Do You Recognize These Oral and Perioral Lesions?

Case 1:

During a routine physical examinationof a 21-year-old man, a 1-cm cysticlesion is detected on the posterior wallof the lower nasopharynx.Can you identify this lesion?

Case 2:

A cystic swelling on a 25-year-oldman's left inner lower lip has been presentfor about 2 months. The lesionis asymptomatic unless trauma to thearea causes discomfort.What is your clinical impression?

Case 1:

The asymptomatic lesion is a

Tornwaldt bursa

or cyst, also called abursa pharyngea. The cyst occurs in the midline of the posterior wall of thelower nasopharynx at about the level of the uvula. A nasopharyngeal mirrorcan help visualize the lower nasopharynx when the patient is unable to elevatethe soft palate and uvula.The cyst represents an embryonic vestige of pharyngeal segments of thenotochord that have remained united to the pharyngeal ectoderm. It extendsbackward and is superior to the occipital periosteum. When the canal is occluded,a bursa, or cyst, develops. The cyst may drain intermittently, which canresult in a bad taste in the mouth, and may form a crust.The vast majority of these lesions are asymptomatic and undiagnosed.Treatment is by excision of the cyst, incision and drainage, marsupialization, orelectrocoagulation. Typically, the lesions are excised if they are painful or infectedor if there is a possiblity of infection. This patient refused treatment.

Case 2:

The history and appearance of the lesion weretypical of a

mucocele.

This intraoral pseudocyst occursmost commonly on the lower lip. Trauma is thought to bethe major cause of mucoceles. The lesion is formed bydisruption of a minor salivary gland and contains a clearmucinous gel.Surgical excision, which is the standard treatment,was performed on this patient. Although mucoceles arebenign, pathologic examination of the excised cyst is warrantedto rule out a mucus-producing adenocarcinomaor a low-grade mucoepidermoid carcinoma, particularly ifthe lesion was located on the posterior palate or retromolararea.

Case 3:

A 29-year-old man presents with araised, pale, sessile nodule just to theright of the tip of his tongue. The0.5-cm, asymptomatic lesion has beenslowly enlarging for 2 years.What approach would you take?

Case 4:

A 15-year-old girl presents with apainful, shallow, elongated, superficialulceration on the floor of her mouthof 1 week's duration. The lesion restson a yellow base that is surroundedby erythema. The patient has had nofever; no cervical lymphadenopathyis evident.What do you suspect?

Case 3:

The patient was given a local anesthetic, and thelesion was removed in the office. Microscopic examinationrevealed a

fibroma

with benign verrucoid epidermalhyperplasia, hyperkeratosis, and parakeratosis; there wasno evidence of malignancy.Fibromas occasionally develop within the mouth;these tumors may be hard or soft and can be pedunculatedor sessile, as in this patient. Oral fibromas need to beexcised and sent for histopathologic examination.This patient healed well without complications afterthe fibroma was resected.

Case 4:

A culture from an ulcer confirmed the suspecteddiagnosis of herpes simplex virus infection. Other conditionsin the differential diagnosis of an oral ulceration arelisted in the

Table.

Most cases of oral herpes simplex virus infectiondo not require drug therapy; however, acyclovir or otherantiviral medication can hasten resolution of severe cases.Many persons with oral ulcerations self-treat with overthe-counter medications rather than seek medical attention.This patient's lesions promptly responded to daily applicationsof a tetracycline-corticosteroid suspension overa week.

REFERENCE:

1.

Gallagher GT, Lyle S. Case records of the Massachusetts General Hospital.Weekly clinicopathological exercises. Case 24-2002. A 48-year-old man with persistenterosive oral lesions.

N Engl J Med. 2002;347:430-436.

Case 5:

A faint brownish pink papulosquamousrash on the chin and lips of a40-year-old woman has been presentfor several months. The patient reportsthat the rash is slightly pruritic.What would you include in thedifferential?

Case 6:

A 6-month-old girl has a symmetric perioral rash that also involves the anteriorneck and neck creases.What is the likely cause?

Case 5:

Tinea faciale, seborrhea, perioral dermatitis, andpsoriasis were included in the differential. The patient hadhad similar rashes in the past on the nasolabial areas, inand behind her ears, and on her scalp.The absence of other stigmata of psoriasis elsewhereon the body effectively ruled out psoriasis. In perioraldermatitis, only the area around the mouth is typically involved.A potassium hydroxide evaluation ruled out tinea;the presentation and history were fairly typical of seborrhea,or seborrheic dermatitis. Applications of topical hydrocortisone,1% once or twice daily, and regular washingwith zinc pyrithione soap controlled the outbreak.The cause of seborrhea is the subject of debate.Some investigators theorize that increased numbers of

Pityrosporum

organisms trigger the eruption.

^1,2

REFERENCES:

1.

Fitzpatrick TB, Johnson RA, Wolff K.

Color Atlas and Synopsis of Clinical Dermatology.

4th ed. New York: McGraw-Hill; 2001:45.

2.

Plewig G, Jansen T. Seborrheic dermatitis. In: Freedberg IM, Eisen AZ, WolffK, et al, eds.

Fitzpatrick's Dermatology in General Medicine.

5th ed. New York:McGraw-Hill; 1999:1482-1489

Case 6:

The erythematous, eczematoid,well-demarcated dermatitis wasassociated with drooling whileteething. Irritant contact dermatitiswas diagnosed. The patient's motherapplied a hydrocortisone cream, which promptly resolvedthe rash; however, it recurred following the child's nextepisode of teething and drooling.Monilial dermatitis, which was considered in the differential,features peripheral satellite lesions and wouldlikely worsen with cortisone treatment.