Auris, Nasus, Larynx 30 (2003) S137
/S139

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A case of large dermoid cyst in the floor of the mouth

Ichiro Akao a,b,*, Shigenori Nobukiyo b, Takehiko Kobayashi b, Hitoshi Kikuchi b,
Izumi Koizuka b
b

a
Department of Otolaryngology, Yokohama General Hospital, Yokohama, Japan
Department of Otolaryngology, St. Marianna University School of Medicine, Sugao 2-16-1 Miyamae-ku, Kawasaki 216-8511, Japan

Abstract
Dermoid cysts in the floor of the mouth are rarely observed. When they develop, they do not appear until they grow large enough
or appear through infection. Some operative approaches and management have been performed to large dermoid cysts in the floor
of the mouth with some variations. Intra-oral approach is the most useful for cosmetic appearance. We presented a 24-year-old
female who underwent expedient surgical excision using finger end serviceable enucleation through the intra-oral approach.
# 2002 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Dermoid cyst; Floor of the mouth; Intra-oral approach; Enucleation using finger end

1. Introduction
Dermoid cysts arise as a result of failure of the surface
ectoderm to separate from the underlying structures.
Dermoid cysts are rarely observed in the floor of the
mouth [1]. The typical characteristics of dermoid cysts
are slow growing, presenting in early adult life as
asymptomatic swelling that may occasionally cause
elevation of the tongue, the interference with speech,
and the appearance of the double chin. They do not
generally present diagnostic or treatment problems. The
only effective treatment for dermoid cysts is surgery
consisting of complete enucleation.
We reported a patient with large dermoid cyst in the
floor of the mouth who underwent surgical excision
using finger end enucleation through the intra-oral
approach.

2. Case report
A 24-year-old female visited our hospital with a major
complaint of double chin. The symptom had been
* Corresponding author. Present address: Department of
Otolaryngology, St. Marianna University School of Medicine, Sugao
2-16-1 Miyamae-ku, Kawasaki 216-8511, Japan. Tel.: /81-44-9778111; fax: /81-44-976-8748

observed from her childhood, but was inconspicuous

because she was obese. After she grew to womanhood
and became slim, the symptom had been disclosed.
The large tumor appeared in the floor of the mouth
when tongue was elevated with keeping the mouth open.
The submental swelling was observed when the mouth
was closed (Fig. 1A and B). Although the tumor was
large, she did not complain of anything. She had no
other significant medical history.
Axial CT scan with contrast enhancement showed the
cystic lesion involving the submental space and the floor
of the mouth (Fig. 2A
/D). No other abnormalities were
noted on clinical examination.
The patient was operated under the general anesthesia
with nasotracheal intubation. A bite-block was positioned to keep the mouth wide open. One traction stitch
was passed through the tip of the tongue, and the tongue
was pulled upward and forward. A mucosal incision was
made along the horizontal line of the floor of the mouth
without injuring both the submandibular ducts (Fig. 3A
and B). The incision was started just behind the lingual
fold, and extended along the ventral surface of the
tongue as far as needed for operation and cyst dimensions. The roof of the cyst was then identified, and a
blunt dissection of the cyst wall using finger end was
started (Fig. 4A
/D). Most of the extraction was
performed through blind manipulation. Since the capsule of the cyst was thick and strong that enucleation
could be completed briefly. Some inside suture was

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I. Akao et al. / Auris, Nasus, Larynx 30 (2003) S137
/S139

Fig. 1. Pre-operative photograph showing a submental mass: (A) a

view from patients left side; (B) a view from patients bottom.

Fig. 4. Consecutive operative findings: (A) the surface of the cyst; (B)
the roof of the cyst was identified, and a blunt dissection of the cyst
wall using finger end was started; (C) most of the extraction was
performed through blind manipulation; (D) the large dermoid cyst was
found post-operatively.

Macroscopically, the specimen consisted of an oval

mass of tissue (7.0 /4.5 /3.5 cm3 in size), whose surface
was rather smooth. When the cross-section of the mass
was observed cut, the lumen was filled with cheesy white
material, and the inner lining was smooth and glistening
(Fig. 5).
Microscopically, the section consisted of stratified
squamous cell epithelium with considerable piling of
keratin into the lumen. The underlying connective tissue
was dense and contained blood vessels, fibrous tissue,
and inflammatory cells (Fig. 6A and B). Based on these
Fig. 2. Consecutive CT (with contrast) scan of the floor of the mouth,
showing a predominant cystic mass within the sublingual space: (A
/D)
scan images from the bottom.

Fig. 3. A mucosal incision was made along the horizontal line of the
floor of the mouth without injuring both the submandibular ducts. The
duct was located using a lacrimal probe: (A) right duct; (B) left duct.

performed in a part of the tumor removal to reduce dead

space. Complete hemostasis and inside suture could be
done safely without using a drainage tube.

Fig. 5. Photograph of surgical specimen (7.0/4.5/3.5 cm3 in size),

whose surface was generally smooth.

I. Akao et al. / Auris, Nasus, Larynx 30 (2003) S137
/S139

Fig. 6. Photograph showing the section consisted of stratified squamous cell epithelium with considerable piling of keratin into the lumen.
The underlying connective tissue was dense and contained blood
vessels, fibrous tissue and inflammatory cells.

findings, the tumor was determined to be an epidermoid

cyst.
The patient recovered without complication and was
discharged 7 days after the operation. She remained well
at a 4-year follow-up without recurrence.

3. Discussion
Dermoid cysts are histopathologically classified into
three types of epidermoid, dermoid, and teratoid. The
epidermoid type, which our case had, is lined with
simple squamous epithelium and surrounding connective tissue. The dermoid type is an epithelium-lined cyst
that contains skin appendages. The teratoid type is also
epithelium-lined, and it contains mesodermal or endodermal elements such as muscle, bone, teeth, and
mucous membranes [2].
Dermoid cysts are commonly found throughout the
patients body. Of all dermoid cysts, 6.9% occur in the
head and neck area, and 23% in the floor of the mouth
[1]. Cysts in the floor of the mouth can be classified by
their anatomical positions. It has long been thought that
most cysts develop in the midline of, above, or below the
geniohyoid and mylohyoid muscles [2,3]. This classification is used as a reference to decide the approach for
operation [2,4]. Most of the cysts in the floor of the
mouth occur in the midline, and lateral dermoid cyst is
rarely observed [5]. Some reports a case of cysts which
occur in the intralingual area [6]. In addition, malignant
transformation of cysts to squamous cell carcinoma has
been reported. When cysts are disclosed, an early
operation is desirable [7].
Clinically, the appearance of dermoid cysts in the
floor of the mouth is quite striking in many cases. Due
to the characteristics of cysts including asymptomatic

S139

behavior, painless tumor and slow growing, the cyst

tends to be large.
Complete surgical removal is required for the treatment for cysts. For operation, there are two approaches,
intra-oral approach and extra-oral (cervical incision)
approach. The approach tends to be decided based on
the size and the location of dermoid cyst in the floor of
the mouth. In some cases, a combined approach is
selected [4].
In the intra-oral approach, an incision is performed
usually through the ventral surface of the tongue. While
marking this incision, the surgeon should give a lot of
care to avoid both submandibular ducts [8]. In the
majority of cases in which the intra-oral approach is
employed, operations are performed under the general
anesthesia delivered by nasotracheal intubation [2,3,8].
To avoid the post-operative airway troubles, pre-operative tracheotomy and overnight intubation may be
performed. When the cyst is too large to be removed,
reduction of the solution in the cyst is required for safety
removal [5].
Dermoid cyst lining is generally very thick, and the
dermoid cyst is relatively easy to be removed completely.
In our case, it was very useful to excise the cyst through
the blind manipulation using finger end. Therefore,
intra-oral approach should be attempted at first, even
if the cyst was large or inferior type. When the removal
of the cyst was difficult using only the intra-oral
approach, the extra-oral approach should be combined.

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