Epignathus combined with cleft palate, lobulated tongue, and lingual hamartoma: Report of a case

A Rare Case of Cleft Palate Associated With Tongue Hamartoma: A Case Report and Systematic Review

INTRODUCTION

Palate development involves a genetic regulation through a complex molecular mechanism that may be disrupted by environmental factors, resulting in impaired fusion and cleft palate formation. An encounter with a case of cleft palate due to dorsal tongue hamartoma prompted us to perform this systematic review.

OBJECTIVE

To review the clinical profile and management approach for a case with cleft palate and tongue hamartoma.

DESIGN

A systematic literature search was conducted using keywords related to cleft palate and tongue hamartoma in PubMed, Scopus, MEDLINE, and Scielo databases through December 2021, with no time or language restrictions.

PATIENTS, PARTICIPANTS

Studies reporting patients with cleft palate and tongue hamartoma were included.

MAIN OUTCOME MEASURE(S)

Information related to clinical profile, diagnostic tests, histopathology, management, and outcomes were extracted.

Fourteen relevant publications were identified with 16 cases reported so far. Among them, thirteen patients were females (81.25%), and 3 were males (18.75%). The age of presentation varied from birth to 19 years. Oral-facial-digital syndrome (type II) was the most commonly associated syndrome.

Congenital tongue hamartoma with cleft palate is a rare presentation, which can present as an isolated entity or part of a syndrome. Genetic evaluation is warranted, particularly for multiple hamartomatous lesions. The preferred treatment is immediate excision of hamartoma while following a standard timeline for palatoplasty.

Case Report: A Giant Epignathus with a Well-Developed Skeleton of Head and Neck

Epignathus is an extremely rare teratoma found in the oral cavity or oropharyngeal region of newborns, whose pathogenesis is poorly understood. We describe a giant epignathus arising from the oropharynx in a newborn. The giant tumor completely obstructed the airway of the newborn resulting in death. Histological and radiological examination of the tumor reveals the presence of a remarkably well-developed skeleton of the head and neck. A row of teeth, the axis and atlas, thyroid and salivary glands, trachea, and cerebral tissue are all detected within the tumor. These findings suggest that the epignathus is fetus-in-fetu which is considered a type 0 germ cell tumor in accordance with current literature.

Teratoma nasofaríngeo inmaduro con diagnóstico prenatal: reporte de un caso y revisión de la literatura

Objetivos: reportar el caso de una gestante con diagnóstico de feto con teratoma nasofaríngeo inmaduro y realizar una revisión describiendo el pronóstico de esta patología. Materiales y métodos: se reporta el caso de una gestante de 27 años, atendida en la Unidad de Ginecología y Obstétrica de un centro de referencia en Bogotá (Colombia), por hallazgo durante el control prenatal de un feto con evidencia de polihidramnios secundario a teratoma nasofaríngeo. Se realizó una búsqueda bibliográfica en las bases de datos Medline vía PubMed, Scopus, SciELO y ScienceDirect, restringiendo tipo de idioma (inglés y español) y por fecha de publicación (enero de 2001 a enero de 2021). Se incluyeron reportes de caso y series de casos que abarcaran el pronóstico de esta patología. Resultados: la búsqueda recuperó 168 títulos, de los cuales 55 cumplieron con los criterios de inclusión. En total se reportó el resultado perinatal de 58 fetos con diagnóstico de teratoma nasofaríngeo inmaduro detectado en etapa prenatal. En los casos identificados, la mortalidad perinatal fue del 25,4 % y el porcentaje de óbito fue cercano al 3,6 %. Conclusiones: el teratoma nasofaríngeo inmaduro es una patología poco frecuente. La literatura disponible sugiere que el pronóstico fetal depende del grado de compromiso de las estructuras intracraneales y de la posibilidad de resección de la lesión. Se requieren más estudios que evalúen el pronóstico de los fetos con teratoma nasofaríngeo inmaduro.

Teratoma of the Tongue in a Fetus: A Case Report and Review of the Literature

Teratomas are tumors composed of multiple embryonic germ layers of tissue, and those occurring in the tongue of the fetus are extremely rare. This paper reports the case of a 20-week-old fetus diagnosed with oral masses combined with a cleft lip and palate using prenatal ultrasonography. The patient decided to terminate the pregnancy due to economic factors after prenatal genetic consultation. The mother underwent induction termination and delivered a stillborn male fetus. The mass originated from the tongue and was pathologically confirmed as a mature teratoma by histology. Teratoma of the tongue is a rare congenital tumor that is usually benign. Its etiology is multifactorial, and prenatal karyotyping is necessary. Ultrasound is the main method of prenatal diagnosis, and magnetic resonance imaging is an effective complement to ultrasonography. Tumors can cause other malformations and abnormalities, and their location and size have an essential impact on prognosis. The imaging approach should focus on the associated abnormalities in order to assess the impact of the mass on the fetal airway and swallowing. Appropriate follow-up imaging can be helpful in the dynamic assessment of management.

Tongue hamartomas in pediatric patients: an international case series and literature review

This study reports 9 additional tongue hamartomas in children paired with a literature review. A retrospective analysis was performed from 3 Oral Pathology laboratories. Additionally, a literature review was conducted through 5 electronic databases and gray literature. A total of 9 cases were identified in the retrospective analysis. Females outnumbered males with a ratio of 1.25:1. The age of presentation ranged from 2 weeks to 7 years. The posterior dorsum tongue was the most affected subsite (n = 4). One case was seen in a patient with oro-facial-digital syndrome, 2 cases in patients with cleft palates, and one case with an encephalocele. The most common predominant component was salivary gland tissue (n = 4). A literature search included 79 pediatric patients presenting with 95 tongue hamartomas. A slight female (n = 47) predilection was observed, with ages varying from 15 hours to 19 years. The posterior tongue dorsum (n = 31) was the most affected site. Seven cases were seen in association with syndromes. The most common predominant component was smooth muscle (n = 35). Although hamartomas are rare in the oral cavity, they should be considered in the differential diagnosis of masses involving the posterior tongue dorsum in children.

Giant Epignathus (Teratoma of Palatine Tonsil): A Case Report

Teratomas are benign tumours containing tissues derived from ectoderm, endoderm and mesoderm Epignathus is a rare congenital teratoma and originates from oropharyngeal region. We present a case of giant epignathus arising from tonsillar region in a neonate. A male neonate that was born with a 38-week cesarean section presented with a pedunculated mass from left tonsilla palatina and protruding outside the mouth. The patient did not have any airway problem. Magnetic resonance imaging and computed tomography scan showed no intracranial extension. The patient was operated on the postpartum 3rd day and the mass was excised successfully. After histopathological examination, mature teratoma was diagnosed. During post-operative 6 months control visit, there was no recurrence. Epignathus is a rare congenital oropharyngeal teratoma, it should be diagnosed in the fetus as early as possible. Teratomas of the tonsilla palatina are extremely rare. In such cases, the mass may cause airway obstruction and feeding difficulties so complete resection is curative in most cases during the early neonatal period.

Lingual Hamartomas: Clinical Characteristics, Diagnostic Evaluation, Treatment, and Outcomes

OBJECTIVES/HYPOTHESIS

To further clinically characterize lingual hamartomas, and to consolidate literature by analyzing clinical presentation, diagnostic evaluation, treatment, and outcomes.

STUDY DESIGN

Retrospective chart review and literature review.

METHODS

Case series from 1989 to 2020 at a tertiary pediatric center; follow-up ranging from 2 months to 12 years. Patient demographics, clinical presentations, physical examination findings, surgical pathology, operative methods, pre-operative imaging, and follow-up. A review of English-language literature from 1945 to 2020 was conducted.

RESULTS

Seven patients (four male, three female) with nine lingual hamartomas were identified. Average age at surgical excision was 7.9 months (SD 3.5 months, range 3 to 14 months). Follow-up ranged from 2 months to 12 years, with all patients having no recurrence. Physical examination identified five pedunculated hamartomas and two sessile hamartomas. One patient had a neck CT, one had neck ultrasound, and two had facial MRIs. CT and ultrasounds confirmed presence of cervical thyroid. MRI suggested no muscular invasion for one patient, whereas motion artifact obscured findings for the other patient. Most patients who presented with dysphagia or poor weight gain achieved post-surgical improvement. The present cases combined with the literature review identified 57 patients with 63 lingual hamartomas.

CONCLUSIONS

Lingual hamartomas appear as hypovascular pedunculated masses near the foramen cecum. There is no demographic predisposition, and most are identified during infancy. Imaging is not necessary, unless there is concern for lingual thyroid, in which case thyroid ultrasound should be performed. Surgical excision is curative, with dysphagia resolution and low likelihood for recurrence.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2080-E2088, 2021.

Bifid Tongue and Cleft Palate With and Without a Tessier 30 Facial Cleft: Cases of Rare Congenital Anomalies and a Review of Management and Literature

Congenital bifid tongue with cleft palate is a very rare malformation with different variations. We are reporting 2 cases of rare congenital bifid tongue with cleft palate in our hospital setting and their surgical management. A multidisciplinary approach, well-planned staged operations, rehabilitation, and follow-up are needed to achieve favorable outcomes.

Congenital Tongue Mass With Concomitant Cleft Palate and Bifid Tongue: A Case Report and Review of the Literature

A case report of a congenital, lingual, salivary gland choristoma with bifid tongue and cleft palate is presented. The patient was born with airway obstruction in supine positioning. Laryngoscopy revealed a midline tongue mass that extended into the hypopharyx and pathological examination showed a congenital ectopic salivary gland. The bifid tongue was repaired at the time of surgical excision. Literature review revealed nine additional cases of congenital lingual mass, bifid tongue, and cleft palate. The most common tongue mass reported was hamartoma (40%), but the differential diagnoses include hamartoma, teratoma, and salivary choristoma.

Oropharyngeal teratoma, oral duplication, cervical diplomyelia and anencephaly in a 22-week fetus: A review of the craniofacial teratoma syndrome

BACKGROUND

Oropharyngeal teratoma may occur by itself or together with other craniofacial malformations, most commonly cleft palate. Oropharyngeal teratoma may be also seen in association with frontonasal dysplasia and/or various degrees of craniofacial duplication. The nosology of these sporadic disorders is poorly defined.

CASE AND REVIEW

We report on a 22-week fetus with a protruding nasopharyngeal teratoma, partial oral duplication, anencephaly, multiple costo-vertebral segmentation defects, and cervical diplomyelia. A review of the literature identified 48 patients published from 1931 to 2013 with co-existing clefting and duplication anomalies of the cephalic pole. Thoracic and abdominal midline anomalies were reported 13 times.

CONCLUSION

The term "craniofacial teratoma syndrome" is introduced to define this phenotype as a recognizable developmental field defect of the cephalic pole. Developmental pathogenesis is discussed with a focus on pleiotropy and stereotaxis. The observation of midline findings suggestive of holoprosencephaly in a few previously reported cases suggests a role for the sonic hedgehog signaling pathway in this malformation pattern.

Perinatal management of congenital oropharyngeal tumors: the ex utero intrapartum treatment (EXIT) approach

PURPOSE

To present our experience in the perinatal management of fetuses with large oropharyngeal tumors by ex utero intrapartum treatment (EXIT).

METHODS

We performed a retrospective chart review of all patients with congenital oropharyngeal tumor who underwent an EXIT procedure between May 2006 and June 2012.

RESULTS

Four patients were included in the series, three females and one male. The diagnoses were epignathus (n=2) and congenital epulis (n=2). Three EXITs were done at term and one at late preterm due to premature rupture of membranes. Median maternal time under anesthesia was 185 min (range: 166-281) and median maternal operative time was 99 min (range: 85-153). Median maternal blood loss was 550 ml (range: 350-2000); one mother required a blood transfusion. Mean maternal hospital stay was 4 days. Median hysterotomy-to-cord clamp time was 24 min (range: 18-66). Mean fetal birth weight was 2.7 kg (range: 2.4-3). The airway was successfully accessed and secured under placental circulation in all cases. In the two patients with congenital epulis the tumors were resected at the base of their pedicles and the airway accessed via direct laryngoscopy before the umbilical cord was clamped. One patient with epignathus underwent a retrograde tracheal intubation under placental circulation and had the tumor resected thereafter. The second patient with epignathus had a tracheostomy done under placental circulation and then had tumor debulking immediately after the EXIT. The maternal morbidity was minimal and there were no mortalities.

CONCLUSIONS

We conclude that the EXIT procedure is the ideal delivery strategy for fetuses with prenatally diagnosed oropharyngeal tumors and potential airway obstruction at birth. Patients with prenatally diagnosed oropharyngeal tumors should be promptly referred to a fetal treatment center with a dedicated multidisciplinary team and EXIT capabilities.

Oral teratomas: a report of 5 cases

PURPOSE

To present a case series of 5 patients with oral teratomas, discussing the treatment and follow-up.

REPORT OF CASES

Five patients (4 girls and 1 boy) with oral teratomas presented at the Maxillofacial Surgery Department of a University Hospital with a reference population of 1,000,000 between 1980 and 2002. The associated lesions, clinical examination, histopathology, treatment and follow-up were registered and described. The newborns presented associated congenital malformations such as cleft palate, bifid tongue, dorso-nasal fistula and nasal dermoid cyst. In all 5 cases the tumor mass was excised at its base with surrounding normal tissue under general anesthesia combining conventional and electric scalpels. Histological analysis resulted in different compositions of multiple tissues typical of teratomas. After a mean follow-up of 8 years no sign of tumor recurrence had been detected.

CONCLUSION

Teratomas were a rare finding within a large population of newborn patients. Five tumors were excised and histologically diagnosed as teratomas. No recurrence occurred after 8 years of follow-up.

Successful in utero treatment of an oral teratoma via operative fetoscopy: case report and review of the literature

The prenatal diagnosis of a nasopharyngeal teratoma carries a very grave prognosis. Although these tumors constitute only 9% of all teratomas, all previous cases diagnosed antenatally have been associated with either fetal demise or emergent surgery at birth. Of the fetuses that survive to birth, delivery can be associated with airway obstruction and multiple postnatal surgeries. These complications could be averted if the tumor could be safely treated in utero. We hereby report the successful treatment of an oral teratoma via operative fetoscopy, with the birth of a healthy infant at term.

Congenital nasopharyngeal teratoma with a cleft palate: case report and a 7 year follow up

Teratomas are benign tumors containing cells from ectodermal, mesodermal and endodermal layers. They occur in about 1 in every 4,000 births and most commonly in the sacrococcygeal region, followed by the ovaries. Congenital epignathus teratomas are rare embryological neoplasms localised in the region of head and neck. An epignathus is found in approximately 1:35,000-1:200,000 live births. This accounts for 2-9% of all teratomas. Size and location of the neoplasm in the oronasopharynx is variable. Teratomas are partly undiagnosed at the time of birth. They may exist with an intracranial extension or as small polyps. Large epignathi can lead to difficult management during and after birth. We present a case of a female infant with a combination of nasopharyngeal teratoma and a cleft palate with successful multidisciplinary management via a staged surgical approach. The epignathus presented as a huge mass extending out of the mouth of the infant girl. On the day of birth debulking of the extraoral portion of the tumor, followed by intraoral extirpation and cleft palate repair at a later stage, was performed. The results of the histopathological examination confirmed diagnosis of a congenital teratoma.

A unique presentation of epignathus

Palatal clefts in conjunction with space-occupying lesions of the oral or nasal cavities are of interest because they may represent a developmental etiology of palatal clefts. Epignathus is a rare space-occupying tumor of the nasopharynx that can arise from the upper jaw, palate, and sphenoid. It can protrude through the mouth, causing respiratory embarrassment and death. The pathogenesis of epignathus is unknown, but several theories have been proposed. Management depends on the size of the tumor and requires a multidisciplinary approach.

Massive immature teratoma in a neonate

Teratomas are embryonal tumours composed of diverse tissues from three germinal layers with variable levels of maturity. The authors report a female patient with a large immature epignathus. Prenatal diagnosis permitted a caesarean section and tracheotomy to be planned under ex utero intrapartum treatment for airway obstruction. The tumour was successfully controlled, even though it was impossible to distinguish from normal tissue because it lacked a pedicle and capsule, using multidisciplinary therapy, including a series of surgical treatments and adjuvant chemotherapy. This case suggested that the level of serum alpha fetoprotein might be a useful indicator after surgery. At present, after 4 years, no regrowth has been observed and the patient has no problems with respiration or swallowing.

Nasopharyngeal teratoma associated with cleft palate in newborn: report of 2 cases

Teratoma is a true neoplasm that consists of tissues from all 3 embryonic germ layers: ectoderm, mesoderm, and endoderm. Nasopharyngeal teratoma is very rare and accounts for only 2% of all teratomas. We present 2 cases of nasopharyngeal teratomas associated with cleft palate in newborns. The first case was a mushroom-like teratoma arising from the base of the sphenoid bone with cleft soft palate. This case was unique and interesting because no earlier paper has reported a teratoma with such a clinical feature. The second case was a teratoma from the nasal septum of an incomplete cleft palate. The combination of the mass and cleft palate made oral feeding difficult. Complete intraoral resection was performed in both cases. Typical components of true teratoma were identified by microscopic examination after operation. Cleft palate reconstruction was performed before 1 year. Clinical follow-up continues, and no recurrence has been observed to date.

Hemipalate deformity caused by a teratoma

Congenital intraoral tumors derived from embryological germ layers are very rare. These lesions include teratomas, dermoids, epignathi, and teratoid tumors. These embryological neoplasms may interfere with normal development and elevation of the palatal shelves, resulting in a cleft palate. We report the case of a patient with an intraoral teratoma associated with a hemipalate deformity and describe the treatment that was carried out. The classification and sometimes the confusing terminology associated with these lesions are discussed, as are the principles of managing them.

Hamartomas, teratomas and teratocarcinosarcomas of the head and neck: Report of 3 new cases with clinico-pathologic correlation, cytogenetic analysis, and review of the literature

Background

Germ-cell tumors (GCT) are a histologically and biologically diverse group of neoplasms which primarily occur in the gonads but also develop at different extragonadal sites in the midline of the body. The head and neck region including the upper respiratory tract is a very rare location for such tumors in both children and adults, which can cause diagnostic and therapeutic difficulties.

Methods

We describe here two new cases of multilineage tumors including sinonasal teratocarcinosarcoma [SNTCS], and congenital oronasopharyngeal teratoma (epignathus) and compare their features with those of a new case of a rare salivary gland anlage tumor [SGAT], an entity for which the pathogenesis is unclear (i.e. hamartoma versus neoplasm). We correlate their presenting clinico-pathological features and compare histologic and cytogenetic features in an attempt to elucidate their pathogenesis and biologic potentials.

Results and discussion

Cytogenetic analysis revealed chromosomal abnormalities only in the case of SNTCS that showed trisomy 12 and 1p deletion. Both cytogenetic abnormalities are characteristically present in malignant germ cell tumors providing for the first time evidence that this rare tumor type indeed might represent a variant of a germ cell neoplasm. The SGAT and epignathus carried no such cytogenetic abnormalities, in keeping with their limited and benign biologic potential.

Conclusion

The comparison of these three cases should serve to emphasize the diversity of multilineage tumors (hamartomas and GCT) of the upper respiratory tract in regards to their biology, age of presentation and clinical outcomes. Malignant tumors of germ cell origins are more likely to affect adults with insidious symptom development, while benign tumors can nevertheless cause dramatic clinical symptoms which, under certain circumstances, can be fatal.