Unusual oral mucocele in a child

Reasons for education

The causes of this disease include previous injuries and inflammatory diseases of various etiologies. There are frequent cases of mucocele due to obstruction of the salivary gland of the oral cavity by stones. In an infant, mucocele symptoms can occur due to a number of different pathologies, such as atresia of the salivary gland ducts.

Experts do not have a consensus regarding the reasons for the development of ranulas - for example, many dentists believe that the frequency of formation of this pathology of the salivary gland is caused by the peculiarities of its structure. Others believe that the likelihood of this pathology occurring is determined genetically or at the stage of embryo development.

One of the significant reasons for the appearance of mucocele of the salivary gland is the habit of constantly biting the lower lip or injuring it in any other way. These constant mechanical microtraumas lead to the creation of a focus of infection and infection. Much less often, a tumor appears, for example, on the inner surface of the cheeks, on the upper lip or on the tongue.

Causes of mucocele formation in the maxillary sinuses

Mucocele of the maxillary sinuses is a cyst-like tumor lined with epithelium and filled with mucus. Rarely seen. It is formed as a result of blocking the hole connecting the sinus with the nasal cavity, leading to disruption of the outflow and accumulation of fluid. It grows slowly, but gradually produces mucus, increases in size and deforms the surrounding bone.

Main causes:

• chronic inflammation of the sinus of an infectious nature;
• maxillary sinus injury;
• allergic diseases;
• fungal sinusitis;
• previous surgical interventions.

Classification of salivary gland mucocele

Based on the location of formation and the course of the pathological process, dentists distinguish cysts of the minor and major salivary glands. If a mucocele is located on the lower lip, due to its origin it is divided into true and extravasal. A true, or, as they are also called, retention cyst does not have its own membrane, but is always covered with a gland capsule on top. The capsule is formed due to the fact that the duct of the salivary gland is clogged, and mucus stagnates.

Extravasal or post-traumatic neoplasm on the lower lip occurs due to a violation of the integrity of the external capsule, which was accompanied by the release of secretions into the external tissues. Absolutely all neoplasms-cysts of the salivary gland, regardless of the nature of their origin, are divided into two main categories:

• A true formation, the shell of which has an epithelial lining. The most popular location for retention cysts is the parotid-masticatory and submandibular areas.
• A pseudocyst lacking an epithelial base. This subtype also includes mucoceles of the salivary glands. They are most often diagnosed on the mucous membrane of the lower lip and in the sublingual area.

Symptoms

Symptoms vary depending on the stage of mucocele development

Latent period

Most often, the initial stage is completely asymptomatic . Rarely, nasal discharge is possible as a result of a temporary opening of a duct or rupture of the contents of a mucocele. At this stage, inflammation of the neoplasm is possible. Patients report symptoms similar to those of a common acute respiratory viral infection or sinusitis. The nose is stuffy and secretes mucus and/or pus. Complaints of an unpleasant odor in the nose, deteriorating sense of smell. Sometimes a mucocele leads to bleeding.

An asymptomatic course or similarity to sinusitis does not cause suspicion in patients, and this is the insidiousness of the disease . At the initial stage, mucocele is most often determined accidentally on a computed tomogram during examination of the sinuses in preparation for other operations. Without detection and timely treatment, the disease continues to develop and eventually spreads beyond the sinus.

Going beyond the sine

As the mucocele grows, it manifests itself as pain and swelling in the face, eyes, and jaw. The pathology may manifest as paresthesia and facial asymmetry as a result of pressure on the first branch of the trigeminal nerve. The pain may radiate to the upper jaw, making it difficult to open the mouth. The mucocele can deceptively extend into the teeth, and non-carious lesions of dental tissues develop . Sometimes the pain radiates to the gums, and cyanosis is possible.

When located close to the orbit, pressure occurs on the organs of vision and the optic nerve. The area near the inner corner of the eye becomes swollen, and the eyeballs may bulge. Patients complain of pressure from inside the eyes, which is accompanied by lacrimation. Vision may become blurred, the picture may appear double, and in severe cases, loss of vision.

In an advanced situation, the patient is overcome by a headache. Only a strong painkiller can relieve it. In parallel, chronic fatigue is observed.

Diagnostics

The process of diagnosing this pathology includes a physical examination that reveals the presence of facial asymmetry, as well as a soft and elastic neoplasm that is painless on palpation.

Puncture of the salivary gland allows you to take a sample of its contents – a viscous yellowish liquid – for examination. Biochemical testing reveals an increase in salivary protein and amylase.

Ultrasound examination of the salivary gland is also used for diagnosis. It reveals the presence of a rounded neoplasm with smooth, clearly defined boundaries. To exclude the possibility of a false diagnosis (this is possible, since it is quite difficult to distinguish a true cyst from a pseudocyst), additional histological examination is recommended.

Diagnosis of mucocele

Since the disease has similar symptoms to other diseases of the maxillary sinuses, differentiated diagnosis is carried out from acute or chronic sinusitis, osteotomy, cyst, polyps and other neoplasms.

The doctor makes a diagnosis based on the patient’s complaints, visual examination, and palpation if the tumor is visible. General blood and urine tests may be required. But only computed tomography allows you to get the most accurate idea of ​​the formation, type, stage and location. Our Center uses a Sirona Galileos 3D tomograph with ENT mode settings.

Only computed tomography in ENT mode allows one to assess the size of the tumor, its exact location and the degree of impact on surrounding structures.
Experienced maxillofacial surgeons determine the disease by characteristic signs on an x-ray. Based on the results of diagnostic studies, the optimal method for eliminating the tumor is selected.

Treatment

The main treatment method for mucocele is surgery. The operation is performed by making two converging incisions to help isolate the cyst and quickly remove it. After the operation is completed, stitches and a special pressure bandage are applied.

However, this method is good when localizing a tumor on the lower lip. If it is located in the sublingual region, the operation may be somewhat more complicated and include “husking” or cystectomy of the salivary gland, or removal of the tumor directly along with the salivary gland.

Since the tumor is covered with a thin membrane, it is not always possible to perform surgery to remove it. Only complete removal of the tumor along with the salivary gland can be considered a fairly reliable remedy.

Giant mucocele of the appendix

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Mucocele is a cyst of the appendix containing mucus of varying consistency - from a jelly-like mass to a watery liquid, which in this case is regarded as hydrocele of the appendix, is a kind of rare neoplasm of the appendix and, according to various authors, occurs in 0.02-0.5% all appendectomies [3, 6, 9]. The pathogenesis of mucocele development is still unclear. Most authors believe that the cause of the formation of a mucoid cyst is chronic inflammation of the appendix with cicatricial narrowing of the base of the appendix, obliteration, compression or blockage of its lumen [4]. In this case, the outflow of mucus is disrupted while the secretory function of the epithelium of the mucous membrane of the appendix is ​​preserved. Others believe that cysts and diverticula can be congenital or acquired, with the latter usually representing a hernia-like protrusion of the mucous membrane through the opening between the muscle fibers as a result of destruction of the wall of the appendix in acute appendicitis [8]. And finally, according to the nomenclature of tumors of the International Union Against Cancer (1965), mucocele develops from the remains of primitive mesenchyme and belongs to benign tumors, sometimes prone to malignancy.

There are complete cysts, which occupy the entire lumen of the process, with the exception of the base, where the lumen is obliterated, and incomplete ones, in which the cyst is located intramurally or occupies part of the lumen [3]. Cysts up to 3 cm in size are considered small, up to 6 cm - medium, and more than 9 cm - giant [3]. The following names for this pathological condition are found in the literature: appendix myxoma, mucous cyst, mucocele, myxoglobulosis.

Complications of mucoid cysts are inflammatory (peritonitis), mechanical in nature (volvulus or torsion of the process, intestinal obstruction), malignancy, breakthrough of mucous masses into the abdominal cavity with implantation and spread of mucus-forming cells throughout the peritoneum, massive contamination of the abdominal cavity and the formation of pseudomyxomatosis, which has a malignant course. Patients with pseudomyxomatosis die within 1-2 years [4, 7]. With the retrocecal location of the appendix with the development of a mucocele, the process may spread like pseudomyxomatosis into the retroperitoneal space with the formation of external fistulas [1]. Cases of fungal infection (cryptococcosis) of mucocele of the appendix have been described [10].

Clinically, mucocele usually occurs under the guise of chronic appendicitis or vague gastrointestinal discomfort, sometimes imitating ovarian cysts, abdominal or rectal tumors. The absence of pathognomonic clinical signs unique to appendiceal mucocele makes accurate preoperative recognition of this rare disease difficult [2, 3, 5, 6]. The diagnosis is established or clarified only during surgery. There are isolated reports in the literature on the preoperative diagnosis of appendiceal mucocele [11, 12].

We present our own observation of a giant myxoma of the appendix, mistaken for a neoplasm of the abdominal cavity. At the same time, we pay special attention to the image of appendix myxoma obtained using various radiological diagnostic methods, which we have not found in the available literature.

Patient K., born in 1936, was admitted to the abdominal department of the MRRC RAMS with a preliminary diagnosis of “abdominal neoplasm”. There are no complaints, the stomach is soft and symmetrical. Upon palpation, a volumetric formation with a diameter of up to 10 cm is determined in the right iliac region. X-ray of the chest organs reveals no focal changes. Excretory urography: the kidneys are without pathological formations, the ureters are located usually, not dilated, the bladder is of the correct shape, with clear contours. During irrigoscopy, no pathological changes in the large intestine were detected.

Computed tomography of the abdominal organs before and after intravenous administration of 40 ml of ultravist: in the right iliac region an irregularly shaped formation measuring 12.4 x 5.9 cm with smooth contours, density 33-35 units is determined, without change after the administration of a contrast agent (Fig. 1). The structure of the formation is heterogeneous, with the presence of point and stringy inclusions; a thin capsule can be traced, thickened and compacted in places, with the presence of calcification along the posterior wall. The upper pole of the formation is located in the ileocecal angle, in front it is adjacent to the anterior abdominal wall, medially - to the sigmoid colon, behind - to the m.iliacus and the right common iliac vessels, below - it descends in the form of a stalk into the small pelvis, tightly adjacent to the wall of the rectum and bladder. There were no signs of damage to these organs. The formation is mobile; when compared with the data of a previously performed CT study, a change in shape and position is noted. No enlarged lymph nodes were detected in the iliac region or retroperitoneum.

Rice. 1.

Mucocele of the appendix. Computer tomogram.

An ultrasound examination in the right iliac region reveals an L-shaped formation with clear contours, measuring 12.7 x 6.4 x 5.9 cm, mobile, at the beginning of the study the formation was located transversely, at the end of the study it moved upward and was located along the ascending section large intestine and the initial third of the transverse colon. The structure of the formation is heterogeneous due to the correct alternation of zones of increased and decreased echogenicity with a thickness of 2-6 mm. Symptoms of dorsal amplification of sound and lateral acoustic shadows are clearly visible (Fig. 2). No free fluid in the abdominal cavity or pathologically enlarged lymph nodes were detected. Liver, kidneys - without focal changes. Conclusion: cystic formation of the abdominal cavity.

Rice. 2.

Mucocele of the appendix. Echograms of the right iliac region in the longitudinal and transverse planes.

During surgery, a mobile formation measuring 14x8x6 cm, closely adjacent to the wall of the cecum, was revealed in the right iliac region. No pathological changes were detected in the liver and lymph nodes; a typical appendectomy was performed.

Macroscopic specimen: appendix 14 cm long with a racemose extension up to 8 cm over 11 cm and the presence of jelly-like contents. The wall thickness in different areas is from 0.3 to 0.6 cm (Fig. 3).

Rice. 3.

Mucocele of the appendix.
Macropreparation: a
— mucous contents of the cyst;
b
— cyst wall.

Histological examination: mucous cyst (mucocele). The cyst wall is represented by fibrous tissue, replacing all layers of the appendix wall, with focal lymphocytic infiltrates. The lumen is filled with mucus, colored pinkish by mucicarmine. Over a larger area, the lining is absent; only in a small area at the base of the cyst is a wall lined with cubic and columnar mucus-forming epithelium, as well as with the presence of mucus-forming cells among the mucus (Fig. 4).

Rice. 4.

A section of the wall of an appendix cyst at its base with a lining of cubic and columnar mucus-forming epithelium with mucus-forming cells in the lumen of the cyst among the mucus. Magnification x 280.

The postoperative course is smooth. A control ultrasound examination after 1 year revealed no pathological changes in the area of ​​the appendix and cecum.

Literature

1. Vladimirtseva A.L., Chattalos M.G., Poletaev V.A. Pseudomyxoma of a retrocecally located appendix with invasion into the retroperitoneal space and external fistulas // Pathology Archives. - 1989. - vol. 51. - N9. — P. 74-76.
2. Dmitrievsky V.N. Appendiceal cyst simulating a retroperitoneal tumor // Bulletin of surgery. - 1981. - N2. - pp. 83-84.
3. Imnaishvili B.E., Korkelia A.A., Dzhvebenava A.G. Giant mucocele of the appendix // Surgery. - 1973. - N1. — pp. 133-138.
4. Korenev N.N., Kasherenkov V.F. Myxoma of the vermiform appendix // Surgery. - 1975. - N7. -WITH. 105-106.
5. Kokhnyuk V.T. Mucocele of the appendix // Issues of oncology. - 1988. - N1. - pp. 87-88.
6. Kuzmin V.I., Yashin N.P., Egorova T.M. Myxoma of the retrocecally located vermiform appendix // Surgery. - 1985. - N3. — pp. 117-118.
7. Markov S.N. Mucocele of the appendix due to its torsion // Surgery. - 1980. - N7. — P. 92.
8. Rusakov A.A. Guide to surgery. — M.: Medicine. - 1960. - vol. 7. - P. 465.
9. Tazhimetov B.T., Ibragimov R.I., Utaev B.A. Strangulation of myxoma of the appendix in the umbilical hernia // Surgery. - 1989. - N2. — P. 124-125.
10. Chekareva G.A., Gorbunova V.V. Cryptococcosis mucocele of the appendix // Pathology Archives. - 1976. - vol. 38. - N11. - pp. 71-73.
11. Athey R.A., Nasken J.V., Estrada R. Sonographic appearance of mucocele of the appendix // J. Clin. Ultrasound. - 1984. - Vol. 12. - N6. — pp. 333-337.
12. Horgan JG, Chow PP, Richter JO etc. CT and sonography in the recognition of mucocele of the appendix // Amer. J. Roentgenol. - 1984. - Vol. 143. - N5. - pp.959-962.

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Types of mucocele

There are two main types of mucocele:

• Oral mucous cyst. Such mucoceles develop exclusively in the mouth. They form near the openings of the salivary glands, often on the lips or floor of the mouth. A cyst in the mouth is known as a ranula. A cyst on the gums is called an epulis. They can also develop around holes made by piercings. Oral mucous cysts are more common in people under 30 years of age.
• Mucous cyst. A mucous cyst (mucocele) can develop not only in the mouth, but also in other areas of the body. These lesions appear as hard sacs near the joints of the fingers or toes. This type of cyst looks like an enlarged joint. They can also develop near the base of the nail. Mucosal mucous cysts are more often diagnosed in older people, usually over 70 years of age.

Treatment of mucocele

Treatment for mucous cysts is often not required. In most cases, a mucocele cyst will disappear on its own.

Under no circumstances should you try to remove a cyst yourself. This will create an open wound that can become infected. After healing, scars will remain. Over time, the cyst will burst on its own.

Rinsing with salt water will help disinfect the mouth and speed up the spontaneous disappearance of the mucocele.

You should try to avoid biting or sucking on the lips and cheeks, as this can cause complications.

You should see a doctor if the cyst causes discomfort or persists for more than a couple of weeks. A specialist can open the cyst with a sterile needle.

You can also remove a cyst using:

• Laser therapy. The cyst can be easily eliminated using laser radiation.
• Cryotherapy. By freezing the cyst, it can be easily removed
• Surgical intervention. In serious cases, the cyst can be removed through surgery.

A mucous cyst is usually removed surgically if it recurs.

Mucocele removal is usually a safe procedure. In rare cases, surrounding tissue may be damaged during the procedure.