GIANT EPIDERMOID CYST OF THE

FLOOR OF MOUTH
Surg Cdr ARUN BEHLvsM"',Surg Lt Cdr D RAGHAVAN+,
-~
......
Surg Cdr (D) SS PANDEy", Surg Lt Cdr H MANI
MjAFI 20(H; 57 : 247-249
Key Words :Epidermoid cyst; Floor of mouth; Mandibular swing.

Introduction

ermoid cysts are frequently used to describe

three closely related histologic cysts; the dermoid, epidermoid and teratoma, which are
rare findings in the floor of the mouth. Bultin in 1885
was the first to report a case [1]. New and Erish in
1937 studied a series of 1,495 cases of dermoid cysts
and only 24 (1.6% of cases) of them were in the floor
of the mouth [2]. Katz (1974) reviewed literature and
reported 1.8% cases of derrnoids to arise from the
floor of the mouth [3]. Among dermoid cysts, epidermoid cysts of the floor of the mouth are still rare. and
King in 1994 among 198 cases of dermoid cysts in the
region described 108 cases of dermoids itself, 32 of
epidermoid and 7 teratomas [4]. We report a giant
recurrent epidermoid cyst located in the midline of the
floor of the mouth and a novel surgical approach to
ensure complete excision because of its recurrent
status.
Case Report

Complete blood count. biochemistry and X-ray chest were

within normallimil. FNAC of the swelling was done through both
an intra-oral and extra-oral route and sugested an inflamed epidermoid cyst. Contrast enhanced CT Scan showed a IOx8 cm cystic
swelling of the sub-lingual space below the genioglossus pushing
the mylohyoid downwards. extending posteriorly upto the base of
tongue. compressing the oropharyngeal airway (Fig-I&2).
Because of the extremely large size of the cyst. failure of nasal
intubation and problem of sharing the oral cavity with endotracheal lube. an extra-oral approach was chosen for surgical excsion.
Through a midline lip-splitting incision the cyst was approached
by carrying out a symphyseal mandibulotomy and swinging the
mandible. The cyst was excised completely and the wound was
closed in layers after stablizing the mandible with miniplates.
Postoperative period was uneventful. Histopathology of the cyst
confirmed a diagnosis of an inflamed epidermoid cyst.

Discussion
Dermoid cysts are rare congenital lesions derived
from ectodermal differentiation [5]. Histologically,
they are divided into three types according to their
contents. If there are no dermic annexes present, the
cy.. t is called epidermoid, if there are annexes such as
sebacious glands, sudoriferous glands or hair follicle,

A 22 year old male patient presented with complaints of progressively increasing swelling of the floor of the mouth and suprahyoid neck of 18 months duration. He gave history of a similar
swel1ing 2 years back which was operated through the intraoral
route but recurred within 2 months. The swelling was initial1y
only in the floor of the mouth, however with gradual enlargement.
it progressively became more prominent in the upper part of the
neck in the midline. There was associated progressive dysarthria
and dysphagia. The symptoms had rapidly progressed in the previous two weeks. There was no dyspnoea.
Examination revealed a tense tender cystic swelling involving
the anterior floor of the mouth pushing the tongue upwards and
backwards. therby distorting and compressing the oropharyngeal
airway. The neck swelling was lOx!!cm in the submental triangle.
tense. cystic. with smooth surface. Local temperature was mildly
elevated. The swelling did not move on swallowing or on tongue
protrusion. Indirect laryngoscopy could not be done due to posterosuperior displacement of the tongue. Flexible Fiberoptic
Laryngoscopy revealed a grossly reduced and distorted oropharynx. The hypopharynx and larynx were normal.

Fig. I: CT scan showing elevated base of tongue with compromised oropharyngeal airway due to giant dermoid cyst
floor of mouth

Classified Specialist (Surgery & Oncosurgery), "Graded Specialist (Otolaryngology), "Classified Specialist (Oral & Maxillofacial Surgery).
"Classified Specialist (Pathology). INHS Asvini, Colaba, Mumbai-400 005.

248

Behl, et 81

the head and neck region and only 1.6% are located
within the oral cavity [12]. The most frequent location
in the head and neck area is the peri-orbital region
followed by peri- or intra-oral sites. The majority of
cases in the head and neck are found in individuals
over 20 years of age, without a sex predilection. The
intraoral cyst generally develops in the floor of the
mouth and it can be found either lateral to the tongue
or in the midline of the oral floor.

Fig. 2: Giant epidermoid cyst floor of mouth with compromised

airway

the cyst is called dermoid [4]. The third type is called

teratoma and is formed by a covering containing structures derived from the three germ layers-ectoderm, endoderm and mesoderm, and it can contain dermic annexes, segments of muscles and bone or respiratory
and gastrointestinal mucosa [6,7,8].
The pathogenesis of dermoid cysts is still undefined
[9] with two theories to explain its origin. The commonly accepted one is the congenital theory, which
suggests that the cyst originates from the median pluripotent tissue incarcerated during the fusion of the first
and second brachial arch in the third and fourth week
of intrauterine life. The second is the aquired theory
in which the implantation of epithelial cells in deep
tissues during intrauterine life is secondary to trauma
(amniocentesis) or accidental.
Dermoid cysts are most frequently manifested between the second to sixth decade of life, although
cases of younger and older patients have been reported. All the authors agree that there is no sex-related preference. In general, the patient becomes
aware of the pathology due to the gradual deterioration
of loco regional functional signals i.e. difficulties related to speech, chewing and swallowing. These
symptoms are closely correlated to the size of the lesion. The development of the cyst is usually slow and
does not involve painful symptoms, but it may become
rapid and painful in the presence of concomitant infection [10].
Epidermoid and dermoid cysts are rare benign tumors that may occur anywhere in the body and can
reach very large sizes. About 7% of them are found in

Colp in 1925 classified the cysts according to their

relation with muscles. They can be located over the
geniohyoid muscle and below the genioglossus muscle, bowing the submental region or below geniohyoid
muscle and above the mylohyoid muscle bowing the
submental region. They can also be located laterally
in submandibular space above mylohyoid muscle laterally under tongue [4]. A CT Scan is essential in
defining its exact location and planning surgery [11].
A scan done in our case showed the cyst to be lying
above mylohyoid muscle extending posteriorly upto
the base of tongue and below the genioglossus muscle.
Lesion extended across midline pushing the median
raphe and the genioglossus to the right. There was no
mandibular erosion or adenopathy.
The location of the cyst is a determining factor for
surgical approach. Most authors prefer to use the intraoral approach for sublingual cysts and submental
approach for the submental and submandibular cysts
[6]. Seward 1965 and Rapidis 1981 advocated the intraoral approach for all cases, except when there are
large blood vessels adjacent to the cysts. Other
authors suggest extraoral approach for large cysts, so
that damage to subjacent structures may be prevented
[4].
In our case because of the size, reccurrence and
secondary infection and sharing of oral cavity with an
endotracheal tube an extra oral lip splitting incision
with medial mandibulotomy and mandibular swing
was used to ensure complete excision.
In patients presenting with lesions of the floor of
the mouth, FNAC should be the diagnostic procedure
of first choice [14]. Several neck cysts and neoplasms
should be considered in the differential diagnosis such
as:ranula, thyroglossal tract cyst, cystic hygroma, cervical lymphoepithelial cyst, and cellulitis among others [15].
The treatment of choice for these cysts is surgery.
We present one such rare case because of its size of
IOx8 em and being a recurrent swelling, required a
unique mid line approach of lip splitting and medial
mandibulotomy with mandibular swing to ensure
MJAFI. VOL 57. NO. J. 2001

Epidermoid Cyst

249

complete excision. This approach has not been described in literature for this benign lesion.
References
1. Bultin HT. Diseases of tongue. London: Cassat, p.237. 1885.
Apud.Al-Khayat, M. Kenyon GS. Midline sublingual dermoid cyst. J Laryngol Otol, 1990:104 :578-80.
2. New GB. Erish JB. Dermoid cysts of the head and neck.
Apud.Al-Khayat, M Kerryon GS . Midline sublingual dermoid cysts . J Laryngol Otol.1990;104:578-80.
3. Kantz AD. Midline dermoid tumors of the neck. Arch
Surg.1974; 109:822-3.
4. King RC, Smith BR. Burk JL. Dermoid cysts in the tloor of
the mouth. Oral Surg, Oral Med , Oral Pathol, 1994;78:56776 .
5. Riera SC. Domenech CEo Valladares MJ. Dermoid cyst of the
mouth floor. Acta Otorrinolaringol Esp 1999;50( I ):78-80.
6. Faerber TH. Hiatt WR. Dunlap C. Congenital teratoid cysts
of the floor of mouth . J Oral Maxillofac Surg, 1988;46:487-

90.
7. Eppley BL. Bell MJ. Sclaroff A. Simultaneous occurrence of
dermoid and heterotropic intestinal cysts in the floor of the
mouth of a newborn. J Oral Maxillofac Surg, 1985;43:880-3.

9. Triantafillidou E. Karakas is D. Laskin J. Swelling of the floor

of the mouth. J Oral Maxillofac Surg, 1989;47:733-6.

10. Bonilla JA. Szeremeta W. Yelton RF. Nazif MM. Teratoid

cyst of the floor of the mouth . Int J Pediatr Otorhinolaryngol
1996;5:38(1):71-5.
11. Turctschek K. Hospodka H. Steiner E. Case report: epidermoid cyst of the floor of the mouth:diagnostic imaging by
sonography, computed tomography and magnetic resonance
imaging. Br J Radiol 1995;68(806):205-7 .
12. Seward GR. Dermoid cysts of the floor of the mouth. Br J
Oral Surg. 1965;3:36-47.Apud:King RC. Smith BR. Burk JL.
Dermoid cyst in the floor of the mouth. Oral Surg, Oral Med,
Oral Pathol, 1994;78:567-76.

13. Rapidis AD. Angelopoulos AP. Scouteris C. Dermoid cyst of

floor of the mouth: report of a case. Br J Oral Surg 1981; 19:
43-51.
14. Carmer H. Lampe H. Downing P. Dermoid cyst of the floor
of the mouth diagnosed by fine needle aspiration cytology : a
case report. Acta Cytol 1996;40(2):319-26.
15. Lohaus M. Hansmann J. Witzsel A. Flechtenmacher C.
Mende U. Reisser C. Uncommon Sonographic findings of an
epidermoid cyst in the head and neck. HNO 1999;47(8):73740.

8. Takato T. Masaru I. Yosh iyuki Y. Heterotropic gastrointestinal cysts of the oral cavity. Ann Plast Surg , 1989;47 :733-6 .

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