Necrotizing Sialometaplasia : A Case Report · 2011. 12. 23. · second molar was observed (Fig 2 A and B). The ulcer had developed following her visit to a private local dentist

Article ID: WMC001704 2046-1690

Necrotizing Sialometaplasia : A Case ReportCorresponding Author:Dr. Royana Singh,Associate Professor, Anatomy, Institute of Mediical Sciences , 221005 - India

Submitting Author:Dr. Royana Singh,Associate professor, Anatomy, Institute of Mediical sciences , 221005 - India

Article ID: WMC001704

Article Type: Case Report

Submitted on:07-Mar-2011, 05:04:26 PM GMT Published on: 08-Mar-2011, 05:51:16 PM GMT

Article URL: http://www.webmedcentral.com/article_view/1704

Subject Categories:DENTISTRY

Keywords:Necrotising Metaplasia , Ulcer, Salivary Glands

How to cite the article: Durrani , Singh R , Durrani F , Ohja U . Necrotizing Sialometaplasia : A Case Report .WebmedCentral DENTISTRY 2011;2(3):WMC001704

Source(s) of Funding:

Banaras Hindu university

Competing Interests:

None

WebmedCentral > Case Report Page 1 of 6

http://www.webmedcentral.com/article_view/1704

WMC001704 Downloaded from http://www.webmedcentral.com on 23-Dec-2011, 09:33:10 AM

Necrotizing Sialometaplasia : A Case ReportAuthor(s): Durrani , Singh R , Durrani F , Ohja U

Abstract

Necrotizing sialometaplasia is a benign, self-limitinglesion of both major & minor salivary glands,it mimicmucoepidermoid carcinoma or squamous cellcarcinoma in its clinical and histological features Thepresentation of such an ulcer, mimicking malignancyshould be diagnosed correctly to avoid mental andsurgical trauma to the patient. We present diagnosisand treatment of ulcers on the palate and in oralvestibule in 26 year old, Indian female .The base of ulcer on the left posterior aspect of the palate restedon the palatine bone and was covered with necroticdebris. The ulcer in the vestibule was deep and afungating mass was seen at its margin. Computedtomography and histopathological examination wasdone. Following the treatment an improvement in thepatient’s condition was observed, the ulcer had healedboth at the vestibule and palate within 10 weeks.

Introduction

Several cases of necrotising sialometaplasia, a benigncondition have been reported in the oral cavity as wellas in other sites in the body that contains elements ofthe salivary gland, from the paranasal sinuses to thelung .1,2,3Correct c l in ical d iagnosis of necrot iz ingsialometaplasia is important because this lesionmimics the appearance of malignant disease, bothclinically and microscopically.4Inability to make thecorrect diagnosis may result in unnecessary surgeryleading to physical and mental trauma to the patientsubsequent to wrong diagnosis of squamous cellcarcinoma and mucoepidermoid carcinoma .5A case of necrotising sialometaplasia of the hardpalate in a 26-year-old woman , following localanaesthesia is reported.

Case Report

A 26 year old Indian female from Bihar, India ,wasreferred to Faculty of Dental Sciences , Institute ofMedical Sciences , Banaras Hindu University.Varanasi. She presented herself with a diffuse swellingand numbness extending from her lower left eyelid tothe lower border of the mandible (Fig 1). Oral

examination revealed a unilateral large ulcer on leftside of her hard palate, 20mm in antero posteriordimension and 10mm in transverse diameter. Itsmargins were raised, inflamed and irregular. The basehad extended to the bone. Another ulcer in the buccalmucosa with a fungating mass and raised margin inthe vestibule on the left side, around the first andsecond molar was observed (Fig 2 A and B). The ulcerhad developed following her visit to a private localdentist for extraction of her first and second molar 26and 27, which were badly decayed and causing hersevere pain. During earlier treatment the dentist hadinjected lignocaine, to anaesthetise the area for teethextraction but could not extract the teeth due to severepain . Subsequently, she developed ulcers within 24hours . She was a non smoker. Her medical history inthe past revealed no relevant medical problem . Forthe said lesion a week course of amoxicillin was takenwith no improvement before. A differential diagnosiswas made which included. Necrotizing Sialometaplasia Another Infective lesionComputed tomography was done which did not revealany abnormality. Biopsy from the ulcer was taken forhistopathological examination.The incisional biopsyshowed no evidence of any neoplastic changes; thehistological examination of the lesion showed severeinflammatory infiltrate,coagulative necrosis and partialnecrosis of salivary gland ( Fig. 1 C and D ). It wasconsistent with early necrotizing sialometaplasia.Patient was kept on observation for six weeks andprescribed painkil lers for occasional pain.Chlorhexidine mouthwash was used vigorously afterevery meal three times daily. Patient underwent rootcanal treatment (RCT) on 26 and 27 with crowns fittedon teeth. An improvement in the patient’s conditionwas observed, the ulcer had healed both at thevestibule and palate within 10 weeks ( Fig. 2 C and D).

Discussion

Necrotizing sialometaplasia was first described byAbrams et al., (1973). It may arise in any areacontaining salivary gland tissue. Classically, it involvesthe mucoserous glands of the hard palate. The lesionis usually painful and presents as a sharplycircumscribed ulcer, frequently 1 to 3 cm in diameter.Palate involvement usually appears as a single,



unilateral ulcer on the posterior hard palate or at thejunction of the hard and soft palates. The ulcer bordersare often erythematous and may be raised. There is awide age range (1.5-83 years), although most patientsare older than 40 years.6,7,8.The incidence appearsto be 2 to 3 times greater in males than females .8.Themost widely accepted theory regarding thedevelopment of necrotizing sialometaplasia is theischemia of the vessels that supplies the salivarygland lobules .1,2. In our case, the possible etiologicfactor appears to be either the use of an expired localanaesthetic or the prolonged use of anaestheticmedication. In an experimental study in a rat model,local anesthetic injections induced necrotizingsialometaplasia.9 A range of histologic findings,ranging from coagulation necrosis of salivary glandacini in early lesions to squamous metaplasia of ductsand reactive fibrosis in late lesions can beseen.Usually there is vascular proliferation, prominentinflammatory infiltrate, and partial necrosis of salivaryglands, associated with regeneration and squamousmetaplasia of the adjacent duct and acini.3,10 The twomost important differential diagnosis includessquamous cell carcinoma and mucoepidermoidcarcinoma The benign, although focally atypical,cytologic appearance of the cells and, moreimportantly, the maintenance of the acinar architecturedistinguishes necrotizing sialometaplasia from eithersquamous cell carcinoma or mucoepidermoidcarcinoma. 10.Management involves adequate biopsy,observation and reassurance. The lesions undergospontaneous healing within 2-3 months. No treatmentis required other than an analgesic for a patient whoselesion is painful. Necrotizing sialometaplasia does notusually recur.8,10 Repeat biopsy is indicated for apatient whose lesion fails to resolve. Awareness of thispotential diagnostic pitfall is of great importancebecause an inaccurate histopathological diagnosis canresult in inappropriate or unnecessary treatment,ranging from conservative excision to maxillectomy3.This case report shows the importance of a carefulclinical examination combined with an adequatehistopathological examination in order to avoidmisdiagnosis as well avoiding mutilating surgery afterwrong diagnosis.

References

1. Abrams AM, Melrose RJ, Howell FV. NecrotizingSialometaplasia. A disease simulating malignancy.Cancer 1973;32:130-5. 2. Brannon RB, Fowler CB, Hartman KS. Necrotizingsialometaplasia: A clinicopathologic study of sixty-nine

cases and review of the literature. Oral Surg Oral MedOralPathol 1991;72:317-25. 3. Sandmeier D, Bouzourene H. NecrotizingSialometaplasia :A potential diagnostic pitfall.Histopathology 2002;40:200-1.4 . Imbery TA, Edwards PA. Necrot iz ingSialometaplasia: Literature review and case report. JAm Dent Assoc 1996;127:1087-925. Anneroth G, Hansen LS. Necro t iz ingSialometaplasia : the relationship of its pathogenesisto its clinical characteristic. Int J Oral Surg1982;11:283-91.6. Matilla A, Flores T, Nogales FF Jr, Galera H.Necrotizing sialometaplasia affecting the minor labialg lands. Ora l Surg Ora l Med Ora l Pathol1979;47:161-3. 7. Willen H, Willen R, Ekman L. Necrotizingsialometaplasia of the buccal mucosa. Acta PatholMicrobiol Scand Am 1981;89:199-2018. Newland J. Bilateral presentation of necrotisingsiolometaplasia –A case report . Dent update2007;34:586-588.9. Shigematsu H, Shigematsu Y, Noguchi Y, Fujita K.Experimental study on necrotizing sialometaplasia ofthe palate in rats: Role of local anesthesic injections.Int Oral Maxillofac Surg 1996;25:239-41.10.Randhawa T, Varghese I, Shameena PM, Sudha S,Nair RG. Necrotizing sialometaplasia of tongue. J OralMaxillofac Pathol 2009;13:35-7.



Illustrations

Illustration 1

Fig 1 .A and B . Patient before and after the treatment . C and D. Microphotographs showingincreased infiltration of the inflammatory cells, necrotising salivary glands coagulative necrosis(*) and associated large hemmorhagic areas ( bold arrow )



Illustration 2

Fig.2. A and B.Ulcers on the posterior part of the palate ( arrow )and in the vestibule ( arrow head). C and D . Healed ulcer withhealthy mucosa on the palate and in the vestibular area.



DisclaimerThis article has been downloaded from WebmedCentral. With our unique author driven post publication peerreview, contents posted on this web portal do not undergo any prepublication peer or editorial review. It iscompletely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscriptbut also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions beforesubmitting any information that requires obtaining a consent or approval from a third party. Authors should alsoensure not to submit any information which they do not have the copyright of or of which they have transferredthe copyrights to a third party.

Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater tothe needs of an individual patient. The web portal or any content(s) therein is neither designed to support, norreplace, the relationship that exists between a patient/site visitor and his/her physician. Your use of theWebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harmthat you may suffer or inflict on a third person by following the contents of this website.


IntroductionArticleIllustrationsIllustration 1Illustration 2

Documents

Necrotizing Sialometaplasia : A Case Report · 2011. 12. 23. · second molar was observed (Fig 2 A and B). The ulcer had developed following her visit to a private local dentist