Osteochondroma
Denervation muscle atrophy ( pseudotumor )
Page 29 of 40
Fig. 28: Denervation muscle atrophy ( pseudotumor )
OTHER BENIGN TUMORS
Rhabdomyoma
Neurogenic neoplasms
Granular cell tumors
Aggressive tumors
FLOOR OF THE MOUTH
PATHOLOGY MALIGNANT TUMORS.
Page 30 of 40
Primary squamous cell carcinoma
Squamous cell carcinomas account for approximately 95% of floor of the mouth and oral
cavity malignant tumors.
The patient population is usually older than 45 years and is associated with tobacco and
alcohol consumption.
The typical squamous cell carcinoma is an ulcerated, infiltrative lesion.
90 % of floor of the mouth squamous cell carcinomas originate within 2 cm of the anterior
midline floor of the mouth.
They penetrate beneath the mucosa into the sublingual gland and subsequently result in
obstruction of the submandibular duct with submandibular gland inflammation.
Dissemination patterns are; the invasion of the entire tongue, the invasion into the
submandibular space, extension to the oral vestibule and mandibular invasion.
Page 31 of 40
Fig. 23: Squamous cell carcinoma of the floor of the mouth
Metastatic squamous cell carcinoma
Different oral cavity and pharynx squamous cell carcinomas have spread patterns wich
may extend to the floor of the mouth:
• Oral and base of the tongue
• Tongue
Page 32 of 40
Fig. 25: Squamous cell carcinoma of the tongue
• Tonsillar
Page 33 of 40
Fig. 21: Tonsillar carcinoma
• Retromolar trigone
Page 34 of 40
Fig. 26: Retromolar trigone Carcinoma
• Buccal mucosa
• Lower gingiva
• Epiglottic
Salivary gland malignancies
• Adenoid Cystic Carcinoma
• Mucoepidermoid Carcinoma
• Adenocarcinoma
Page 35 of 40
Fig. 27: Nonspecific adenocarcinoma
Lymphoma Hodgkin
Lymphoma No Hodgkin
Other Histopathologic Tumors
Distant metastases
Page 36 of 40
Fig. 22: Metastases of hypernephroma
Results
The mean in patients with malignant tumors affecting any contents of the floor of the
mouth was 62 years.
80% were men and 20% female.
95% of men malignant tumors , were invasive squamous cell carcinomas, and 5% (one
case) was a bone metastasis of a hypernephroma in the lower jaw, with invasion of soft
tissue.
Page 37 of 40
In women, 60% were squamous invasive. Only 8% of them were non-smokers, it was
2 women whose pathology was NH lymphoma and adenocarcinoma N.O.S. of the
submandibular gland .
100% of invasive squamous cell tumors affecting , were severe grade smokers and 40%
were moderate-severe drinkers.
In our series, the most commonly affected anatomic locations , which progressed with
local metastases by direct invasion to the floor of the mouth, were: oropharyngeal
carcinoma of the tonsils (n=5) and base of tongue (n = 5), followed by carcinoma of the
epiglottis (n = 3) and other locations as the floor of the mouth, retromolar trigone, the
gingival mucosa, tongue and hypopharynx (n = 2)
Among the masses histologically benign, we have included cases of atrophy with fatty
replacement of post-surgical denervation, which logically have been the most common
(n = 3), followed by salivary gland pleomorphic adenomas (n = 2). Other findings were:
Lipoma, Tumor pseudoinflamatorio, ameloblastoma and osteochondroma mandibular
with secondary involvement of the floor of the mouth (n = 1).
Among patients with congenital disease which affected the floor of the mouth;
within vascular malformations the most frequent, were equally venous and lymphatic
malformations (n = 2), showing a mixed case in a 3 years old boy.
The ectopic thyroid , lingual and floor of mouth location, was the most frequent pathology
found among non-vascular (n = 3). Other entities were: digastric muscle abnormalities,
persistence of the thyroglossal duct, dermoid cyst and epidermoid cyst (n = 1).
Conclusion
The complex anatomy of the floor of the mouth is more easily recognizable by CT and
MRI than with ultrasound.
For congenital and infectious diseases that occur in children and young adults, ultrasound
is very good method for the diagnostic approach, being CT and MR imaging indicated
to evaluate extension.
Page 38 of 40
The tumor disease must necessarily be studied by CT and / or MRI. Being MRI markedly
more sensitive than CT to evaluate the degree of involvement and spread.
Malignant tumors, due to direct invasion from anatomical areas surrounding, are the most
common condition that affects the floor of the mouth, and also squamous cell carcinoma
are the most common histology. For this reason , smokers are the patients, whose this
anatomic area is more frequently affected. Most of them are men.
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of the Mouth and the Sublingual SpaceRadiographics September-October
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Hamilton,Gary L. Hedlund, Jason P. Hunt, and H. Ric Harnsberger
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oropharynx and oral cavity: How imaging makes a difference. Semin
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Personal Information
Ignacio Alba de Caceres , UCR , HOSPITAL INFANTA SOFIA, SAN SEBASTIAN DE

LOS REYES, MADRID,SPAIN
email: ignacio.alba@salud.madrid.org
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Review of imaging anatomy and pathology of the floor of the

Poster No.: C-1245

Methods and Materials

Abscesses, cellulitis and infectious non-obstructive submandibular sialadenitis , stopped

• The floor of the mouth is a U-shaped area covered by squamous mucosa.

FLOOR OF THE MOUTH; CONGENITAL PATHOLOGY

Hemangiomas are neoplastics that demonstrate cellular hyperplasia , proliferation and

On T1WI are isointense o hypointense to muscle. They are moderately hyperintense

Fig. 11: Hemangioma

Low-flow lesions, including port-wine stains (as a component of a syndrome such as

Mixed lymphaticovenous malformations share characteristics of both types on MR

On CT scanning are poorly circumscribed , multiloculated hypoattenuating masses with

Fig. 13: Cystic lymphangioma

Lingual artery aneurism

It is an uncommon congenital lesion, but it is important to recognize them to not to

Fig. 14: Dygastric muscle anomaly

Thyroglossal duct cyst

At ultrasound as an anechoic mass with a thin outer wall.

On CT appears as a smooth well-circumscribed hypodense mass with thin wall, and

On MRI use to be hypointense on T1 and hyprintense on T2 but it may be variable due

Fig. 15: Persistent thyroglossal duct and cyst

Fig. 19: Lingual thyroid

Dermoid cysts refer collectively to three histologically different processes. Epidermal

Teratoid cysts contain skin appendagesas as well as mesenchymal connective tissue

Epidermoids tend to be fluid density without enhancement on CT and without invasion of

FLOOR OF THE MOUTH

It is a diffuse infection that involves cutaneous and subcutaneous tissues.

On imaging studies cellulites may be seen as thickening of the skin, reticulation or

Fig. 16: Acute abscess

Fig. 17: Ludwig´s angina

Ranulas can be classified as simple or diving based on their extension in relationship to

Fig. 24: Simple ranula

Sialolithiasis can contribute to sialoadenitis and it is predominantly a disease of the

CT findings in acute sialoadenitis include glandular enlargement and excessive

Fig. 18: Sialoadenitis secondary sialolithiasis

FLOOR OF THE MOUTH

PATHOLOGY BENIGN TUMORS.

15 % occur in submandibular and sublingual glands. Pleomorphic adenomas are almost

On MR, pleomorphic adenomas are hypointense on T1WI, enhance inhomogeneously

Denervation muscle atrophy ( pseudotumor )

OTHER BENIGN TUMORS

Granular cell tumors

FLOOR OF THE MOUTH

PATHOLOGY MALIGNANT TUMORS.

The typical squamous cell carcinoma is an ulcerated, infiltrative lesion.

Metastatic squamous cell carcinoma

• Oral and base of the tongue

Salivary gland malignancies

• Adenoid Cystic Carcinoma

Other Histopathologic Tumors

80% were men and 20% female.

Ignacio Alba de Caceres , UCR , HOSPITAL INFANTA SOFIA, SAN SEBASTIAN DE

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