Head and neck teratoma: from diagnosis to treatment

Hamartomas, choristomas, and teratomas of the oral cavity: A 49-years cross-sectional study in an oral diagnostic service

BACKGROUND

To investigate the incidence and demographic profile of hamartomatous, choristomatous, and teratoid lesions in a Brazilian population over a 49 years-period.

METHODS

A retrospective cross-sectional study was performed, and data regarding demographic and clinical aspects were obtained from the medical records of a Brazilian referral center (1970-2019). The collected data were submitted to descriptive analysis and Pearson's chi-square, Fisher's exact, and Kruskal-Wallis tests (p ≤ 0.05).

RESULTS

In a total of 16,412 medical records analyzed, 300 (1.83 %) were hamartomatous, 2 (0.01 %) choristomatous, and 1 (0.01 %) teratoid lesions. Hamartomas were most diagnosed in females and adults. Statistical significance was observed between hamartoma and age group (p < 0.001). Odontoma was the most frequent hamartomatous lesion. In choristomatous and teratoid lesions, there was no occurrence in males. The jaws were the most affected anatomical site by hamartoma. Choristomas were observed on the mandible and tongue, while a teratoid lesion was seen on the floor of the mouth.

CONCLUSIONS

Low occurrence of choristomatous and teratoid lesions over hamartomatous lesions and a heterogeneous occurrence profile regarding sex, age group, and anatomic site were observed. Hamartomas are relatively common and benign conditions that may cause damage and require special care during dental treatment. Thus, the dentist needs to be able to identify and treat them appropriately. Likewise, although choristomas and teratomas present no risk to patients and have a lower occurrence than hamartomas, they also require treatment.

Unilateral Periorbital Swelling in a Pediatric Patient

Infratemporal fossa (ITF) tumors are rare in children and may present with a variety of symptoms. Teratomas are neoplasms derived from the 3 germ layers and approximately 6% to 10% are within the head and neck. Our study discusses one of the first reported cases of teratoma in the ITF in a pediatric patient. A 3-year-old girl presents with 2 years of recurrent monthly left periorbital swelling accompanied by fevers, skin discoloration, and pain. Prior episodes were treated with antibiotics with incomplete resolution. Imaging revealed a cystic lesion centered in the ITF. She was taken for endoscopic endonasal biopsy of the lesion and had no complications. Pathology revealed a mature teratoma composed primarily of pancreatic tissue. Providers should consider masses such as teratoma in the differential for ITF tumors and periorbital edema unresponsive to typical treatment.

Prenatally Diagnosed Congenital Oral Teratoma Successfully Treated in a Neonate

Teratomas are congenital malformations that rarely occur in the oral cavity. In the case reported here, fetal magnetic resonance imaging performed at 30 weeks of gestation informed the decision-making of the multidisciplinary management team, who closely followed the pregnancy until the scheduled cesarean delivery at 38 weeks of gestation. After delivery, tracheal intubation was performed to ensure airway patency, and tumor resection was scheduled immediately after ruling out contraindications to surgery based on preoperative examinations, allowing for safe excising of the tumor. Postoperative follow-up at 3 months showed no abnormalities.

An operation on placental support in a fetus with a nasopharyngeal teratoma

Airway obstruction diagnosed antenatally in the fetus due to congenital high airway obstruction syndrome or nasopharyngeal masses are the primary indications for performing an operation on placental support. Prenatally diagnosed nasopharyngeal masses pose the risk of total airway obstruction upon delivery. Placental support utilises uteroplacental blood flow to facilitate an airway intervention on the fetus while maintaining oxygenation. These interventions must be completed in under 20 min due to amniotic fluid loss and uterine contractions. This case report describes the anaesthetic management of a fetus with a nasal teratoma. In this report, we discuss the clinical indications and anaesthetic considerations of the operation on placental support procedure for nasopharyngeal masses.

Cervical mature teratoma in pediatric

Cervical teratomas are one of the rare tumors. Relating to the size of the tumor, they present as a huge neck mass with solid and cystic components. Furthermore, they are able to induce a hyperextension of the neck, neonatal respiratory distress, and possible malignancy. The computed tomography scan examination of this case revealed that there was a mass. It was a component of a teratoma and pathological anatomy which supported the finding. Thus, this study provided a case of a fully excised and cured cervical mature teratoma occurred in an infant. Surgical management must be undergone as thorough as feasible in order to prevent recurrences and the development of the cancer.

Odontogenic choristoma embedded in the cheek of an old patient

Odontogenic choristomas are a rare and recently classified entity, defined as neoplasms containing tissues of odontogenic derivation, found in abnormal locations and usually diagnosed in the early age. The authors report a unique case of a 79-year-old patient who presented to our attention for a skin lesion in the right cheek with no history of trauma or recent dental procedures, that underneath presented an indolent tooth-like structure inside the soft tissue of the right cheek, which at the histological study resulted to be an odontogenic choristoma. This rare histopathological diagnosis should be considered when a hard lesion is present in the head and neck region.

Surgical management of palatal teratoma (epignathus) with the use of virtual reconstruction and 3D models: a case report and literature review

Epignathus is a rare congenital orofacial teratoma that arises from the sphenoid region of the palate or the pharynx. It occurs in approximately 1:35,000 to 1:200,000 live births representing 2% to 9% of all teratomas. We present the case of a newborn of 39.4 weeks of gestation with a tumor that occupied the entire oral cavity. The patient was delivered by cesarean section. Oral resection was managed by pediatric surgery. Plastic surgery used virtual 3-dimensional models to establish the extension, and depth of the tumor. Bloc resection and reconstruction of the epignathus were performed. The mass was diagnosed as a mature teratoma associated with cleft lip and palate, nasoethmoidal meningocele that conditions hypertelorism, and a pseudomacrostoma. Tridimensional technology was applied to plan the surgical intervention. It contributed to a better understanding of the relationships between the tumor and the adjacent structures. This optimized the surgical approach and outcome.

Congenital tooth-bearing tumor of the eyelid leading to lacrimal system obstruction

PURPOSE

We present an unusual case of a congenital lesion presenting with concomitant chronic dacryocystitis. The clinical presentation, examination, management, and histopathology are reviewed.

OBSERVATIONS

A healthy male infant born at 37 weeks gestation presented with an isolated painless 5mm congenital mass of the left medial lower eyelid. Parents also reported episodic epiphora and discharge from the left eye. A surgical excision of the mass revealed an underlying dacryocystitis and the presence of a formed tooth. A dacryocystorhinostomy was performed together with a repair of the soft tissue defect. Histopathology revealed components of disorganized epithelial and mesenchymal tissues including a tooth, skeletal muscle, fat, fibrous tissue, nonkeratinized epithelium, and myelinated nerves. A diagnosis of an odontogenic choristoma of the eyelid was made. Furthermore, a lacrimal sac culture was positive for oxacillin-susceptible Staphylococcus aureus with pathological evidence of chronic dacryocystitis.

CONCLUSIONS AND IMPORTANCE

Odontogenic choristoma is a very rare finding in the periocular region with only a few cases reported in the literature. Awareness of clinical findings from this case may allow for a more accurate clinical diagnosis and understanding of the embryologic mechanisms underpinning eyelid and nasolacrimal development. Timely management of this condition is critical to ensure normal oculofacial development and prevent future complications.

A SEER database study of malignant teratomas in the head and neck region

OBJECTIVE

To review tumor and patient characteristics as well as survival of pediatric head and neck malignant teratomas (HNMT) in comparison to the adult population.

DESIGN

This investigation was a retrospective cohort study. The Surveillance, Epidemiology, and End Results (SEER) database (SEER-18 Regs Custom registry, November 2018) was reviewed for all cases of head and neck malignant teratomas from 1975 to 2016. A log rank test was used to compare survival between infant, pediatric, and adult HNMT, and between head and neck and non-head and neck malignant teratomas. Infant, pediatric, and adult patients were defined as younger than one year old, younger than 18 years old, and older than 18 years old, respectively.

RESULTS

Sixty-three malignant teratoma cases (1.96%) occurred in the head and neck region from 1975 to 2016, including 11 adult (17.46%) and 52 (82.54%) pediatric patients. 79.37% (50 patients) were diagnosed during infancy. The most common location was the soft tissue of the head and neck in pediatric patients (65.38%) and the thyroid gland in adults (54.54%). The 5-year survival was 45.83% (±7.19%) in infants and 46.00% (±7.05%) in pediatric patients. There were differences in 1-year and 5-year survival between pediatric HNMT and non-head and neck malignant teratomas, (76.01% versus 86.20%) (p = 0.022) and (46.00% versus 67.10%) (p < 0.001), respectively. There was no difference in 1-year and 5-year survival between pediatric patients and adults with HNMT, (76.01% versus 81.81%) (p = 0.618) and (46.00% versus 54.54%) (p = 0.560), respectively.

CONCLUSION

HNMT occurred most frequently in patients under the age of 1. Prognosis of pediatric HNMT is poor in comparison to pediatric non-head and neck malignant teratomas. Repeat studies after accumulating more patients in the database would be beneficial to confirm our findings.

Congenital lateral facial teratoma: A case report and review of literature

Facial teratomas are uncommon tumours in children that distort the face and may be associated with functional problems. They are less common than cervical teratomas though they are often grouped together and considered an emergency due to their tendency to cause respiratory compromise. They tend to be large and cause cosmetic issues; hence usually noticed early and medical help sought promptly by parents. The close proximity of facial teratomas to structures like eyes, parotid gland, facial nerve, vessels and brain makes them challenging and requires a patient and meticulous exploration during surgery. We present a case of an 11 month old girl with left sided temporal teratoma. Well planning of the incision and complete excision of the tumour with careful sparing of the facial nerves and parotid gland yielded good result.

Rare Diseases of the Oral Cavity, Neck, and Pharynx

Diseases occurring with an incidence of less than 1-10 cases per 10 000 individuals are considered as rare. Currently, between 5 000 and 8 000 rare or orphan diseases are known, every year about 250 rare diseases are newly described. Many of those pathologies concern the head and neck area. In many cases, a long time is required to diagnose an orphan disease. The lives of patients who are affected by those diseases are often determined by medical consultations and inpatient stays. Most orphan diseases are of genetic origin and cannot be cured despite medical progress. However, during the last years, the perception of and the knowledge about rare diseases has increased also due to the fact that publicly available databases have been created and self-help groups have been established which foster the autonomy of affected people. Only recently, innovative technical progress in the field of biogenetics allows individually characterizing the genetic origin of rare diseases in single patients. Based on this, it should be possible in the near future to elaborate tailored treatment concepts for patients suffering from rare diseases in the sense of translational and personalized medicine. This article deals with orphan diseases of the lip, oral cavity, pharynx, and cervical soft tissues depicting these developments. The readers will be provided with a compact overview about selected diseases of these anatomical regions. References to further information for medical staff and affected patients support deeper knowledge and lead to the current state of knowledge in this highly dynamic field.

Mature Cervical Teratoma Extending Into the Anterior Mediastinum of an Adult

There have been few reports of mature cystic teratoma, also known as a dermoid cyst, in the head and neck. Cervical neck teratoma extending into the mediastinum is also relatively rare. Here, we report a mature teratoma found in a cervical tumor in a 21-year-old man. This is the first reported case of a mature cervical teratoma extending into the anterior mediastinum. A combination of frontal X-ray, ultrasonography, computed tomography, and magnetic resonance imaging indicated a large oval heterogeneous mass surrounding the thyroid gland and trachea, underneath the sternocleidomastoid and sternohyoid, which pressed on the left lobar thyroid and trachea and extended into the anterior mediastinum. Based on preoperative observation, a diagnosis of an embryonal benign tumor was made. Although rare, this case demonstrates that these tumors should be completely removed during workup of cervical tumors.

Management and Reconstruction of a Massive Neonatal Neck Teratoma

Cervical teratoma is a rare tumor comprised of multiple tissue types. These masses can result in significant functional and aesthetic complications, and surgical intervention is the mainstay of treatment. The authors report the treatment and 8-year follow-up of a patient born with a massive cervicofacial teratoma. The mass was diagnosed in utero and required perinatal airway management. The patient underwent several procedures to enhance his appearance and function early on in life with an excellent outcome at intermediate follow-up.

Superior Vena Cava Syndrome and Hypoxic Ischemic Encephalopathy Secondary to a Massive, Right-Sided Immature Cervical Teratoma

Cervical teratomas are a rare form of fetal teratoma that can grow to massive size. Generally, these masses can be surgically excised after birth with excellent physical and functional prognosis because the benign variants respect anatomical borders. The primary complications of these masses are associated with compromise of the trachea and esophagus: upper airway obstruction and polyhydramnios. We report the first documented occurrence of superior vena cava syndrome and hypoxic ischemic encephalopathy associated with a massive, right-sided cervical teratoma. This case highlights that when cervical teratomas are right-sided and sufficiently large, they can extend inferiorly and compromise central venous return to the heart. This unique presentation would likely have required fetal surgical excision to avoid catastrophic cerebral injury.

Case of nasopharyngeal teratoma: challenges in the management

Teratomas are tumour with tissue or organ components resembling normal derivatives of more than one germ layer. The most common site of congenital teratoma is sacrococcygeal region. Teratomas in head and neck region are rarer. We report a 4-day-old male baby who presented with nasopharyngeal mass, which led to respiratory distress and feeding difficulty. It was managed with surgical excision with multidisciplinary approach.

Mature teratoma treated as lymphatic malformation for 5 years: a case report and literature review

Teratomas and lymphatic malformations are included in the differential diagnosis of congenital neck masses. They can exhibit similar clinical findings. The authors present a case of mature teratoma that had been managed as a lymphatic malformation for years. Clinicians should be careful not to dismiss clues for the correct diagnosis.

Fetal Evaluation and Airway Management

Congenital causes of airway obstruction once noted at birth are now diagnosed prenatally. The adoption of ex utero intrapartum treatment has allowed for planned airway stabilization on placental support, dramatically decreasing the incidence of hypoxic injury or peripartum demise related to neonatal airway obstruction. Airway access is gained either through laryngoscopy, bronchoscopy, or a surgical airway. In complete airway obstruction, primary resection of the obstructing lesion may be performed before completion of delivery. This article reviews the current and emerging methods of fetal evaluation, indications for ex utero intrapartum treatment, and provides a detailed description of the procedure and necessary personnel.

Giant Epignathus Teratoma Discovered at Birth: A Case Report and 7-Year Follow-Up

Teratomas are tumors composed by tissues derived from the three germ cell layers, and they are relatively uncommon in head and neck. The term epignathus has been applied to teratomas from the oropharynx. This paper reports the case of a giant epignathus teratoma discovered at birth, which was successfully managed and followed up for 7 years. A newborn boy presented a polypoid tumor mass exteriorizing through the mouth over a length of 9 cm, with some surface areas resembling skin and others exhibiting hair. Computed tomography showed that the mass arose deep from the left hemiface. Alpha-fetoprotein (AFP) levels were high (316,000 ng/mL). Surgery was performed and microscopic analysis confirmed the diagnosis of mature teratoma. Because of residual tumor and high AFP levels, the patient was submitted to chemotherapy, resulting in complete regression of the lesion and normalization of AFP levels. Surgical repair of a cleft palate was performed at 5 years of age. At 7 years of age, the patient was in good general health and showed no clinical signs of recurrence. Although epignathus is a rare condition, it should be diagnosed in the fetus as early as possible. Prenatal care provides unquestionable benefits, providing the early diagnosis of anomalies that can jeopardize the life of the fetus and contributing to the indication of cases that require treatment before birth.

Diagnostic imaging and surgical management of a congenital cervical teratoma

Congenital cervical teratomas are rare tumours arising from the neck and consist of three major tissue layers of an embryo: the ectoderm, endoderm, and mesoderm. A great majority of cervical teratomas are benign tumours. However, the clinical significance of these tumours arises from the complications they can cause during pregnancy due to the postnatal mass effect on the airway and oesophagus of the neonate.

Diagnosis of a congenital cervical teratoma is possible during an early prenatal ultrasound evaluation. The appearance depends on the size of the tumour, but it is typically a large neck mass with solid and cystic components that causes hyperextension of the neck and is frequently associated with polyhydramnios. In the postnatal period, ultrasound helps in differentiating cervical teratoma from other common congenital cervical masses. MRI is the modality of choice to evaluate the consistency of the tumour, surrounding soft tissue extent of the tumour, and any mass effect on other cervical structures. In our case report, we present a case of a full-term baby that was delivered with a large cervical mass. MRI was helpful in demonstrating the complex content of the mass, surrounding soft tissue extension, and mass effect on other major cervical structures. The clear demarcation of the mass facilitated complete surgical removal without complications.

Cystic cervical teratoma: A diagnostic and management challenge

Cervical teratomas are relatively rare congenital tumors pathologically defined by their three germ cell layer composition. Classically they manifest as solid or mixed solid-cystic lesions. Purely cystic teratomas pose a diagnostic challenge due to their clinical and radiologic similarity to lymphatic vascular malformations. Sclerotherapy, rather than operative excision, may be offered as therapy. We present an unusual cystic neck mass to highlight this dilemma.

Prenatally diagnosed fetal tumors of the head and neck: a systematic review with antenatal and postnatal outcomes over the past 20 years

AIM

The aim of this study was to review prenatally diagnosed tumors of the head and neck in the fetus and to report antenatal and postnatal outcomes.

METHODS

PubMed/Medline, EMBASE/SCOPUS, Cochrane database and Google Scholar were reviewed over the last 20 years. No language or article type restriction was used.

RESULTS

A total of 1940 record were retrieved. Of the 713 records screened, 566 full-text articles were assessed for eligibility. After 445 articles were excluded for specified reasons, 111 studies met the research criteria and were included for qualitative analysis. Overall, 306 cases of fetal tumors of the head and neck were reviewed. Maternal age was an independent factor. The mean maternal age was 28.2 years and gestational age at prenatal diagnosis was 27.1 weeks. Conventional 2D ultrasound was the standard diagnostic procedure in 27.9% of cases and was implemented in 27.3% of cases by 3D ultrasound and fetal magnetic resonance imaging (MRI). Diagnostic evaluation of intracranial spreading and high-airway obstructions was greatly enhanced by fetal MRI. The more common type of fetal tumor was hemangioma/lymphangioms (42.1%), followed by teratomas (29.7%), tumors of the gingiva (10.1%) and lymphatic venous malformations (9.1%), respectively. Fetal karyotyping was performed only in 9.8% of cases; within fetuses undergoing karyotype, chromosomal abnormalities accounted for 20% of cases. The most common pregnancy complication was polyhydramnios (26.3%). Ex utero intrapartum treatment (EXIT) procedure was performed in 30.1% of cases while surgical excision was used in 22.9% during postnatal life. The survival rate was 35.35%.

CONCLUSION

Fetal tumors of the head and neck are rare congenital malformations. Two-dimensional ultrasound is diagnostic in almost all cases; however, MRI may be an important diagnostic adjunct in targeted cases and help patient selection for immediate intubation at the time of delivery. EXIT procedure and surgical removal of the tumor was associated with good prognosis.

Congenital facial teratoma in a neonate: Surgical management and outcome

Teratomas are among the most common tumors of childhood, but craniofacial teratomas are rare. They can be diagnosed antenatally. Craniofacial teratomas may cause airway obstruction in the newborn. We present a case of a newborn male child who was diagnosed to have a facial tumor in the 8^th month of gestation. He was delivered normally and had no respiratory or feeding difficulties. He was also found to have a cleft palate. Serum alpha fetoprotein levels were normal. He underwent excision on day of life 9. At 11 months follow-up, he is well with no evidence of recurrence and good functional outcome.