Volume 49, Issue 1 , Pages 67-69, January 2011
Unusual case of spontaneous discharge of pus (infected cyst) through the dorsum of the tongue
Article Outline
Abstract
Neck swellings are often a result of infections that spread from the teeth. This case highlights an unusual presentation of spontaneous pustular discharge from the anterior dorsum of the tongue.
Keywords: Thyroglossal cysts, Dermoid cysts, Dorsum tongue, Infection
Case report
A 40-year-old male teacher presented to a London accident and emergency department with a one-day history of submental facial swelling (Fig. 1), trismus, dysphagia, and “coughing-up” purulent sputum. He had had no previous symptoms, had a history of mild asthma for which he occasionally used a salbutamol inhaler, and drank alcohol lightly.
Fig. 1.
Photograph of submental swelling.
On examination, the floor of the mouth, tongue, and neck showed gross inflammatory involvement, and he could not swallow saliva. A foul smelling, purulent discharge emanated from the anterior dorsum of the tongue (Fig. 2), and a lower left molar was grossly carious, but was remote from the infection. He was apyrexial, had a mildly elevated pulse rate, and a raised white cell count. Clinical and radiological examination of his chest showed no abnormalities. There was no evidence of sputum.
Fig. 2.
Photograph of discharge from dorsum of the tongue.
As this did not seem to be of an odontogenic origin, a computed tomogram (CT) of the neck was requested, and he was prescribed intravenous co-amoxiclav (Augmentin®) and dexamethasone (steroids) for management of a potential obstruction of the airway. In theatre he had an extraoral submandibular and submental incision and drainage, and extraction of the carious molar. On culture the copious seropurulent discharge grew mixed flora that was sensitive to Augmentin®. Postoperative intravenous antibiotics, fluids, and analgesics were prescribed, and he was discharged four days later with a further five days of oral antibiotics.
He continues to attend for outpatient review, and there has been no evidence of recurrence clinically or on CT repeated nine months postoperatively.
Discussion
From the symptoms we reduced the differential diagnosis to that of dermoid or thyroglossal duct cyst.
Thyroglossal duct cysts are the second most common neck mass (the first being lymphadenopathy),1 and account for 70% of congenital neck masses.2 They are intimately associated with the hyoid bone and are located anywhere along the course of the thyroglossal duct from the foramen caecum to the pyramidal lobe of the thyroid gland.3 Diagnosis is based on the finding of a progressively enlarging swelling within 2
cm from the midline4 that moves on protrusion of the tongue.5 Most have a squamous lining and they rarely contain thyroid tissue within their walls.3 Radiologically they present as cystic lesions in the midline of the anterior neck, or within the strap muscles just off the midline.5
Dermoid cysts in the floor of the mouth are rare (1–2% of all dermoid cysts).6 Typically they present in early adult life7 as painless, slow growing, soft, well-encapsulated swellings that increase in size at the onset of puberty or an infective episode. Infected cysts may be associated with pain, trismus, fever, dysphagia, and odynophagia.8 Radiographically they have a high fat content.7 Surgical enucleation results in low recurrence.8 This was our working diagnosis in this case.
Preoperative contrast CT (Fig. 3) showed a large midline cystic lesion deep within the tongue that had ruptured through the dorsum. It contained multiple locules of gas, had a fluid-debris level, and showed peripheral enhancement, features suggestive of an infected lesion. Although midline in location, there was no fat within the lesion, and the overall appearance was not typical of a dermoid cyst. Its point of discharge on the dorsum of the tongue did not correspond with the normal position of a remnant of the thyroglossal duct, and its position deep within the tongue was also atypical for a thyroglossal cyst.
Fig. 3.
Computed tomogram of the cyst (sagittal view).
This case did not correlate with either diagnosis, and we were unable to obtain a tissue diagnosis as the potential risk to the airway necessitated urgent decompression.
Infected cysts of the head and neck region are relatively common. Their anatomical position often aids diagnosis, particularly in cases of thyroglossal duct cysts, but the extraordinary clinical presentation of discharge from the dorsal anterior tongue, the lack of radiographic features, and absence of histological confirmation ensured that definitive diagnosis remains a mystery in this case.
References
- . Evaluation of neck masses in children. Am Fam Physician. 1995;51:1904–1912
- . The thyroglossal cyst. Head Neck Surg. 1982;5:134–146
- Parenchymal cysts of the lower neck. Radiology. 1985;157:399–406
- . Review of head and neck lesions in infancy and childhood. Surg Clin North Am. 1992;72:1429–1447
- . Congenital cystic masses of the neck: radiologic-pathologic correlation. Radiographics. 1999;19:121–146[Erratum in: Radiographics 1999; 19:282]
- . Dermoid cysts of the floor of the mouth. Br J Oral Surg. 1965;3:36–47
- . Dermoid cyst of the floor of the mouth: CT appearance. AJR Am J Roentgenol. 1983;141:1239–1240
- . Case report of a dermoid cyst at the floor of the mouth. Ann Acad Med Singapore. 2004;33(4 Suppl.):77–79
PII: S0266-4356(10)00015-X
doi:10.1016/j.bjoms.2009.12.011
© 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Volume 49, Issue 1 , Pages 67-69, January 2011
