原文題目(出處)： Median maxillary alveolar osteolytic lesion in a 50-year-old female. Oral Surg Oral Med Oral Pathol Oral Radiol 2017;123:3-7
原文作者姓名： Jeffrey A, Ho-Hyun Sun, Shirley Y. Kang 通訊作者學校： Western University of Health Sciences 報告者姓名(組別)： 郭宗彥 Intern I 組
報告日期： 2017/4/6
內文：
1. Clinical Presentation
I. C.C.: referred for evaluation of an asymptomatic median maxillary alveolar lesion II. Patient information
-age: 50-year-old -gender: female
-residence: middle eastern
-alcohol, tobacco, or recreational drugs: denied -history of surgery or trauma: denied
-medical history: hypothyroidism and osteoarthritis
-current medical regiment: levothyroxine as well as naproxen, as needed, for periodic arthritic pain
-pain, bleeding, swelling, altered sensation: denied
-anterior tooth felt “looseness” was noted after presentation of the lesion -extraoral examination revealed no facial swelling or asymmetry
-regional lymphadenopathy was not noted III. Oral examination
-oral hygiene: fair
-no swelling in the median maxillary alveolar area -mobility: grade I: tooth 12, 22
grade II: tooth 11,21(reproducible, atraumatic occlusion) -cold and electric pulp testing: tooth 12~22:(+)
IV. Panoramic radiograph
-a 9X9 mm, round, well-defined, corticated, low-density area in the region of the incisive canal -Vertically, the lesion extended from the area close to the periapical aspects of the maxillary central incisors superiorly to a region just inferior to the anterior nasal spine
-cause thinning of both the labial and palatal cortices, but preferential palatal cortical erosion, raising the possibility of nasopalatine nerve or canal involvement
-cause enlargement and a mild, uniform expansion of the inferior aspect of the nasopalatine foramen. Consequently, maxillary lateral and central incisors roots were notably shortened
V. Needle aspiration: negative for any type of fluid VI. Surgical exposure
-a solid, doughy, but friable mass of tissue which yielded no signs of foreign bodies within or around the lesion
2. Differential diagnosis
Anterior intrabony maxillary midline lesions with cortical erosion -Malignant lesions are unlikely here for reason
-malignancies originating in the vicinity of the nasopalatine duct are rare -limited size
-well-defined borders
-asymptomatic nature of the presentation I. Nasopalatine Duct Cyst (NPDC)
-nonaggressive cyst of oronasal duct epithelium.
-most common nonodontogenic cyst of the oral cavity(○)
-median round or ovoid radiolucency overlapping the nasopalatine duct and a peak occurrence in middle age(○)
-well circumscribed and unilocular, with minimal involvement of the nearby bony trabeculae(○) -relatively asymptomatic nature(○)
-palatal swelling without cortical erosion(X)
-strongly associated with the Caucasian race and the male gender(X) -larger size, with diameters typically ranging from 1.2 to 3.2 cm(X) -Palatal perforation as visualized in our case is unusual for NPDCs(X) II. Sinonasal Schwannoma
-benign neoplasm of Schwann cells, may arise from the various nervecontaining ductal structures of the maxilla and the face
-only about 4% of those arise within the sinonasal cavity(X) -no age, race, or gender predilection
-typically asymptomatic(○)
III. Langerhans cell histiocytosis (LCH)
-abnormal proliferation of inflammatory componentsddendritic cells and macrophagesdthat -unilocular radiolucency of a flat bone that may or may not exhibit clear demarcation -capacity to erode through calcified structures(○)
-high rate of recurrence, approximately 60%
-general predilection for bony locales, including the nasopalatal area(○), several times more likely to arise within the mandible than within the maxilla.(X)
-80% of LCH cases were seen concurrently with inflammatory, systemic presentations, such as skin lesions, hepatosplenomegaly, and prolonged fever.(X)
IV. periapical inflammatory disease(PID)
-the most common odontogenic lesion, with a wide spectrum of presentations that vary from simply inflammatory to cystic to granulomatous.
- radiolucent with well-circumscribed borders and may yet cause significant dissolution of the surrounding bone(○)
-produce swelling and cortical erosion, although both symptoms lack a directional preference and appear over a more generalized section of the face instead of resulting in a single discontinuity of the palatal cortex.(X)
-symptomatic inflammatory mass(X) -pulp nerosis(X)
V. keratocystic odontogenic tumor (KCOT)/ odontogenic keratocyst (OKC)
-uncertain radiographic presentations and a greater potential for bony destruction
- most commonly: lesion of the canine ,roots ,with or without apparent association with an apex(X) - one of the few pathologies that may cross the oral midline(○), typically by extent from the
posterior mandible and attains a midline presence(X)
- shown that maxillary midline presentations found in men and in those over 60 years of age.(X) - propensity for multilocularity(X)
3.Diagnosis And Managent
- the lesion was removed in its entirety via a palatal full-thickness flap when biopsy. A peripheral ostectomy of the bony crypt was performed to ensure that all lesional soft tissues were removed.
- mineralized allograft was placed for central incisors bony surport.
- biopsy: moderately cellular, dense, fibrous connective tissue surrounding the cholesterol clefts associated with a giant-cell reaction, with no evidence of epithelial cystic lining
-post-operation follow up:healthy with anterior tooth mobility no more than class 4. Discussion
- Cholesterol granulomas present as fatty depositions within bony structures
- typically identified histologically by visualizing collections of thin cholesterol crystals and fibrous tissue within a granular mass accompanied by foreign body giant cells and macrophages
- rare entities in the mediofacial region (including the mouth) but show a strong predilection for the aerated regions of the head
- exact etiology remains unclear, thought to occur as a result of poor ventilation of the lymph and/or air
-commonly accepted model: erythrocytes die in enclosed area and releasecholesterol crystals and membrane lipids,than cholesterol particles are perceived as foreign bodies and taken up by macrophages, which, in turn,
(1) transform into engorged histiocytes because of their inability to properly disintegrate cholesterol and
(2) release inflammatory mediators that initiate bone resorption and granulation.
-Slutzky- Goldberg et al. found that the rate of cholesterol granulation increased with age -that poses another threat to those with hypercholesterolemia
-The benign features and the low recurrence rate of cholesterol granuloma indicate that early
detection can eliminate virtually all unfavorable sequelae.
題號 題目
1 關於鼻腭管囊腫（nasopalatine duct cyst）下列敘述何者錯誤？
(A) X-光影像顯示此種病變通常是心臟型（heart shaped）
(B)會造成嚴重周圍骨吸收 (C)好發於中年男性
(D)好發於白人 答案
(B)
出處：Oral and Maxillofacial Pathology, 3e
題號 題目
2 關於蘭格罕細胞組織球增生症(Langerhans cell histiocytosis)下列敘述何者錯誤？
(A)雖然病理型態學上是良性,但臨床有轉移的特質 (B)多伴隨全身性發炎等症狀
(C)會造成病灶區域骨吸收 (D)再發率低
答案 (D)
出處：Oral and Maxillofacial Pathology, 3e
