approach to swelling in maxillofacial region

1. Approach to
swelling
Presented by:
Dr Nikil Jain

2. CONTENTS
INTRODUCTION
EXAMINATION OF SWELLING
SWELLINGS IN OROFACIAL REGION
CERVICAL LYMPHADENOPATHY
CONCLUSION

3. • Swelling in the head and neck and
orofacial region is very common
• It is necessary to approach a swelling to
illicit the correct diagnosis for the correct
treatment plan.

4. • Swelling-
An abnormal Enlargement or protuberance in
the body
Two types –
 Generalized e.g. congestive heart failure
 Localized e.g. cellulitis

5. • An integral aspect of patient evaluation and
management is the development of a clinical
diagnosis.
• Diagnosis should be done in sequential manner
1. Complete history
2. Clinical examination
3. Radiographic and other investigation
4. Diagnosis

6. • Case history includes:
• Name /age /sex
• Chief complaint
• History of presenting illness
• Past medical history/past dental history
• Family history
• Personal history
• Clinical examination: General examination
Local examination

7. Examination of swelling
• History
• Duration –
If swelling is present since birth,it might be
meningocoel or sacrococygeal
Shorter duration swellings are inflammatory
and painful
Shorter duration – rapid growth –malignancy
Long duration - not painful - might be
neoplastic but more likelihood of being
benign

8. • Mode of onset-
Appears immidiately after trauma eg
hematoma
Develop spontaneously and grow rapidly
eg inflammation
Steadily growth eg.malignancy
Very slowly eg benign growth

9. • Exact size and shape –
• It gives clue to the anatomical structure from
which the swelling has originated
• Progress of swelling –
Enquire swelling growing slowly or
remained stationary for a long time
If growing again after a stationary period of
time ,indicates malignant transformation of
a benign tumor

10. • Pain –
Note site
Localized/Genralized/Referred
Throbbing /Dull/ Aching
Throbbing pain suggests an inflammatory
lesion tending to suppurate
Pain before swelling – inflammation
Swelling before pain – growth
Pain absent in benign and early carcinomas
When pain appears in carcinoma,it signifies
complications such as ulceration,deep
infiltration ,involvement of nerve .

11. • Secondary changes –
If ulceration,fungation ,softening present
enquire when they first appeared
Similar swelling – elsewhere in body
Loss of body weight – since appearance of
swelling

12. Local Examination
• Inspection
• Palpation
• Percussion
• Auscultation
• Measurement
• Examination for pressure effects
• Aspiration

13. Inspection
• Number
• Situation or site – observe the extent of swelling
in horizontal and vertical directions or in
relation to landmarks present in vicinity of the
swelling
• Shape and size – ovoid/spherical /pyriform
/irregular

14. • Colour –
• Red or purple eg heamngioma
• Blue eg ranula , mucous cyst
• Black eg melanoma
• Surface –
• smooth / lobulated /nodular /irregular

15. • Edge –
• Circumscribed or diffuse
• Base pedunculated or sesile
• Skin over the swelling –
• Smooth or discharge
• Engorged vein or visible pulsation
• Pigmentation
• Any scar formation

16. Palpation
• Defined as examination with hands
• It implies a deliberate attempt to elicit
physical signs and includes the
performance of certain tests
• It confirm the results of inspection and
provides additional information

17. • Local temprature- local temprature always
raised in inflammatory swellings
• Tenderness – tenderness is a sign
• Ask pt.to show the tender area so unnecessary
discomfort avoided
• Locate the point of max. tenderness
• Position ,size & extent – all inspectory findings
confirm by palpation
• Feel all around the swelling and estimate the
depth to estimate the 3 dimensions

18. • Surface –
• Smooth – cyst
• Lobular – lipoma
• nodular – mass of large lymph node
• Rough and irregular- carcinoma
• Edges or margins – may be clearly
defined or diffuse, fading into
surrounding tissues

19. • Consistency
• Soft- lipoma
• Cystic – cyst or chronic abscess
• Firm – fibroma
• Stony hard – secondary carcinoma of lymph
nodes
• Bony hard - osteoma
• Fluctuation – valuable sign indicating the
presence of fluid with in the swelling
• When pressure applied to mass on one side ,a
transmitted impulse felt on other side.

20. • Translucency - to determine fluid inside
the swelling clear or otherwise
• Swelling containing clear fluids e.g. ranula
meningocoel
• Anatomical plane and fixidity
• determine whether swelling attched to
,adherent or fixed to skin, subcutaneous
tissue,deep fascia, muscles, tendon, vessel
nerve ,bone,

21. • Pulsation- two types
1. Transmitted – whole swelling moves en mass
due to pulsation in some near by structure
usually a artery
2. Expansile - swelling itself expand and contracts
with heart beats ,e.g.aneurysm of artery

22. Percussion
• Mainly usedd to differentiate gaseous swelling
from fluid swellings,former being resonant and
later dull
• Sometimes percussion is used to elicit
renderness over a bony swelling

23. Auscultation
• All pulsatile swelling should be examined with
stethoscope for any murmur
• Determine whether it is distolic systolic or
continous

24. Measurements
• should be taken to ascertain the size of tumor
and to determine its rate of growth by taking
measurements at intervals
• Approximate measurement gives an idea of
extend of swelling or tumor

25. Lymphnodes
• Draining area of the tumor or swelling must be
examined

26. Aspiration
• Primary value of aspiration is to investigate the
fluid contents of soft ,cheesy or rubbery masses
• Nature of material contained in mass contribute
significantly to the formulation of appropriate
differential diagnosis

27. Types of Aspirate Diagnosis
Clear , pale , straw
coloured fluid with
cholesterol crystals
Dentigerous cyst
Creamy white , thick
aspirate
Odontogenic cyst
Yellowish ,foul smelling
fluid
Infected cyst
Blood 1. Needle in blood vessel
2. Vascular lesion
Air 1. Maxillary antrum
2. Traumatic bone cyst

28. • LAB INVESTIGATIONS
▫ This can be done according to suggested
diagnosis from history and the clinical
Examinations.
 Blood Tests : CBC, Urea and
Electrolytes, RBS, T3, T4, TSH
▫ Tuberculin test
▫ CXR, Cervical X-rays
▫ FNA
▫ USS
▫ Thyroid Scan
▫ Head and Neck CT-Scan
▫ MRI

29. • Swelling in oral cavity
• The primary disease processes that give rise
to swellings and tumors of the oral cavity
include cysts, mucous extravasation and
retention in the minor salivary glands, foci of
granulation tissue and
inflammation,abscesses and connective-
tissue proliferations that are well defined or
encapsulated, as well as infiltrative
sarcomas.
• As for location, certain diseases tend to
occur in specific sites to the exclusion of
others.

30. Orofacial Soft-Tissue Swellings
according to Site
• Lips and buccal mucosa - Fibroma,
Mucocele,
Mesenchymal tumor,
Salivary tumor,
Squamous cell carcinoma
• Gingiva - Parulis, Pyogenic granuloma,
Peripheral fibroma, Peripheral Giant cell
granuloma, Peripheral Ossifying fibroma,
Gingival cyst, Peripheral Odontogenic
tumors,Ssquamous cell carcinoma

31. • Palate - Abscess,
Torus,
Salivary gland tumor
• Dorsolateral tongue - Fibroma,
Granular cell tumor,
Pyogenic granuloma,
Squamous cell carcinoma

32. • Ventral tongue and oral floor -
Mucocele,
Ranula,
Lymphoid aggregates,
Lymphoepithelial cyst,
Osteocartilagenous choristoma,
Squamous cell carcinoma

33. • Masseteric region - Cellulitis,
Space infection,
Jaw cysts and tumors,
Masseteric hypertrophy
• Parotid region - Sialadenitis,
Sialolithiasis,
Salivary neoplasm

34. • Submandibular region -
Lymphadenopathy,
Sialolithiasis,
Salivary neoplasm
• Lateral neck -
Lymphadenopathy,
Mesenchymal neoplasm,
Branchial cleft cyst,
Metastatic carcinoma,
Lymphoma,
Carotid body tumor

35. • Anterior neck - Goiter,
thyroid neoplasm,
thyroglossal cyst
• Face –
Seborrheic keratosis,
basal cell carcinoma,
adnexal skin tumors,
squamous cell carcinoma,
melanoma

36. • In terms of frequency, the majority of oral
mucosal masses are reactive proliferations, such
as fibrous hyperplasias, pyogenic granulomas,
and mucous extravasation reactions.
• Mesenchymal and salivary neoplasms are
uncommon, and lymphomas and sarcomas are
rare causes of oral swelling.

37. • take note of the location, coloration, surface
texture, and palpable nature of the mass before
attempting to secure a definitive diagnosis.
• Sound rule that all the acute swellings about the
face should be considered to be dental origin
until proved to be otherwise
• occasionaly angioneuratic oedema and an
allergic reaction produces facial swelling but
usually history and the absence of infection
clarify the diagnosis

38. Intra oral swellings
• Traumatic fibroma
• round, dome shaped sessile, soft
asymptomatic masses
• In line of occlusion or lip caused by
repeated irritation

39. • Mucoceles
• soft and fluctuant swelling
• due to minor salivary gland duct severage
with resultant escape of mucus into the
submucosal connective tissues
• Mucoceles rarely involve the upper lip yet may
occur at any site where minor salivary glands
are located.

40. • Inflammatory fibrous (denture)
hyperplasia
• multinodular flabby masses along the
maxillary or mandibular vestibule
• in the palatal vault denture hyperplasias are
• diffuse and papillary, a lesion termed
inflammatory papillary hyperplasia.

41. • Mucous retention cyst
• True cysts of the minor salivary ducts
• develop as a consequence of ductal
obstruction or occlusion by mucous plugs.

42. • Reactive gingival tumefactions
• Proliferation of granulation tissue gives rise to
pyogenic granulomas, which may fibrose to
peripheral fibroma
• periodontal ligament cells give rise to cells
capable of osteogenesis and cementogenesis,
causing the ossifying fibroma; periosteal
progenitor cells, including osteoblasts and
osteoclasts, proliferate, producing a lesion
termed peripheral giant cell granuloma

43. • Pyogenic granulomas and peripheral
ossifying fibromas are common in
pregnancy.
• The pyogenic granuloma is usually red;
fibromas and ossifying fibromas are pale
pink and giant cell granulomas are bluish

44. • Peripheral odontogenic cysts and
tumors
• most common entity is the gingival cyst of
the adult,a lesion that appears as a nodule
on the attached gingiva and may erode the
underlying cortex
• Benign odontogenic tumors also occur
here, the peripheral odontogenic fibroma
being the most common

45. • Rare peripheral odontogenic tumors that
appear as gingival masses include
ameloblastoma,dentinogenic ghost-cell
tumor, and calcifying epithelial
odontogenic tumor.

46. • Diffuse gingival enlargement
• Gingival hyperplasias can be nonspecific, drug-
induced,hormonally-related, granulomatous, or
even neoplastic.

47. • Parulis
• Odontogenic infections that evolve into
periapical inflammatory lesions may
perforate the cortex, with drainage into the
oral soft tissues.
• Focal drainage of an acute inflammatory
process creates a tract that delivers
suppurative material into the gingival
submucosa.
• These drainage tracts may occur anywhere
from the free gingival margin down to the
vestibule

49. • Ectopic lymphoid tissue is commonly seen in the
oral cavity where it appears as a yellow nodular
or multinodular mass
• The common sites are the floor of the mouth and
the soft palate.
• Many of these lymphoid aggregates emulate
tonsilar tissue in that epithelial lined crypts
extend into the lymphoid tissue and some
become impacted with keratin, exhibiting a cystic
appearance.

51. Varix
• Focal varices are most common in the lower lip
and are probably the consequence of trauma,
such as lip biting, to the submucosal vessels.
• Venous channels proliferate and become
dilatated. These lesions may be flat or, more
often, raised blue or purple masses

52. Salivary gland
• Some types that are commonly found in the
major glands are rare or may never be found in
the minor glands of the mouth,
• There are minor salivary gland tumors that
rarely arise in the major glands.
• The most common site is the palate, where the
mass is off the midline, arising in the posterior
aspect of the hard palate or at the hard–soft
palate junction

53. • The buccal mucosa,
upper lip, and ventral
tongue are also
common sites for these
neoplasms.
• The benign tumors
that occur in minor
glands include the
pleomorphic adenoma,
monomorphic
adenoma, and
canalicular adenoma,

54. • Clinically, the benign adenomas are typically
smooth surfaced, nonulcerated nodules that are
movable, unless located in the palate, where the
tumor is trapped between the palatal bone and
mucosa.

55. Clinical features of facial tumors
and swellings
• Two major types:
1. Diffuse
2. Focal nodules
• Diffuse swellings are usually inflammatory lesions,
such as edema, emphysema, space infection, or
cellulites.
• Facial asymmetry also may be seen when there is
an underlying central lesion of the maxillary or
mandibular bone

56. • Focal nodules of the face may be covered by
normal skin or they may be verrucous, ulcerated,
or pigmented.
• Most small facial nodules are sebaceous cysts,
basal cell carcinomas, nevi, and seborrheic
keratoses.

57. • Odontogenic infections
• Buccal drainage from a periapical abscess
can result in significant facial swelling,
which may localize over the mandible or, less
frequently, below the zygoma.
• diffuse swelling , soft or fluctuant and tender
on palpation.
• The clinical distinction between cellulitis
and space infection is germane to treatment,
since the former cannot be incised and
drained

58. • Depending upon the status of the tooth,
endodontic therapy or extraction must be
performed, and antibiotic therapy is
indicated

59. • Acute infection arising from dental origin
• Pericoronitis
• Acute alveolar abscess
• Periodontal abscess
• Cellulitis
• Space infections
• Ludwig angina

60. • Chronic inflammatory growths
• Epulis
• Giant cell hyperplasia
Infections of jaw bones
Ostitis
Osteomylitis
Pagets disease

61. Common cyst in oral cavity
• Soft tisue cyst:
• Gingival cyst
• Mucoceles
• Ranula
• Dermoid cyst
• Odontogenic cysts:
• OKC
• Dentigerous
• Calcifying odontogenic kerato cyst

62. • Conditions involving maxillary sinus:
• Fibrous dysplasia
• Paget’s disease
• Ossifying fibroma
• Swellings in salivary glands:
• Major salivary gland swelling- acute sialo
adenitis, recurrent swelling persistent swelling

63. • Benign odontogenic tumors
• Ameloblastoma
• Adenomatoid odontogenic tumor
• C.E.O.T.
• Cementoma

64. • Mandible and Predominant Region
• Ameloblastic fibroma (molar, premolar)
• Ameloblastoma (80%; posterior, 70%)
• Aneurysmal bone cyst (much more
common in molar)
• Benign nonodontogenic tumors (molar,
ramus)
• Caffey's disease
• Calcifying odontogenic cyst (70%)
• Cancer
• Acute leukemia (molar)
• Ewing's sarcoma

65. • Metastatic carcinoma (95%; molar, premolar)
• Osteogenic sarcoma (body)
• Squamous cell carcinoma
• Peripheral (3: I, molar)
• Central (2: I)
• Cementifying and/or ossifying fibroma (molar,
premolar)
• Cementoblastoma (first molar, premolar)
• Cementoma (90%; incisor)

66. • Central giant cell granuloma (65%; two thirds
are anterior to molar)
• Central hemangioma (65%; ramus, premolar)
• Cherubism (ramus, third molar)
• Complex odontoma
• Condensing osteitis
• Eosinophilic granuloma
• Follicular cyst

67. • Odontogenic fibroma
• Odontogenic keratocyst (65%)
• Odontogenic myxoma (molar, premolar)
• Osteomyelitis (7: I; body)
• Pindborg tumor (2: I; molar, premolar)
• Postextraction sockets
• Primordial cyst (third molar)
• Proliferative periostitis
• Sclerosing cemental masses

68. • Maxilla and Predominant Region
• Adenomatoid odontogenic tumor (canine)
• Chondrosarcoma (2: I)
• Compound odontoma
• Fibrous dysplasia (4:3)
• Paget's disease (20:3)
• Residual cyst (65%)

69. • Rare in Maxilla
• Caffey's disease
• Cementifying and/or ossifying fibroma
• Ewing's sarcoma
• Osteomyelitis
• Proliferative periostitis
• Reticulum cell sarcoma
• Traumatic bone cyst

70. THANK
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