466 Journal of Maxillofacial & Oral Surgery 2008 Vol. 7 : No. 4

Suhas Godhi1, Sonia Goyal2, ManishPandit3

1 Professor2 Associate Professor3 PG student

Department of Oral and MaxillofacialSurgery, I.T.S Centre for Dental Studiesand Research

Address for Correspondence:

Suhas GodhiDepartment of Oral & MaxillofacialSurgeryI.T.S Centre for Dental Studies &Research, MuradnagarDelhi-Meerut RoadGhaziabad – 201 206, Uttar PradeshPh: 09899450488E-mail: drgodhi@yahoo.com

Received for publication August 2008Accepted after peer review December 2008

Available online Dec. 2008 at www.jmosi.com

Lipoma in theSubmandibular Region: ACase Report

Suhas Godhi, Sonia Goyal, Manish Pandit

Abstract: Lipomas in the submandibular region are relatively rare. This casereport presents a case of lipoma in submandibular region in a 35 year old Indianmale. Lipomas and its variants are common soft tissue tumors but are notcommonly are in the oral and maxillofacial region. Lipoma of the oral andmaxillofacial region occurs most commonly in the parotid region, followed closelyby buccal mucosa. It is composed of adult fat cells that are subdivided into lobuleby septae of fibrous connective tissue. Surgical excision is the treatment of choicewith recurrence not expected.

Keywords: Lipoma and submandibular.

Case Reports - Cysts & Tumours

IntroductionLipoma is a common, slow growing,

benign, encapsulated tumor of fatty tissuethat is rare in the oral cavity. It was firstreported in 1887 by Grosch.1 Lipomas arethe most common soft tissue mesenchymalneoplasms, with 15 to 20% of the casesinvolving the head and neck region and 1%to 4% affecting the oral cavity.2

Geschickter3 found only three oral tumorsin a series of 440 lipomas.

The lipoma represents 0.1% to 5% ofall benign tumors of the mouth. They areusually found as long standing soft nodularasymptomatic swellings covered by normalmucosa. Oral lipomas affect predominantlythe buccal mucosa, floor of mouth, tongueand lips.4

Histologically, they can be classifiedas simple lipomas or its variants such asfibrolipomas, Spindle Cell Lipomas(SCL), intramuscular l ipomas,angiolipomas, salivary gland lipomas,plemorphic lipomas, myxoid lipomas andatypical lipomas. Angiolipomas andinfiltrating lipomas are rarely found in theoral cavity.4

According to Furlong et al lipoma ofthe oral and maxillofacial region occur most

commonly in adult male in the parotidregion, followed closely by buccal mucosa.This entity is rare in children.5

Case reportA 35 year old male patient presented

with a painless,gradually increasing, welldefined, oval shaped extraoral swellingmeasuring, approximately 6x4 cm in leftsubmandibular region with 13 yearsduration. On palpation, a soft rubbery masscould be felt and slipping sign was present.The transillumination test was negative.Medical history was noncontributory. Theultrasonograph revealed an elliptical massin right submandibular region that washyper-echoic relative to the adjacentmuscle. Based upon the classical sign ofslipping edge and ultrasonography thediagnosis of lipoma was made. The patientwas admitted for excision of the mass undergeneral anesthesia. Routine preoperativeinvestigations were within normal limits.

A submandibular incision was made,and a yellowish, soft encapsulated mass wasremoved by blunt dissection. The massshelled out easily with no adhesion toadjacent structures. Postoperative recoverywas uneventful. The patient was under

followup for 22 months and showed norecurrence.

Histological investigation showed thelesion to be macroscopically solid andconsisting entirely of microscopicallyencapsulated fatty tissue with areas offibrosis. The adipocytes are looselyarranged in large areas which showpresence of empty cytoplasm and smallnuclei.

DiscussionLipoma presents clinically as a sessile

or pedunculated mass which is slowgrowing, freely mobile, and may or maynot have a yellow hue, depending on depthof localization and degree of fibrosis.6

De Visscher et al studied the clinicaland histological characteristics of lipomasand fibrolipomas of the oral cavity. Themale-female ratio for lipomas was 1.5:1,and for fibrolipomas 1:1.3. In most casesthe only symptom was a painless, palpabletumour. The cheek was the most favouredsite, followed by the tongue, floor of mouthand buccal sulcus and vestibule equally, lip,palate, gingiva and retromolar area.7

The benign fatty tumor, the lipoma, iscomposed of adult fat cells that are

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Fig. 3: Excision of lesionFig. 1: Preoperative frontal view of the patientphotograph

Fig. 2: Exposure of the lesion

Fig. 4: Specimen Fig. 5: Lipoma Photomicrograph

subdivided into lobules by septae of fibrousconnective tissue. It appears frequently inthe subcutis of adults and is histologicallyindistinguishable from normal adiposetissue. The metabolism of lipoma differsfrom that of normal adipose tissue.8

Various variants of lipoma such aschondrolipoma9, osteolipoma10, infiltratinglipoma11 and spindle cell lipoma12-15 arereported in the literature. Lipomas in thesubmandibular region are relatively rare.Masaaki et al reported a case of lipoma insubmandibular region in 67 year old male.16

Dattilo et al also reported lipomas insubmandibular space.17

Sialolipoma is a new variant of salivarygland lipoma first described in 2001. Rameret al presented 2 cases of sialolipomainvolving the soft palate and buccal mucosaof 2 female patients.18

Spindle cell lipoma is a distincthistological variant of lipoma. Clinically,it appears as a solitary, subcutaneous,circumscribed lesion. Spindle cell lipomaaccounts for about 1.5% of all adipocytictumours. Very few cases of intraoral SCLwere found to be reported in literature.13

According to Piattelli et al Spindle celllipoma is a benign tumour composed by:(1) mature fat cells; (2) spindle cells; (3) amyxoid matrix separated by thick bands ofbirefringent collagen. Agoff et al reportedthe first case of intramuscular Spindle-cell

lipoma of the oral cavity. Oral SCLs arerare, and only four cases of intramuscularSCL exist in the literature.14

According to Billings et al; Spindlecell lipoma is typically seen in the neck/trunk region of middle aged and oldermen. Billings et al also described thelargest series of oral spindle cell lipomainvolving the tongue, buccal mucosa, floorof mouth, and lip. The patients (3M; 4F)ranged from 31 to 88 years of age.Immunohistochemical stains for CD34highlighted the bland spindle cells in allcases. Spindle cell lipoma should beconsidered in the differential diagnosis oforal cavity mesenchymal tumors.15

Oliveros et al reported a case of a bigoral fibrolipoma in a 72 year old woman.After surgery, a mass of 13 x 8 x 6 cm wasobtained. The tumor had an implantationpedicle of 1 cm on the floor of the mouth.The microscopic evaluation showed thepresence of polygonal cells grouped intonests and separated by fibrous connectivetissue septa.19

Lipomatous lesions of the parotid glandare rare. Lipomatous lesions accounted foronly 1.3% of parotid tumors and occurredmore frequently in males, at a ratio of 3:1.The most common presentation was that ofa slowly enlarging, painless mass.20

Kindblom et al reported 21 cases ofatypical lipoma. The tumors were mainly

composed of univacuolated fat cellswithout cellular or nuclear atypia, but alsoshowed univacuolated fat cells withenlarged, moderately polymorphic, darknuclei. In two of the tumors a fewmultivacuolated fat cells with scallopednuclei were found. Small multinucleatedcells with overlapping, peripherallyarranged nuclei, reminiscent of so calledfloret-like cells as in pleomorphic lipoma,could occasionally be seen. Areas ofgenerally delicate linear or patchy fibrosiswith atypical nuclei were a commonfinding.21

To facilitate the diagnosis of a lipoma,specific imaging such as ultrasound orMagnetic Resonance Imaging (MRI) isneeded. According to Ahuja et al thecharacteristic sonographic appearance ofhead and neck lipomas is that of an ellipticalmass parallel to the skin surface that ishyperechoic relative to adjacent muscle.22,23

CT scan shows a density from 83-143Hamsfield units with well or bad definedmargins depending on capsule. With MRI,it is possible to confirm the diagnosis byvisualization of fat equivalent intensityvalues.24

Solitary lipomas and familial multiplelipomatosis are very well encapsulated.They are very slow growing and have thepotential for recurrence if incompletelyexcised and a very remote chance formalignant changes. These can be freed fromsurrounding tissue without difficulty, butbecause of the fibrous nature of the capsule,its violation is more likely to occur withthe suction technique. This may result inan inadequate resection, possibly leadingto recurrence. Al-basti and El-Khatibreported the treatment of moderate (>4-10cm) and large (>10 cm) lipomas withliposuction-assisted surgical extraction ofthe capsule via the same wound (1 cm inlength).25 This capsule extraction was aimedat avoiding recurrence and evaluating the

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histopathological nature of these swellings.There has been no recorded recurrence insix years postoperative followup.

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Source of Support: Nil, Conflict of interest: None declared.