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Excision of Mouth Lesions

Overview

Introduction

A wide range of disorders can lead to mucosal changes in the oral cavity. Typically, lesions arise from processes that are infectious or inflammatory and that respond to medical therapy. Not infrequently, autoimmune and neoplastic diseases may affect the mucosal surfaces of the oral cavity or its contents. The latter changes often require tissue biopsy for clinical pathology review before initiation of therapy.

The initial history of the clinical presentation is most critical to formulating a differential diagnosis of potential disease processes. Important historical points to elicit include the time of onset of symptoms, the presence or absence of pain, dietary intake, and visible lesions of the face, lips, tongue, or mucosal membranes. Clinicians must also ask about the presence of any associated systemic symptoms, such as fever or weight loss, and history of prior neoplasm or malignancy. Other critical elements of the history include exposure to medications, alcohol, tobacco, chemicals, recent oral trauma or dental work, and vaccination history. Patients with HIV or other immunocompromised states, such as leukemia or neutropenia, can have opportunistic pathogens affecting mucosa. Most commonly, these are invasive fungal infections, which are not seen in otherwise healthy patients.

Most oral lesions are adequately diagnosed based on a detailed history and thorough physical examination alone and can be treated accordingly. A detailed head and neck examination should be performed, with particular emphasis on the oral cavity and oropharyngeal examination. Palpation of the face, cheeks, floor of mouth, and neck reveals any localized areas of induration, tenderness, or cysts.

The appearance of any lesions should be documented in detail (dimension, location, color) and followed closely over the following days or perhaps, weeks. However, lesions that persist despite adequate treatment or raise concerns for neoplasm should undergo excisional biopsy promptly. Any associated changes in symptoms (such as weight loss, rash, discoloration of the overlying skin) should be noted in a complete review of systems. Radiological imaging is essential for large lesions and may be reserved for lesions with either extensive involvement or critical proximity to vital structures.

A video depicting the excision of mouth lesions can be seen below.

Oral mass excision.

Relevant Anatomy

The oral cavity represents the first part of the digestive tube. It includes the lips, gingivae, retromolar trigone, teeth, hard palate, cheek mucosa, mobile tongue, and floor of the mouth. The major salivary glands are in close relation with oral cavity structures, although they are not part of the oral cavity. For more information about the relevant anatomy, see Mouth Anatomy and Tongue Anatomy.

Indications

The most common indication for the excision of an oral cavity lesion is to obtain tissue for diagnosis. Most commonly the lesions are benign and reflect congenital or acquired injuries or structures. Prompt biopsy is especially important when trying to confirm a possible soft tissue sarcoma or other neoplastic malignancy. Benign lesions, such as large mucocele, lymphangioma, or enlarging cysts, which are disrupting normal function or causing significant discomfort, may also warrant excision.

Contraindications

Excision of oral cavity lesions has few contraindications but must be planned carefully to assure high functional and cosmetic outcomes. Patients who are on medications and may be anticoagulated or with underlying bleeding disorders should undergo medical clearance prior to any major procedure. A hematologist may be consulted for management considerations. Depending on the type and severity of the coagulation disorder, patients may require pretreatment with blood products, such as transfusion of platelets or coagulation factors.

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