Sub-mucosal swelling

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Sir, a patient presented for a check-up with no complaints other than for an occasionally sensitive upper left first molar. The patient is a 52-year-old male who has attended regularly for check-ups and supportive hygiene therapy for almost 20 years. There is no medical history of note. He is a non-smoker and an occasional social drinker. Having completed the dental part of the check-up, the soft tissues were assessed working methodically around the lips, tongue, palate and soft tissues including the floor of the mouth.

On raising the tongue, a sub-mucosal swelling was present in the left hand side of the floor of the mouth (Fig. 1) which was also clearly evident when the patient moved their tongue toward the right (Fig. 2). The swelling was firm to touch and there was neither ulceration nor any break of the overlying mucosa. There was no comparable swelling in the right hand side.

Figure 1

Sub-mucosal swelling clearly visible in left floor of the mouth

Figure 2

Swelling remains in left floor of the mouth when extending tongue to the right

The patient was referred to a consultant oral and maxillofacial surgeon for assessment and management following a discussion about the possibility of a saliva gland problem as being the most likely of several provisional diagnoses.

Tests, including a biopsy, were carried out within a few days and a diagnosis of a MALT lymphoma (or MALToma) was made. This form of non-Hodgkin's lymphoma normally involves the 'mucosa-associated lymphoid tissues', most commonly within the stomach and upper gastro-intestinal lining, although virtually any mucosal site can be affected.

The prognosis of such a MALToma is good with early identification and surgical removal (Figs 3 and 4). A PET-scan six months after surgery confirmed that there had been no metastatic spread and, as a result, neither chemotherapy nor radiotherapy was indicated for this patient at this time. Close monitoring over the years ahead will be essential.

Figure 3

Lifting tongue – three months after surgical removal

Figure 4

Moving tongue to the right – three months after surgical removal

This case study reports an unusual presentation and highlights the need for a comprehensive and thorough assessment of all the soft tissues at each appointment to ensure the earliest possible diagnosis and management.