Int. J. Oral Maxillofac. Surg.

2008; 37: 497499

doi:10.1016/j.ijom.2007.12.004, available online at http://www.sciencedirect.com

Case Report
Oral Surgery

Alternative surgical approaches

for excision of dermoid cyst of
the floor of mouth

I. E. El-Hakim1, A. Alyamani2
1
Ain Shams University, Cairo, Egypt; 2Dental
School, King Abdulaziz University, Jeddah,
KSA

I. E. El-Hakim, A. Alyamani: Alternative surgical approaches for excision of dermoid

cyst of the floor of mouth. Int. J. Oral Maxillofac. Surg. 2008; 37: 497499. # 2007
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.
Abstract. Two different treatment approaches for large dermoid cysts are presented in
this article. The extraoral approach was utilized for a patient who presented to the
emergency room with a respiratory problem. The intraoral approach was performed
in a female patient presenting with a large swelling involving both the submental
and sublingual areas, and this approach led to good esthetic results without
recurrence.

Sublingual dermoid cysts may develop

above or below the mylohyoid muscle,
causing a submental or submaxillary
mass8. Surgical excision from the floor
of the mouth is indicated to relieve symptoms and prevent possible infection. An
intraoral incision may be used for small
cysts, but large ones require an external
approach which avoids intraoral contamination and allows better visualization and
control of surrounding structures5. LONGO
et al.6 recommended the use of an extraoral approach only when the cyst presents
under the geniohyoid muscle. An intraoral
approach is described for a large midline
cyst that lay above the mylohyoid muscle;
this is preferable whenever possible for the
sake of cosmetic appearance1.
Case 1

A 22-year-old male presented to the emergency room complaining of breathing dif0901-5027/050497 + 03 $30.00/0

ficulties and inability to talk or eat, which

he attributed to a large swelling in the front
of the neck. The swelling had been present
since he was a child, but had enlarged over
the years. The patient was febrile, and had
bilateral sub-mandibular lymphadenopathy. Physical examination showed a large
swelling involving the submental, submandibular and sublingual areas measuring 12  12 cm in diameter, freely
movable and causing elevation of the floor
of the mouth. The tongue was elevated to
the extent that the soft palate could not be
visualized. The swelling was found to be
smooth, non-tender, of normal overlying
skin, and extended from the submental to
the submandibular regions on both sides.
There was no previous trauma or contributory medical history. An axial computerized tomography (CT) scan revealed a
large midline unilocular radiolucent lesion
of the floor of the mouth. The differential
diagnosis included lipoma, Ludwigs

Keywords: dermoid cyst; floor of mouth; surgical treatment; intraoral surgical approach.
Accepted for publication 19 December 2007
Available online 12 February 2008

angina, acute infection or cellulitis of

the floor of the mouth, ranula, thyroglossal
duct cyst, cystic hygroma, unilateral or
bilateral blockage of Whartons ducts,
branchial cleft cysts, infection of submaxillary and sublingual glands, and benign
and malignant tumors of the floor of the
mouth and adjacent salivary glands.
As the clinical diagnosis is usually
inconclusive and due to the life-threatening situation, the patient was treated
immediately for exploration and to establish an airway. Under general anesthesia
with nasal intubation, a transverse incision
was made in the right submandibular area
extending beyond the midline to the opposite side. This was carried through skin,
subcutaneous tissue and platysma. The
mass was found deep to the mylohyoid
muscle (which was cut). Blunt dissection
was utilized to free and remove the mass,
and then the wound was sutured in layers
with a corrugated rubber drain placed in

# 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

498

El-Hakim, and A. Alyamani

Fig. 1. a Sagittal T1-weighted MRI view, showing the posterior 3/4 of the mass lying above the mylohyoid muscle. The lesion appears with a
heterogeneous high signal intensity. (b) Clinical presentation. (c) Midline incision in the ventral surface of the tongue. (d) Enucleation of the cyst.
(e) Suture of the undersurface of the tongue.

position. The lesion had a cystic structure

filled with semi-solid content. During enucleation, the wall was perforated releasing
a cheese-like, purulent exudate. The surgical specimen was submitted for histopathological examination. Microscopic
examination revealed sebaceous glands
in the cyst wall and keratin fibers in the
lumen, consistent with the diagnosis of

dermoid cyst. No carcinomatous changes

could be identified. Postoperative course
was uneventful and there was no evidence
of recurrence at 2 years after surgery.
Case 2

A 20-year-old female presented with a

large swelling involving both the sub-

mental and sublingual areas. An esthetic

problem was her main complaint. Magnetic resonance imaging (MRI) showed
a large lesion on the floor of the mouth
(Fig. 1a). A tentative diagnosis of
large midline dermoid cyst lying above
the mylohyoid muscle was made. An
intraoral approach was decided on to
enucleate this lesion for cosmetic pur-

Alternative surgical approaches for excision of dermoid cyst of the floor of mouth
poses after routine laboratory examinations.
A midline incision was done at the
tongue base after infiltrating the area with
adrenaline 1/200,000 for homeostasis.
Sharp and blunt dissection was performed
until the cyst wall could be recognized and
dissection around the cyst wall completed.
The cyst was delivered into the oral cavity
without perforating the cyst wall. The
lesion was found to be sitting on the
genioglossus muscle. The mass was enucleated completely without complications.
The wound was then closed in layers and
finally the back surface of the tongue was
closed using interrupted sutures. Recovery
was uneventful except for modest edema
in the immediate postoperative period and
there was no recurrence after 3 years of
follow up (Fig. 1b, c, d and e). The specimen was examined histopathologically
and was consistent with the diagnosis of
dermoid cyst.
Discussion

An intraoral dermoid cyst grows slowly,

but may enlarge and interfere with deglutition and speech, or can pose a critical risk to
the airway as in the case presented in this
article, and therefore require immediate
surgical intervention. Also carcinomatous
change, although extremely rare, should be
considered in long-standing cases7.
The diagnostic work up for suspected
dermoid cyst should include ultrasonography, CT or MRI. CT or MRI allows more
precise localization of the lesion in relation

to anatomic structures, which helps in

choosing the most appropriate surgical
approach2,3. Surgical excision is the treatment of choice and recurrence is rare.
LONGO et al.6 recommended the intraoral
approach for the treatment of large lesions
presenting above the mylohyoid muscle for
good cosmetic and functional results. This
approach was utilized in the second case
because the cyst was not infected; it was
found to be an easy technique with good
esthetic outcome, and there were no complications except for modest edema and no
relapse could be observed on follow up.
The extraoral incision was preferred in the
first case as the cyst was infected and the
patient had an airway problem from the
swelling; it was possible to obtain adequate
surgical exposure using this approach.
It appears from the presented cases that
dermoid cyst may cause life-threatening
situations if left untreated. The intraoral
approach can be utilized in large, deeply
seated, non-infected lesions, and this led to
very good cosmetic and functional results
with no complications. The extraoral
approach is utilized for very large dermoid
cysts involving simultaneously the floor of
the mouth and the submental space, and in
cases of severe infection that compromise
the patients airway4.
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Address:
Professor Ibrahim E. El-Hakim
Ain Shams and King Abdulaziz University
Cairo and Jeddah
Egypt and KSA Mailing address:
6 El-Gendy Street
Hadayek Helwan
Cairo-Egypt 11433
E-mail: imelhakim@hotmail.com