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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 17  |  Page : 62-64

Excision of solitary neurofibroma of the palate using diode laser


Department of Oral Medicine and Radiology, Swami Devi Dyal Hospital and Dental College, Barwala, Haryana, India

Date of Submission21-Aug-2019
Date of Decision11-Sep-2020
Date of Acceptance23-Sep-2020
Date of Web Publication24-Apr-2021

Correspondence Address:
Dr. Aravinda Konidena
Department of Oral Medicine and Radiology, Swami Devi Dyal Hospital and Dental College, Barwala, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nnjcr.nnjcr_41_19

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  Abstract 


Oral physicians may encounter tumors of neural origin in the orofacial region. Solitary neurofibroma is a rare benign nonodontogenic tumor which may present either as a solitary lesion or as part of the generalized syndrome of neurofibromatosis or von Recklinghausen's disease of the skin. Clinically, oral neurofibromas present as pedunculated or sessile slow-growing painless nodules. Due to their benign, painless, slow-growing nature, they resemble various other lesions and can present a diagnostic challenge. We present a case of neurofibroma of the palate presenting as a sessile nodule in a 38-year-old female that was treated by excision using diode laser along with a relevant review of the literature.

Keywords: Diode, laser, neurofibroma, palate, solitary


How to cite this article:
Bansal V, Konidena A, Mann AK, Yumnam N. Excision of solitary neurofibroma of the palate using diode laser. N Niger J Clin Res 2021;10:62-4

How to cite this URL:
Bansal V, Konidena A, Mann AK, Yumnam N. Excision of solitary neurofibroma of the palate using diode laser. N Niger J Clin Res [serial online] 2021 [cited 2021 Dec 4];10:62-4. Available from: https://www.mdcan-uath.org/text.asp?2021/10/17/62/314602




  Introduction Top


Neurofibroma is a benign peripheral nerve sheath tumor, comprised of Schwann cells, perineural like cells, fibroblasts, and presenting commonly as submucosal painless masses on tongue and buccal mucosa.[1] These lesions may be seen as solitary or multiple neurofibromas or as part of a generalized syndrome of neurofibromatosis (NF) (von Recklinghausen's disease). Based on their clinical presentation, they may be categorized as localized or solitary growths, diffuse discrete or multiple nodules, and plexiform types.[2] We report the case of nonsyndromic neurofibroma of the hard palate seen in a female patient along with a relevant review of the literature.


  Case Report Top


A 38-year-old female presented with a complaint of a painless swelling of gradual onset in the oral cavity of 6 months duration. History was negative for pain and pus discharge or bleeding from the lesion. Examination revealed a single well-defined pale pink-colored swelling of size 5 mm × 5 mm on the hard palate, located 5 mm from the midline toward the left side [Figure 1]. The mucosa over the swelling was intact. On palpation, it was sessile, smooth in texture, firm in consistency, compressible, and nonfluctuant. A provisional clinical diagnosis of the benign neoplasm of minor salivary gland was made. Differential diagnosis of benign mesenchymal tumor and necrotizing sialometaplasia were considered. Occlusal radiograph did not reveal any significant abnormality [Figure 2]. Surgical excision of the lesion with diode laser was planned after routine hematological investigations. The palatal mass was excised in toto with 980 nm diode laser with settings of 1 watt, initiated tip, continuous mode under infiltration with local anesthesia (0.5 mL 2% lignocaine with adrenaline 1 in 80,000). There was no intraoperative bleeding [Figure 3]. Histopathological examination of the specimen revealed parakeratinized stratified squamous epithelium with fibrocellular stroma. Connective tissue showed elongated spindle-shaped wavy nuclei, separated by fine wavy collagen fibers and few areas show myxomatous degeneration, suggestive of neurofibroma [Figure 4]. Postoperative healing was uneventful [Figure 5].
Figure 1: Submucosal nodule on the palate

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Figure 2: Maxillary cross-sectional occlusal radiograph revealing no bone erosion

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Figure 3: Immediate postoperative picture after laser excision

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Figure 4: Histopathological picture

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Figure 5: Postoperative healing after 1 week

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The patient was re-evaluated with dermatological and ophthalmic examination to rule out NF-I. The absence of systemic involvement and negative family history confirmed it to be a solitary case of NF of the hard palate. The patient was asymptomatic and was on follow-up for 4 months with no evidence of recurrence or residual neurologic deficit.


  Discussion Top


NF is a benign tumor of the peripheral nerve sheath. Riccardi described at least seven types of NF; however, only two distinct forms are widely accepted, namely a peripheral form known as NF-I and a central form known as NF-II.[3] NF-I first described by Recklinghausen in 1882, is the classical form, accounts for 90% of NF and presents as a part of von Recklinghausen's disease of the skin.[4] The diagnostic features of NF-I include multiple NFs on the body, cutaneous café au lait macules, and lisch nodules (pigmented iris hamartomas). NF-II has a much lower prevalence and is usually characterized by the presence of bilateral acoustic neuromas; it may also be associated with multiple endocrine neoplasia III.[4]

Somatic inactivation of NF-1 gene located on chromosome 17 causes an increased, abnormal production of neurofibromin followed by cellular proliferation of Schwann cells resulting in neurofibroma. Neurofibromas express androgen and estrogen receptors and grow in the presence of their excess. It has been proposed that solitary NF represents a hyperplastic hamartomatous malformation rather than neoplastic disease.[5] They are thought to originate from Schwann cells, perineural cells, or fibroblasts.

Among the neural lesions affecting the head and neck, NFs are relatively common, with a reported incidence in the head and neck being 37%.[6] NFs of the oral cavity and oropharynx are extremely rare, ranging from 2% to 7%, and are mostly associated with NF-I. In the oral cavity, the tumor often involves the trigeminal and upper cervical nerves, with the most common site in the oral cavity being the tongue followed by buccal mucosa, the floor of mouth, lips, and gingiva.[6] Solitary NF is a rare variant of NF; it seldom affects the head and neck. They are distinct as unlike other NFs, they lack the systemic and hereditary components.[1],[2],[5] Our patient presented with a solitary neurofibroma at an unusual site, the hard palate. No racial or gender predilection has been described for oral NF. NF can present at any age ranging from 10 months to 70 years with an average of 45 years.[5] Our patient was a middle-aged female.

The oral lesions usually present as a slowly progressive, painless, discrete swelling which are either sessile or pedunculated with nonulcerated mucosa as in our case. The mucosal color varies between pink, red, or even yellow. Sometimes, they may be painful due to pressure effects and may compromise with normal physiological function due to mass effect.[1],[5] Differential diagnosis such as schwannoma, fibroma, traumatic neuroma, lipoma, or salivary gland tumor may be considered. However, in the mandible, intraosseous lesion arising in the posterior mandible as unilocular or multilocular radiolucencies on radiographs has been described.[7]

The role of plain film radiography or orthopantomogram is limited and may be used for determining the extent in cases of intra-osseous lesion. Ultrasonography, computed tomography (CT), magnetic resonance imaging are useful diagnostic tools for the estimation of tumor margins and determining infiltration to surrounding structures. For bony erosion due to a malignant tumor, CT scans are useful.[2]

The treatment for solitary NF is complete surgical excision. However, recurrence is common due to noncapsulated and infiltrative nature of the disease. The recurrence is seen in as many as 20% of the patients with a NF after complete resection and increases to 44% with subtotal resection.[8] Intraosseous NFs often require radical surgery including hemimandibulectomy or en bloc excision of the mandible. The common complication encountered during surgery is hemorrhage. Our patient was treated by diode laser excision, reducing the chances of intraoperative bleeding. Diode laser has been used for the treatment of neurofibroma in the present case, as it is less invasive and sutureless with minimal postoperative pain. They provide hemostasis as blood vessels are sealed, promote healing, reducing the need for postsurgical dressings. It also depolarizes nerves, thus reducing postoperative pain, and also destroy many bacterial and viral colonies that may potentially cause infection.[1] Reduced postoperative discomfort, edema, scarring, and shrinkage have all been associated with its use.[2] Excellent postoperative healing was observed in our case.

The role of radiotherapy is limited and may be used if the patient is not fit or unwilling for surgery; especially in solitary plexiform type, where radiotherapy may retard the growth and shrink the tumor.[8] Malignant transformation of benign NF is rare, and more commonly, it has been associated with radiotherapy-treated schwannomas.[1],[2] The most common malignancy is neurofibrosarcoma or malignant Schwannoma, estimated to occur in about 5% of cases, an aggressive tumor with a poor prognosis.[2],[8] Therefore, continued surveillance after surgery is mandatory to look for any recurrence or malignant transformation.


  Conclusion Top


Solitary NF has to be considered under differential diagnosis of oral soft-tissue lesions. The use of laser for the removal of neurofibroma would lessen stress and fear of patients and would also minimize discomfort during and after surgery. Long-term regular follow-up is warranted.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand 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.



 
  References Top

1.
Angiero F, Ferrante F, Ottonello A, Maltagliati A, Crippa R. Neurofibromas of the oral cavity: Clinical aspects, treatment, and outcome. Photomed Laser Surg 2016;34:56-60.  Back to cited text no. 1
    
2.
Venkataswamy AR, Ranganath SP, Challapalli SM, Mohanty L. Non syndromic solitary neurofibromas in the oral cavity. Case series and literature review. J Indian Acad Oral Med Radiol 2016;28:52-6.  Back to cited text no. 2
  [Full text]  
3.
Riccardi VM. Neurofibromatosis: Clinical heterogeneity. Curr Probl Cancer 1982;7:3-34.  Back to cited text no. 3
    
4.
Bharath TS, Krishna YR, Nalabolu GR, Pasupuleti S, Surapanenin S, Ganta SB. Neurofibroma of the palate. Case Rep Dent 2014;2014:898505.  Back to cited text no. 4
    
5.
Marocchio LS, Oliveira DT, Pereira MC, Soares CT, Fleury RN. Sporadic and multiple neurofibromas in the head and neck region: A retrospective study of 33 years. Clin Oral Investig 2007;11:165-9.  Back to cited text no. 5
    
6.
Thimmaiah AH, Santharam L, Gangaraj SS, Vijay S. Neurofibroma of soft palate: A rare case report. Otorhinolaryngol Clin 2013;5:109-10.  Back to cited text no. 6
    
7.
Jain D, Chaudhary M, Patil S. Neurofibroma of the maxillary antrum: A rare case. Contemp Clin Dent 2014;5:115-8.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Needle MN, Cnaan A, Dattilo J, Chatten J, Phillips PC, Shochat S, et al. Prognostic signs in the surgical management of plexiform neurofibroma: The Children's Hospital of Philadelphia experience, 1974-1994. J Pediatr 1997;131:678-82.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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