Introduction
Mucocele is a mucous-filled cavity that can appear at various locations in the oral cavity. It is the 17th most common salivary gland lesion seen in the oral cavity. Two types of mucocele can appear – extravasation and retention.[1] The lower lip is frequently affected.[2] They are mostly asymptomatic, but in some cases, they may cause discomfort.[1] Various modalities are available for the treatment including surgery, laser ablation, cryosurgery, sclerotherapy, micro-marsupialization, laser surgery, and intralesional injection of sclerosing agent or corticosteroid. Although surgery is the most commonly used modality, it has numerous disadvantages such as lip disfigurement and damage to adjacent ducts with further formation of satellite lesions.[3] Therefore, the focus of interest has shifted toward nonsurgical treatment modalities such as sclerotherapy. We hereby present a case of a 49-year-old male patient with an unusual case of oral mucocele on the buccal mucosa, treated with sclerotherapy.
Patient Information
A 49-year-old male patient reported to the department of oral medicine and radiology with the chief complaint of painless swelling in the left-back region of the jaw for 6 months [Figure 1a]. The medical, family, and psychological histories were noncontributory. There was a history of constant trauma due to the third molars and a clear fluid discharge from the swelling. He had a history of visit to multiple clinics with the same complaint. With the advice of one dentist, he underwent extraction of the upper and lower third molars on the left side, 2 months back but did not have relief [Table 1]. After the extraction, trauma had subsided, but the swelling was persistent.
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Figure 1: (a) A round swelling on the buccal mucosa near occlusal level of teeth 28 and 38. (b) Size of the swelling approximately 4mm
Table 1: Timeline of history
Clinical findings
On examination, a solitary round-shaped swelling was seen on the left buccal mucosa near the occlusal level of 28 and 38, measuring approximately 4 mm in diameter [Figure 1b]. The mucosa surrounding the swelling appeared to be keratotic. It was soft in consistency, painless, compressible, nonmobile and, fluctuant. Based on history and clinical findings, a diagnosis of oral mucocele on the left buccal mucosa was given. All the other teeth were present, with no abnormality apart from mild stains.
Therapeutic interventions
Due to inaccessibility of the posterior buccal mucosa, sclerotherapy with sodium tetradecyl sulfate (STS) (Setrol 60 mg/2 mL) was planned. STS was diluted with normal saline in the ratio of 1:1 and an intradermal patch test was performed which showed no hypersensitivity to the drug. The swelling region was disinfected with betadine solution. Topical anesthetic gel was applied in the region of swelling and 0.3–0.5 ml of the solution was injected with an insulin syringe into the lesion until the solution leaked out [Figure 2a] Pressure was applied to the injection site for 5 min.
Figure 2: (a) Sodium tetradecyl sulfate injected with insulin syringe into the lesion. (b) Follow-up after 1 week of therapy showing no decrease in size. (c) Follow-up after another 1 week showing complete disappearance of the lesion
Follow-up and outcome
After 1 week, the patient was recalled to check healing. There was no obvious decrease in the size of the swelling. It was approximately 3 mm in diameter when measured with a Vernier caliper [Figure 2b]. Therefore, another injection was planned following the same protocol. After the next 7 days, the swelling had completely vanished [Figure 2c]. The patient is being regularly followed up and there is no report of recurrence, after 6 months of therapy.
Discussion
Sclerosing agents are irritants that act on the endothelial surfaces, resulting in the obliteration of space between the surfaces. The resultant obliteration causes tissue fibrosis and further reduction or disappearance of the lesions.[4] [Figure 3] There are three types of sclerosants: hyperosmolar, detergent, and chemical.[5] STS is a synthetic, surface-active substance which falls into the detergent category.[4] Necrosis and sloughing of the tissue occurs when STS is used in the lesion leading to total or partial regression of the lesion.[6] Sclerotherapy is effective in the management of mucoceles, pyogenic granulomas, ranulas, vascular malformations, hemangiomas, and lymphatic malformations.[4]
Figure 3: Flow-chart showing mechanism of action of the sclerotherapy
These asymptomatic, fluid-filled cavities occur at any age with a higher frequency in the second and third decades of life.[7] Surgery is the most commonly used modality in the treatment of oral mucocele.[3] Sclerotherapy has several advantages over surgery: It is a safe, simple, effective, and minimally invasive technique, with negligible complications. There is minimal loss of blood and no requirement for any particular care.[4] Keeping this in mind, STS was used for treatment in our case.
In a case report by George et al.,[8] a similar agent was used for the treatment of oral mucocele occurring on the lower lip. There was complete disappearance of the lesion within 3 weeks with residual pigmentation. In another case reported by Shetty et al.,[9] a complete resolution of mucocele occurring on the lower lip was seen after 10 days of sclerotherapy with STS. In our case, two sessions of sclerotherapy were required to eliminate the lesion completely, which was present on the buccal mucosa. Due to the unusual location and inaccessibility of the posterior buccal mucosa region, sclerotherapy has emerged as a fruitful option of treatment in our case.
Our case exhibited the typical clinical features of irritational fibroma, including a nodule with normal color, occurring on the second most common site and presenting no pain. Here, history played a crucial role in diagnosis since the patient mentioned about the fluid discharge from the swelling.
Apart from STS, polidocanol has also proved to be an effective alternative.[10] At times, several sclerosants have been known to cause localized swelling, anaphylaxis, hyperpigmentation, local discomfort, etc.[468] However, no negative effects of the therapy or recurrence were seen even after 6 months of therapy in our case.
Patient perspective
The patient was worried about the lesion since it was painless and did not regress in size even after the extraction of his third molars. However, after the sclerotherapy, there was complete regression of the lesion with no signs of recurrence even after 6 months of therapy.
Conclusion
Mucoceles are one of the most common salivary gland lesions of the oral cavity. Various treatment modalities are available for their treatment, but they have various disadvantages and can lead to frequent recurrence. Sclerotherapy is being performed for ages to treat vascular disorders which can be a very useful, safe, and cost-effective alternative in the treatment of oral mucoceles with the advantages of less invasiveness and reduced chances of recurrence, especially in inaccessible areas.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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