Oral Lipoma in Elderly Saudi Patient : A Case Report

Lipomas are relatively uncommon benign tumor occurring in the oral cavity with a prevalence rate of 1% to 4% of all oral lesions. They present as a slow growing, painless, asymptomatic submucosal mass and surgical excision is the treatment of choice. Oral lipomas have been known to grow to large sizes causing interference with speech, mastication and construction of denture. A case of 77 years old male patient with lipoma of buccal mucosa in oral cavity which exhibited a sudden growth after a lag time of 3 years with mastication and speech difficulties. The tumor excised in total with restoration of normal speech and mastication.


Introduction
Lipomas are benign mesenchymal neoplasms composed of mature adipocytes, usually surrounded by a thin fibrous capsule (Trandafir D et al., 2007).Lipoma is a very common tumor of adipose tissue, but its presence in oral cavity is relatively uncommon with a prevalence rate of 1% to 4% of all benign oral lesions (Bandeca MC et al., 2007).Oral lipomas can occur in various sites but the most common sites are buccal mucosa, floor of the mouth, tongue,lip, palate and vestibule (Deepti S et al., 2005).Oral cavity lipomas usually present as slow growing, painless and asymptomic lumps (Dattilo D J., 1996).It is known that with continued growth their size may interfere with speech and mastication (Keskin G et al., 2003).The buccal mucosa and tongue are commonly the predominant sites in adults with some studies showing a female dominance while others shows no gender difference (Fregnani E R et al., 2003;Lawoyin J O et al., 2001).The tumors are either encapsulated or non encapsulated or present in an infiltrating manner.The unusual intraoral sites of lipoma include the palate, lips and gingiva (Rapidis A D et al., 1082).Studies showed that oral lipomas can occur in all ages but more common over 40 years of age (Hatziotis J C et al., 1971).
A case of oral cavity lipoma in an elderly male treated by surgical excision is reported.

Case Report
A 77 years old Saudi male reported to the oral and maxillo-facial surgery department of Buraidah Central Hospital, Qassim with a large intraoral soft and smooth mass of approximate size 5x4x2 cm in the right buccal sulcus which developed in last 3 years (Figure 1).It was painless and suddenly increased in size.For the last few months the lesion started to interferes with speech and mastication.Extraoral examination revealed a swelling at the right side of cheek.No palpable lymphnodes was observed.Intraoral lesion was soft with no any evidence of mucosal ulceration.
A panoramic radiograph was taken which revealing no bony involvement (Figure 2).Aspiration of the lesion was done but no fluid drew in the syringe.Complete blood examination was done.Excision of the lesion was done under local anesthesia because of the age factor and medical condition of the patient.Longitudinal incision was made over the mucosa and the lesion was removed through blunt dissection in total(Figure 3).Long buccal nerve become visible and protected (Figure 4).The incision was closed with 3/0 black silk sutures obliterating the dead space (Figure 5).The specimen was sent for histopathological examination (Figure 6).Follow up was done monthly for seven months .No complications or recurrence was reported.There was uneventful recovery from the surgery and patient regained normal function (Fig 8 ).

Gross inspection
Yellow white mass measuring 5 x 4 x 2 cm.Cut section showed homogenous yellowish white mass.

Histopathological examination
The histopathological examination described circumscribed mass of mature fat cells with varying number of collagen strands interlacing through the lesion and supporting small blood vessels.Nucleus is flattened against the cell wall.The tumor cells are arranged in lobules with an intervening connective tissue stroma (Figure 7).

Discussion
The most common sites of lipomas in the oral cavity are cheek, tongue, palate,mandible and lip where lipomas occur as a sessile or encapsulated mass.The etiology is unknown, however it is thought that trauma may trigger proliferation of fatty tissue and cause a lipoma (Epivations A et al., 2000).The first description of oral lipoma was provided in 1848 by Roux in a review of alveolar masses which he referred it as a "yellow epulis" (Roux M. 1848).Oral lipoma may present as solitary or multiple lesions as in Gardner , s or Bournville , s syndrome (Del Castillo et al., 2004;Gray AR et al., 1991) or as macroglossia (Diattelli A et al., 2000) or lipomatosis (Katou F et al., 1993), their clinical course is usually asymptomatic until they grow to large sizes.The majority remain unulcerated but ulceration causes a diagnostic problem.Some deep lipomatous lesions produce only slight elevation of the surface while others can cause changes in function.The most common anatomical site in the oral cavity frequently reported is buccal mucosa followed by parotid region (Kakani R S et al., 1993).The current reported case is one of those occurred in buccal mucosa towards right side.Occasionally lipoma of buccal mucosa cannot be distinguished from a herniated buccal pad of fat.MRI is very useful in clinical diagnosis and ultrasound is less informative.When CT scan is used, the diagnosis is mainly on the low mass density of lipomas.This method can be used to differentiate infiltrating lipoma from well encapsulated lipomas.MRI gives a greater soft tissue definition than CT scan (John Spencer M et al., 2006).None of these imaging techniques was necessary for preoperative assessment in the presented case as the lesion was located in accessible area of the buccal sulcus and there were no anatomical hazards to complicate the surgery.Surgical excision with safety margins is the treatment of choice to prevent recurrence chances (Furlog M A et al., 2004).
Well encapsulated lipomas as in the present case are easily popped out with no possibility of recurrence or damage to the surrounding structures (Midion M C et al., 2006).The buccal mucosa was the most affected site (53.7%),followed by the buccal sulcus (14.6%) and tongue (9.8%0.Tumor size ranged from 0.5 to 10cm and the mean reported duration was 48 months (Juliasse LE et al., 2010).

Conclusion
Buccal soft tissue lipomas are rare tumors.A high index of suspicion is required for making a diagnosis.Surgical excision is the ideal treatment with excellent outcome.The importance of histological examination cannot be overemphasized and the features of lipoma are usually straight forward and classic.

Figure: 1
Figure: 1 Intral oral view of the patient showing Figure: 2 No bony involvement seen in radiograph tumor at right buccal sulcus.

Figure: 3
Figure: 3 Different stages of tumor popping out from buccal mucosa