Surgery to remove cysts in the floor of the mouth

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The floor of the mouth cyst is a type of cyst on the floor of the mouth that forms locally and is painless. These structures are present in various sizes, from small cysts on the floor of the mouth to large cysts extending all the way to the neck. Treatment options for floor-of-mouth cysts vary, depending on the size of the cyst and the available facilities. Among them, cystectomy in the floor of the mouth is the most common.

1. What is an oral floor cyst?

The oral cavity has 3 major salivary glands, which are joined together in addition to hundreds of accessory salivary glands that drain directly into the mouth. Plays a role in providing moisture to the oral cavity.
The blockage of the ducts that carry the small salivary glands and the drainage of mucus into the surrounding tissues can lead to mucositis. The same process occurs in the sublingual salivary glands, resulting in a pseudocyst of the floor of the mouth instead of escaping into the deeper layers of the oral cavity.
Some salivary ducts may also drain into the Wharton duct, becoming pseudocysts and cystic structures without epithelium. They can still be seen as cysts in the floor of the mouth as they add a septum and expand.
Clinically, the floor of the mouth pseudocyst is described as a painless mucinous pseudocyst. They are often slow-growing, cyclical, and recur. The structure of the floor pseudocyst is simply a mucus-filled sac with a septum above the muscle below the floor. Sometimes there are complex or growing parotid cysts that extend around the subscapular muscle and deeper into the neck. Some parotid cysts are easily misinterpreted as submandibular tumors or abscesses because they can escape into the submandibular space.

2. Indications for the treatment of pseudocysts on the floor of the mouth

The floor of the mouth cyst usually presents as a painless, blue cyst. Floor pseudocysts can vary but are characterized by a soft neck mass, localized under the jaw.
In order to better evaluate the structure of the oral floor pseudocyst, the doctor needs to order more computed tomography or contrast-enhanced magnetic resonance imaging of the neck. This is also the evidence for planning subsequent surgical intervention.

3. Methods of surgical intervention to cut cysts in the floor of the mouth

3.1 Cyst drainage Oral floor cysts have a simple structure and are treated in a variety of ways. Of these, the most gentle method is to drain the cyst. This procedure can be performed in the clinic and the patient is anesthetized with local anesthetic with 1% lidocaine. Then, the central mucosa of the floor pseudocyst was cut into an ellipse, measuring 5 x 5 mm. This piece of tissue will be sent for pathology.
After the fluid inside the pseudocyst has been drained, Vicryl 4-0 sutures are placed on each side to help the salivary ducts to drain mucus continuously into the floor of the mouth.
3.2 Excision of floor pseudocyst and sublingual gland The preferred indication in most cases is resection of the entire floor of the mouth or sublingual pseudocysts in general. Unlike the other major salivary glands, the sublingual gland continuously secretes mucus. When one of the drainage tubes is blocked or injured, the continuous flow of the sublingual gland pushes the mucus out to form a duct, which over time will form a pseudocyst.

When surgical intervention to remove the cyst on the floor of the mouth, the patient will be intubated and under general anesthesia. The location of the cyst marker on the floor of the mouth to determine the incision was planned in advance. Lidocaine 1% with epinephrine is used topically to relieve pain and stop bleeding during incision.
The surgeon will make an elliptical incision around the pseudocyst on the floor of the mouth, and during this process, it is necessary to pay attention to dissecting the middle to identify the laryngeal nerve, because the 2 sublingual glands are always adjacent. with nerves.
First, 2 sublingual glands are removed from the laryngeal nerve. Later, the floor of the mouth pseudocyst was also separated from the mandibular lateral border as well as the deep lower part of the floor of the mouth muscle. Finally, the surgeon will complete the excision of the parotid cyst by loosely closing it with Vicryl 4-0 sutures.
Although care is taken to remove the entire pseudocyst of the floor of the mouth, if any pseudocyst ruptures or remains, it is not critical to the success of the surgery.
3.3 Combined surgical resection of the neck and transoral floor omentum of the cyst When the floor of the mouth pseudocyst descends through or around the muscle layer of the floor of the mouth, it will have a concave appearance. The classic approach in this case is to make an incision about 2 fingers wide below the extent of the cyst.
After incising the muscle layers of the floor of the mouth, carefully dissect to expose the envelope of the floor of the mouth pseudocyst. The hypogastric nerve is also well defined and maximally protected. The structures involved superior to the submandibular gland including the branches of the facial artery may need to be protected while freeing the soft tissue from the mandibular structure.
Next, the surgeon will use a ductal probe to identify Wharton's duct. Later, this approach was also used to assist with resection of the remaining sublingual gland and floor pseudocyst.
At the end of surgery, the wounds will be closed in several layers, closing the floor of the mouth with Vicryl 4-0 sutures. The neck of the floor of the mouth pseudocyst is also closed to form a duct leading to the floor of the mouth. Pay attention to close the floor of the mouth with muscle layers from the neck to the jaw in layers without damaging the lingual and hypogastric nerves, as well as the Wharton canal.
3.4 Minimally invasive treatment for concave floor-of-mouth cyst Accordingly, the patient was given general anesthesia by intubation. Next, the adjacent Wharton tube is closed to determine the outflow of the subchondral gland. Lidocaine 1% with epinephrine is injected locally into the floor of the mouth via the sublingual gland. An incision in the floor of the mouth and the sublingual gland was identified, dissected, and removed from the lingual nerve. During sublingual gland resection, the surgeon also often identifies pseudocysts of parotid cysts.

The edges of the parietal cyst will be marked with a Vicryl 4-0 suture in 3 points. A 1/4-inch (6mm) long Penrose drain was placed through the opening of the parotid cyst and then sutured in. The last remaining oral layers will be closed loosely with Vicryl 4-0 sutures.
During the postoperative period, the patient will be wearing a bandage to put pressure on the outside of the neck, helping to prevent the formation of the floor of the mouth cyst from recurring. The patient was also given prophylactic antibiotics and was discharged from the hospital, the compression bandage was removed after 2 weeks. During the first week after surgery, the patient may have inflammation around the lateral neck area but it will go away on its own.
In summary, the success of cystectomy in the floor of the mouth must be based on the process of determining the extent of the cyst and removing the sublingual gland. The detailed intervention method will depend on the size and location of the cyst in the floor of the mouth. Currently, Vinmec International General Hospital is a prestigious address in the examination and treatment of common nasopharyngeal diseases, head and neck tumors, congenital malformations in the ear, nose and throat area by different methods. Internal medicine - surgery optimal for patients, both children and adults. Coming to Vinmec International General Hospital, patients will receive a direct, dedicated and professional examination from a team of qualified and experienced medical staff.

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