Sir, we would like to bring your attention to an interesting case that presented to us quite recently which we feel would be of benefit to your readers. An 87-year-old gentleman was referred to our department by his general dental practitioner regarding a marked facial swelling on the right side of his face. The patient had been aware of the swelling for approximately two months and had also been seen by his general medical practitioner for the same condition. He had been given multiple courses of antibiotics to resolve the swelling, which was thought to be a dental abscess. The medical history included COPD, type II diabetes and hypertension. There was no history of smoking.

On examination, he had a hard, slightly tender swelling of the medial aspect of the frontal prominence of the maxilla on the right side (Fig. 1). The overlying skin was normal. There was an area of altered sensation affecting the upper right lip, probably due to the pressure of the swelling on the right infra-orbital nerve. Intra-orally, the patient was edentulous in the maxilla and tender in the upper right buccal sulcus. Swelling was impinging on the patient's complete upper denture and causing traumatic ulceration. The soft tissues were otherwise healthy. The cranial nerves were otherwise grossly intact. Plain radiographs indicated a fluid level in the right maxillary sinus with an altered bony appearance. True cut biopsies were performed and revealed B cell lymphoma as the aetiology of the swelling. A staging CT scan and bone marrow biopsy confirmed the diagnosis of diffuse large B lymphoma (Fig. 2). The patient was subsequently referred to Haematology for further management of the disease.

Figure 1
figure 1

Swelling of the medial aspect of the frontal prominence of the maxilla on the right side

Full size image
Figure 2
figure 2

Right infra-orbital foramen, indicated by arrow

Full size image

B cell lymphoma is a collective name for a group of lymphoproliferative malignancies with differing patterns of behaviour and treatment responses. There are 14 different types of B cell lymphoma with 80-90% classed as Non-Hodgkin lymphoma. Diffuse large B cell lymphoma (DLBCL) is the most common lymphoid malignancy in adults and is curable in less than 50% of patients.2 Late stage disease has a poorer prognosis. It has a bimodal distribution, affecting children under 12-years-old and adults over 40-years-old. The disease is commonly diagnosed by extra-nodal presentation of the stomach, CNS, bone, testis and liver but is rare in the orofacial region. The treatment for DLBCL is usually combination chemotherapy and/or radiotherapy, dependent on the staging and type of disease.3

Persistent solid facial swelling is a rare condition.1 Facial swelling has been associated with several disease processes including immune disorders and common pathology such as dental infection and cystic lesions. The literature has shown that orofacial diagnosis of DLBCL can be delayed, due to the disease mimicking more common conditions, and this may lead to a poorer prognosis.

We would like to make the dental practitioner aware of DLBCL as a differential diagnosis for a facial swelling of unknown origin. DLBCL is a disease that responds well to treatment in the early stages so prompt referral to an oral and maxillofacial department for further investigation may lead to a better prognosis.