Author: Ural, Ahmet; Imamoglu, Mehmet; Isik, Abdülcemal Ümit; Bahadir, Osman; Bektas, Devrim; Çobanoglu, Bengü; Çobanoglu, Ümit
Date published: November 1, 2011
Journal code: ENTJ
The submental space, which is also called the submental triangle and the median suprahyoid zone, hosts the submental lymph nodes, the mylohyoid nerve and vessels, the submental branches of the facial artery, and the facial vein. The base of this space is composed of loose connective tissue located between the superficial layer of the deep cervical fascia and the mylohyoid muscle. The boundaries of the submental space are formed by the hyoid bone inferiorly, the mandible superiorly, and the anterior bellies of the digastric muscles bilaterally (figure). The submental lymph nodes are few in number, but they are clinically important because they drain the lymphatics of the buccal mucosa, the anterior floor of the mouth, the anterior part of the nose, the gums, and the lips.1
Involvement of the submental space by inflammatory, neoplastic, or congenital lesions of the head and neck is relatively uncommon compared with the prevalence of such lesions in other cervical zones. M Possibly owing to this fact, lesions occurring in this space have not been as weil studied. We did not find any previously published series concerning submental space masses during our search of the literature. Nevertheless, such pathology can result in the development of a mass lesion, so careful assessment of the area is important.
In this article, we describe our study of masses of the submental space, and we review what little literature there is on the subject.
Patients and methods
We retrospectively reviewed the charts of 24 patients - 1 7 males and 7 females, aged 13 to 68 years (mean: 45.88 ± 8.48)- who had undergone surgery at our tertiary care center for the treatment of masses of the submental space from October 2002 through December 2008. In addition to demographic data, we compiled information on signs and symptoms, diagnostic and therapeutic methods, histopathologic findings, and recurrences.
Signs and symptoms. The chief complaint of these patients was a painless submental lymph node enlargement. Also, 9 patients exhibited dental problems, and 2 had cheilitis.
Diagnosis. Fine-needle aspiration biopsy (FNAB) and ultrasonographic evaluation were used to make a presumptive diagnosis in all patients. However, the definitive diagnosis was possible only after histopathologic examination ofthe excised specimen. The patients with dental problems underwent examination by a dentist, which included an orthopantograph.
Treatment. Complete excision was performed in cases of neoplastic lesions. For abscesses, local drainage with systemic antibiotics was the treatment protocol. Postoperative complications included paresthesia in 4 patients, scar formation in 2, and cellulitis in 1.
Histopathologic findings. The histopathologic findings included 1 2 cases of reactive lymphoid hyperplasia; 3 cases each of non-Hodgkin lymphoma, dermoid cyst, and abscess; and 1 case each of sarcoidosis, hemangioma, and lipoma (table).
Recurrence. Follow-up ranged from 1 to 74 months, and no local recurrences were found during that time.
Mass lesions ofthe submental space represent a diverse group of histopathologic diagnoses. The differential diagnosis should include reactive lymphadenitis, lymphoma, dermoid cyst, abscess, and benign neoplasms such as hemangioma and lipoma.2,3 Typically, submental lesions exist as nontender, cystic, or solitary masses.2·4 The clinical presentation may offer some cues to the underlying pathology. Local or systemic signs of inflammation should raise one's suspicion of an abscess. Patients should be carefully questioned about recent infections and ulcerations of the oral cavity and nose. Special attention must be paid to the floor ofthe mouth, the teeth, the gingiva, and the buccal mucosa.1,5 In our series, more than one-third of patients had dental caries or periodontal disease. Therefore, cooperation with dentists is important to hasten the eradication of the underlying problem.
Acute and subacute infections can cause lymphadenopathies, while chronic infections may give rise to indolent abscesses. All possible foci of infection must be carefully examined and treated. The buccal mucosa and lips were not involved in any infection or neoplasm in our patients, but these areas should be examined carefully.
We believe that empiric antibiotic treatment can be administered to patients during the diagnostic search period. In our series, antibiotics were administered for 2 to 4 weeks prior to surgical intervention. Lesions that persisted after this course of treatment were excised to address any possible neoplastic disease that might have been masked by an accompanying infection.
The diagnostic value of FNAB for persistent lymphadenopathies following antibiotic treatment has been a topic of debate because surgical excision is still necessary to establish a definitive diagnosis in this circumstance. Therefore, infectious lesions that did not resolve with empiric antibiotic treatment were excised for both diagnostic and therapeutic purposes. Radiologic and cytologic evaluations in such cases were not sufficient. The inflammatory masses that were treated surgically were presumed to be neoplastic before the exact diagnosis was established by histopathologic examination.
The usefulness ofFNAB for distinguishing lymphomas from benign lymph node hyperplasias or neoplasms is limited. It is also noteworthy that the accuracy ofFNAB is closely related to the skill and experience of the physician who is performing the biopsy and the cytopathologist who is analyzing the specimen.6 Ultrasonography may yield more valuable information in terms of discriminating benign from malignant neoplasms. If clustered lymph nodes are observed on ultrasonography, we must be aware of the possibility of a malignancy involving the lymph nodes, particularly non-Hodgkin lymphoma.
We found no cases of epidermoid carcinoma presenting with a submental node metastasis as the initial sign. In head and neck malignancies, the submental space appears to be less involved than the submandibular, jugular, and other cervical lymphatic drainage zones.
Dermoid cysts tend to occur in the midline, and they may develop in the submental space, as well. These cysts contain epidermal inclusions such as sebaceous glands, hair follicles, and sweat glands. They can arise above or below the mylohyoid muscle, and they may become symptomatic as a response to infection or trauma.
In the vast majority of cases, submental masses arise from local inflammation or a benign neoplasm, but malignancies and systemic diseases such as sarcoidosis cannot be ignored.25 The most important symptom in our lymphoma patients was a painless submental lymph node enlargement Signs of inflammation (erythema, edema, or drainage) maybe lacking, and an enlarged submental lymph node might be the only sign of a systemic disease such as lymphoma or sarcoidosis. The presence of systemic symptoms (weight loss, fever, night sweats, etc.) must be investigated, and any foci of malignancy or a multisystem disorder should be ruled out.
As far as we know, the patient in our series with a submental swelling that was found to represent sarcoidosis was the first such case to be described in the literature. The histopathologic examination in this patient revealed that the mass was a noncaseating epithelioid granuloma. Fungal and mycobacterial infections had been excluded in the differential diagnosis in this case. Chest x-ray and high- resolution computed tomography detected no additional abnormalities. Therefore, we can state that otorhinolaryngologists may play a central role in the diagnosis of sarcoidosis presenting with a cervical lymph node because obtaining a biopsy is quite easy in most circumstances.
General anesthesia was preferred during surgical intervention, and a horizontal submental incision was made above the level of the hyoid bone to expose the lesion. Such an incision must be made approximately 4 cm inferior to the lower edge of the horizontal ramus of the mandible; if the incision is made higher, the lateral extensions of the incision may cause injury to the mandibular branch of the facial nerve. In cases of abscess in our series, the capsule was incised, culture samples were obtained, and a drain was placed for 3 to 5 days. Antibiotic treatment was based on culture results.
The surgical complications we observed during the postoperative period were few: 4 cases of paresthesia, 2 cases of scar formation, and 1 case of cellulitis. The paresthesias over the incision site did not completely resolve in any of these 4 patients, but they were partially relieved at the end of the first postoperative year. The 2 patients with scar formation were started on topical allantoin. The case of cellulitis in our series occurred on the 10th postoperative day, and it manifested as erythema and pain over the incision site. The inflammation subsided 5 days after the administration of systemic antibiotics.
One limitation of our study was the fact that we had no data on submental lesions that were not treated surgically. Therefore, we were unable to make a comparison of surgical and nonsurgical outcomes.
In conclusion, lesions involving the submental space are most likely to be caused by lymphadenopathies secondary to a local infection of the head and neck. Both benign and malignant neoplasms in the submental space present as slowly growing masses. Suspicion of a systemic disease or malignancy should arise in the presence of constitutional symptoms. FNAB and ultrasonography can be used for diagnostic evaluation, but they seldom yield sufficient information on the nature of the lesion. Complete surgical excision of submental space lesions is usually necessary for both diagnosis and treatment.
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Ahmet Ural, MD; Mehmet îmamoglu, MD; Abdülcemal Ümit I§ik, MD; Osman Bahadir, MD; Devrim Bekta§, MD; Bengü Çobanoglu, MD; Ümit Çobanoglu, MD
From the Department of Otorhinolaryngology (Dr. Ural, Dr. lmamoglu, Dr. Isik, Dr. Bahadir, Dr. Bektas, and Dr. B. Çobanoglu) and the Department of Pathology (Dr. Ü. Çobanoglu), Karadeniz Technical University School of Medicine, Trabzon, Turkey.
Corresponding author: Dr. Ahmet Ural, Karadeniz Teknik Universitesi, Tip Fakultesi Farabi Hastanesi, Kulak Burun Bogaz Anabilim DaIi, Kalkinma Mah., 61080 Trabzon, Turkey. Email: ahmeturaI2001@ yahoo.com