Article Type : Research Article
Authors : Guerri F
Keywords : Cyst of the Blandin-Nuhn glands; Biopsy; Classical scalpel
Aim: The aim of this article is to report a rare case
of mucocele of Blandin-Nuhn glands and discuss the most appropriate therapeutic
approach.
Materials and Methods: A 16-year-old female patient
was referred to us reporting the recurrence of a circumscribed neoformation
located on the apex of the ventral surface of the tongue. The parents reported
the relapse of the lesion following the initial surgery. Based on the clinical
aspects and since it was a relapse, the probable diagnosis is determined as a
cyst of the Blandin-Nuhn glands. A histopathological examination followed the
excisional biopsy of the lesion performed with a classical scalpel. Within 7
days of the biopsy, complete repair of the tissue was observed.
Results: The definitive diagnosis of the case was
mucocele of Blandin-Nuhn glands. The Pathologist described the sample as an
oral mucosa with stroma occupied by lymphocytic and histocitic infiltrates in a
context of eosinophilic amorphous material, with intense chronic inflammation
and ectasia of the peri-lesional lymphatic vessels.
The Mucocele is defined as a cyst
caused by an abnormal accumulation of mucin. They can be classified into
extravasation and retention type. Extravasation mucocele develops from a broken
salivary gland duct causing spillage into the soft tissues. The tissue reacts and
creates a pseudo capsule around the gland. This type of mucocele has a higher
incidence in young patients and its development is linked to bad habits like
lips and cheek self-trauma. The retention mucocele is caused by a stenosis or a
complete obliteration of the duct that results in a decrease or absence of
glandular secretion [1,2]. The mucocele could appear as a bluish, soft, and
transparent cystic swelling frequently resolves spontaneously. The color of the
mucocele depends on its size.
The most frequent area of development appears frequently on the lower lip followed by the tongue, buccal mucosa, and palate [1,2]. A rare development area for the mucoceles is the Blandin-Nuhn’s glands. These particular types of glands are localized on the tip of the ventral surface of the tongue on its mean line. The Blandin-Nuhn’s mucocele is also called Nuhn’s Cyst. In a retrospective trial, Harrison et al. observe the localization of 400 mucoceles, only nine of which grow on the tongue's mucosa. This amount represents only 2.3% of the total of mucoceles. According to Saza et al. and Jinbu et al., only 9-10% of mucoceles develop from the Blandin-Nuhn’s glands [3-7]. Its incidence is higher in young people and especially in women. The main etiological factor for the development of Nuhn Cyst is the trauma of the duct and its subsequent stenosis or complete obliteration [6,8]. Clinically, they are considered quite unusual and could be confused with other oral lesions such as venous varices, vascular lesions, polyps, and squamous papillomas [6]. Its treatment is different from a normal mucocele because the gland does not have a liner capsule and leans directly on the muscular tissue [9]. This article presents a case of a Nhun Cyst removal.
A 16-year-old female patient, in good general health,
came to our attention reporting the recurrence of a circumscribed neoformation
localized on the apex of the ventral surface of the tongue. The patient
reported a prior surgical excision of an oral lesion in the same anatomical
area. On the clinical records, the first excisional tissue sample was described
as a grayish-white color oral lesion with a diameter of 4 mm. The pathologist’s
diagnosis was mucoid cyst. The clinical examination highlighted the presence of
a normochromic pedunculated popular neoformation of 5 mm in diameter on the tip
of the ventral surface of the tongue on the middle line. The neoformation was
asymptomatic, the patient didn’t report pain or bleeding
Vicryl 4/0 sutures were finally applied. The tissue
sample was put in a 35-40% of formaldehyde solution and sent to the
pathologist. An antiseptic therapy with chlorhexidine 1% gel was prescribed 3
times a day for 10 days and Paracetamol 1g only in case of need as a pain
killer. After 7 days the tissue appears normochromic, neurotrophic, and
normohydrated, the stitches were removed.
The histological report confirmed the clinical
diagnosis of mucocele, observing oral mucosa with stroma occupied by
lymphocytic and histiocytic infiltrates in a context of eosinophilic amorphous
material, with intense chronic inflammation and ectasia of perilesional
lymphatic vessels.
Blandin Nuhn mucoceles can be treated
in different ways: surgical excision, marsupialization, cryosurgery, laser
ablation, and steroid injections [9]. The authors preferred to avoid this last
and more conservative solution, considering that in this case the mucocele was
a relapse of a precedent lesion and wanted to completely eliminate the
neoformation, which can otherwise lead to irritation and discomfort to the
patient. Other solutions, such as marsupialization are more appropriate in
larger mucoceles or when the surgery would be too invasive and dangerous for
the patient. In this case, the dimensions of the cyst were modest, for this
reason, surgical excision was carried out. Excision of the mucocele may have relapsed
after the surgery. The site in which recurrence are most frequently developed
is the ventral surface of the tongue [10]. No significant difference in relapse
rates was observed comparing the different surgical procedures according to
Yun-Jeong Choi [10-13].
Surgical removal of the mucocele is the first-choice
treatment; removal of the traumatic aetiological agent is an alternative
conservative therapeutic treatment. It is indeed very important to identify
them in order to provide complete excision of the Blandin-Nuhn gland and avoid
relapses.
The authors declare that they have no conflict of
interest.
The authors declare that they have not received any
funding for the present study.
The authors declare that informed consent has been
obtained from the patient for publication of the case, including photographs.