Many differential diagnoses must be considered in the diagnosis of cervical lymphadenopathy. Lymph nodes, which are responsible for the production of lymphocytes, are crucial to the body's defense mechanism and are responsible for the immune response to bacteria, viruses, toxins, and other materials that invade the lymph vessels. They are also susceptible to metastasis of malignant tumors. Therefore, cervical lymphadenopathy may indicate a variety of disorders. In addition to interviews, visual inspection, and palpation, blood tests and diagnostic imaging such as X-ray, CT, MRI, and ultrasound are also essential. In cases where a diagnosis can not be made based on these tests, biopsy of the swollen lymph node must be performed. Cervical lymph node biopsy requires the utmost care in addition to the patient's informed consent. Many nerves and blood vessels are present in the neck region, and accidental injury to these nerves and blood vessels may result in serious sequelae, which in many cases incur medical malpractice lawsuits. Therefore, cervical lymph node biopsy should not be performed unassisted by inexperienced surgeons. Herein, we present the lymph node disorders and diagnostic methods that are important for differential diagnosis, and describe the points of caution regarding lymph node biopsy.
Differential diagnosis of the neck masses is a little bit difficult. However, appropriate procedures for diagnostic imaging make it possible to focus on several possible lesions. First step to differential diagnosis is to localize the mass in a particular anatomical space using contrast enhanced CT or MM. This step facilitates the differential diagnosis by limiting the types of the lesions arising in the given anatomical location. The sites related to the neck masses are submandibular, carotid, parapharyngeal and parotid gland spaces. Displacement of the vessels is an important sign to differentiate lymph node diseases from other diseases. They are facial artery and vein in the submandibular space, and carotid artery and jugular vein in the carotid space. It is also difficult to differentiate among lymph node diseases. A combination of several imaging modalities, such as CT, MRI, and ultrasonography makes differential diagnosis more accurate. Lymph node diseases that must be differentiated each other are lymph node metastasis, malignant lymphoma, and lymphadenitis. Specific lymphadenitis such as tuberculosis must be also differentiated from simple lymphadenitis. Important findings for differential diagnosis are inflammatory changes in the border of the nodes or fascia, in CT, and echogenic hilum and vascularity in the ultrasonography. However, patient history, clinical findings, and laboratory data must be also considered to make the final clinical diagnosis.
Diagnosis of malignant lymphoma should be made basically morphological observation with HE specimen as well as data by multimeric analyses. Otherwise there are some cases that cannot obtain a precise diagnosis. In addition, pathologists must understand the characteristics of many subclassification of lymphoma enough, and based on the knowledge, it becomes often necessary to add various kinds of analysises.
We report a rare case of a brain abscess secondary to radioosteomyelitis of the jaw. A 61-year-old man who had received irradiation to a tumor of the tonsil in 1991 had been conservatively treated for radioosteomyelitis of the mandible at our hospital at regular intervals. Then he felt narrowing of the visual field with a serious headache and was immediately admitted to our hospital in September 2006. On the next day, convulsive seizures occurred. Brain CT scanning was immediately performed and demonstrated a low density area in the right occipital lobe. The patient was given a diagnosis of brain abscess. A craniotomy followed by aspiration with drainage was performed by a neurosurgeon. After the operation, the narrowing of visual field improved immediately, and both CT and MRI revealed disappearance of the low density area. Hematogenous infection due to radioosteomyelitis of the jaw was strongly suspected to have caused the brain abscess. After discharge from our hospital, no further symptoms have occurred.
Angioleiomyoma is a benign tumor of smooth-muscle origin with a predilection for the extremities, but has rarely been reported to occur in the oral cavity. We describe a case of angioleiomyoma of the tongue. A 48-year-old man had a 5-year history of a mass arising in the left margin of the tongue, which repeatedly enlarged and regressed. When the tumor became enlarged and ulcerated, he consulted our department. On physical examination, an elastic firm, non-tender mass measuring approximately 11×10×12mm with a surface ulcer approximately 4 mm in maximal diameter was detected. Because a diagnosis of angioleiomyoma was established by biopsy, he was scheduled for tumor resection; however, at the patient's request, the sharp edges of the teeth in contact with the tumor were ground, and the patient was followed up. Although the tumor initially regressed, it ceased to regress about 4 months after grinding of the teeth and was resected. Immunostaining with anti-α-smooth muscle actin antibody and anti-caldesmon antibody was useful for histopathological diagnosis of the tumor. We speculate that mechanical stimulation and smoking slightly influenced the development of the tumor.
Mucosa-associated lymphoid tissue (MALT) lymphoma is an extranodal low-grade lymphoma found mainly in the gastrointestinal tract. However, it rarely occurs in the oral cavity. A case of MALT lymphoma arising in the minor salivary glands of the buccal region is reported. A 21-year-old woman was referred to our department because of a swelling in the left buccal mucosa. Clinically, the mass was elastic hard and painless, but did not adhere to the skin or oral mucosa. After resection of the mass, it was diagnosed to be a malignant lymphoma arising in the buccal gland. The lymphoma was classified as MALT type on the basis of histopathological and immunohistochemical findings. Further evaluation suggested that the patient might have Sjögren's syndrome. An association of the MALT lymphoma with Sjögren's syndrome was suggested. Six months after treatment, there was no evidence of recurrence.
A case of bilateral coronoid process hyperplasia of the mandible is presented. A 12-year-old boy was referred to our hospital because of limited mandibular movement. He was aware of decreased mouth opening 8 months before presentation. He was treated for TMJ dysfunction at a certain clinic. However, his condition did not improve. His maximum mouth opening was 10mm (interincisal distance). Panoramic radiography and CT of the mandible revealed bilateral coronoid process hyperplasia, extending above the zygomatic arch. Bilateral coronoidectomies were performed through an intraoral approach under general anesthesia, and continuous mouthopening training was done after surgery. Histopathologically, the specimens were not tumor, but hyperplasia of the coronoid process. After the coronoidectomy, jaw trismus resolved, and no reccurence has occurred.