|Year : 2019 | Volume
| Issue : 3 | Page : 608-614
A study on the clinical indicators in the diagnosis of orofacial nonodontogenic tumors
Dickson Sopuru Okoh, Mercy Okoh, Felix Osawe Omoregie, Michael Akin Ojo
Department of Oral Pathology and Medicine, University of Benin Teaching Hospital, Benin City, Nigeria
|Date of Web Publication||29-May-2019|
Dr. Dickson Sopuru Okoh
Department of Oral Pathology and Medicine, University of Benin Teaching Hospital, Benin City
Source of Support: None, Conflict of Interest: None
Objective: This study aims to determine the clinical features which are helpful as significant indicators in the diagnosis of malignant and nonmalignant nonodontogenic orofacial tumors.
Materials and Methods: This was a prospective study performed on patients with swellings in the oral and maxillofacial region clinically suspicious of being tumors of nonodontogenic origin in a Nigerian Tertiary Health Institution. The statistical variables that were analyzed included patients' resume, clinical and radiological features as well as the histopathological diagnosis of the lesions. The level of significance was set at P < 0.05. Inferential analysis was done using Student's t-test, Chi-square, binary logistic regression, and adjusted odds ratio as appropriate.
Results: There were forty patients histopathologically diagnosed as nonodontogenic tumors of the orofacial region. Twenty-five (62.5%) were females and 15 (37.5%) were males with mean age of 36 ± 21.9 years. Histopathological features showed three different categories of the lesions: Reactive and benign (nonmalignant) and the malignant lesions. Lymphadenopathy (P = 0.035) and nonmobility of the swellings (P = 0.029) were significant clinical indicators that were strongly associated with histological diagnosis of the malignant nonodontogenic tumors.
Conclusion: This study showed that the nonodontogenic tumors occurred mostly in younger patients with a female preponderance. The mandible and the preauricular region were the most common sites. Lymphadenopathy and nonmobility of the swellings were strong clinical indicators for the diagnosis of the malignant nonodontogenic tumors.
Keywords: Clinical indicators, diagnosis, nonodontogenic tumors
|How to cite this article:|
Okoh DS, Okoh M, Omoregie FO, Ojo MA. A study on the clinical indicators in the diagnosis of orofacial nonodontogenic tumors. J Can Res Ther 2019;15:608-14
| > Introduction|| |
Tumors of the orofacial region are a heterogeneous group of pathologic disorders with various histologic types and clinical behavior. They may be reactive/inflammatory, benign, or malignant with diverse clinical behavior, biologic characteristics, and histologic types that affect various tissues in the oral and maxillofacial region. Nonodontogenic tumors are those orofacial tumors which do not arise from the dental epithelial and mesenchymal., Similar to every orofacial tumor, they constitute a major health problem. Moreover, affected patients, especially in our environment, present late in the course of the disease with tumors that are advanced with increased morbidity and mortality., Early diagnosis of the orofacial nonodontogenic tumors is necessary to reduce morbidity and mortality and an understanding of their clinical presentation is essential in the histopathological diagnosis. These clinical features can serve in predicting lesions that are benign or malignant. The aim of this study was to determine the clinical features of nonodontogenic tumors which are helpful as indicators in the diagnosis of malignant and nonmalignant nonodontogenic orofacial tumors.
| > Materials and Methods|| |
This was a prospective study performed on patients with swellings in the oral and maxillofacial region clinically suspicious of being tumors of nonodontogenic origin in a Nigerian Tertiary Health Institution, for a period of 9 months (March to November, 2013). Permission was obtained from the Ethics Committee of our health institution prior to the commencement of the study and individual patient consent was obtained. The sample size was calculated using the Cochran formula:  N = Z2 × P (1 − P)/D2. For 95% confidence level, Z = 1.96, D = 0.05, for P, using 2.4% of incidence of orofacial tumor. Using the above formula, a minimum sample size was calculated to be 36. Calculation for attrition (possible dropouts) was 2. Therefore, N + attrition = 36 + 2 = 38. In this study, for 95% confidence level and a 0.05 margin of error, a sample size of forty patients was used.
Inclusion criteria included patients of all age groups with clinical swellings suspected to be an orofacial nonodontogenic tumor arising from soft tissue or intraosseous lesion that consented to participate in the study and to have fine-needle aspiration cytology followed by surgical open biopsy done. Exclusion criteria included patients who were not willing to participate in the study, patients with swellings diagnosed simply as orofacial infections, patients with previously diagnosed orofacial nonodontogenic tumor after a surgical biopsy, patients with recurrent lesions with previous surgical biopsy diagnosis of orofacial nonodontogenic tumor, and patients diagnosed with odontogenic tumors. Patients' resume were obtained. Interviewer-administered questionnaires were used to collect the medical history of the selected patients, vis-à -vis the duration of the swelling, site, and associated symptoms. Clinical examination of the patients included extra- and intra-oral examination to determine if the swellings were hard, firm, soft, and fluctuant and if the swellings were soft tissue lesion or an intraosseous lesion. Radiographic investigations were done to determine the intraosseous lesions and their extent. Clinical photographs were also taken and documented. All cases had fine-needle aspiration cytology followed by open surgical biopsy done for definitive diagnosis. Data obtained from the study were checked for accuracy, entered into a computer data spreadsheet, and analyzed using the Statistical Package for Social Sciences (SPSS; version 17.0, Chicago, IL, USA). The statistical variables that were analyzed included the clinical and radiographic features as well as the histopathological diagnosis of the lesions. The level of significance was set at P < 0.05. Inferential analysis was done using Student's t-test and Chi-square, binary logistic regression, and adjusted odds ratio as appropriate.
| > Results|| |
0f the forty patients histopathologically diagnosed as nonodontogenic tumors within this study period, 25 (62.5%) were females and 15 (37.5%) were males giving a female to male ratio of 1.7:1 [Table 1]. The age range of patients was 2–71 years with mean age of 36 ± 2I.9 years. The distribution of the gender among the age groups was statistically significant (P = 0.019). Female occurrence was seen in all age groups with the highest prevalence in the third decade (n = 6, 24.0%), whereas the highest prevalence in males was observed in the first decade of life (n = 5, 33%) and from the fifth decades of life [Table 1].
Twenty-two patients (55.0%) had tumors involving multiple sites whereas 18 patients (45.0%) had lesions in solitary sites. The mandible and the preauricular area with four cases (10%), each was the most common solitary sites [Figure 1].
|Figure 1: Right submandibular swelling with ulcer and associated multiple discharging sinus|
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The duration of swelling was between 1 week and 8 years with a mean duration of 71 ± 52.08 weeks. Twenty-five patients (62.5%) presented with pain. The patients in this study had rapidly growing swellings (n = 20, 50%) and slow-growing swellings (n = 20, 50%). There was associated discharge (n = 13, 32.5%), paresthesia (n = 3, 7.5%), and constitutional symptom (n = 11, 27.5%). Examination revealed swellings that were mostly firm (n = 30, 75%) with mobile swellings (n = 12, 30%) and fixed swellings (n = 28, 70%). The swellings measured between 2 cm and 14 cm in diameter with a mean diameter of 7.2 ± 3.19 cm. There were 18 (45%) patients with lymphadenopathy and 12 (30%) patients with ulcers. Aspirates obtained were mostly blood-stained tissue fluid (BSTF) (n = 28, 70%) and blood (n = 8, 20%) [Table 2].
Radiolucent masses (n = 18, 45.0%) were mostly seen in this study. Six cases (15%) had radiolucent jaw lesions and six cases (15%) were masses showing radiolucent soft tissue expansion. In general, there was no significant association between the radiological appearance with histological diagnosis of the orofacial nonodontogenic tumors in this study (P = 0.795) [Table 3].
Histopathological evaluation showed three different categories of the nonodontogenic tumors: Benign, reactive, and malignant lesions in this study. Twenty-nine (72.5%) cases were malignant, 8 (20%) were benign, and 3 (7.5%) cases reactive/inflammatory lesions. Malignant lesions were mainly non-Hodgkin's lymphoma (n = 12, 30%), which consists of the non-Burkitt type (n = 8, 20%) and Burkitt's lymphoma (n = 4, 10%) [Figure 2] and [Figure 3]. This is followed by the salivary adenocarcinomas (n = 9, 22. 5%), which consists mostly of mucoepidermoid carcinoma (n = 6, 15%). There were four cases (10%) of squamous cell carcinoma. The benign lesions were mostly vascular tumors (n = 5, 12.5%) consisting of hemangioma (n = 2, 5%) and lymphangioma (n = 2, 5%). The reactive lesions included the peripheral giant cell granuloma (n = 1, 2.5%) and lymph node hyperplasia (n = 1, 2.5%) [Table 4].
|Figure 2: Burkitt's lymphoma. Section showing malignant lymphocytes (a) interspersed by pale staining macrophages (b) giving a starry sky appearance (H and E, ×100)|
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|Figure 3: Non-Hodgkin's lymphoma showing sheet of darkly stained lymphocytic cells in a scanty fibrous connective tissue stroma (H and E, ×400)|
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|Table 4: The histopathological features and diagnosis of orofacial nonodontogenic tumors|
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An association of the clinicoradiological features with the histopathological diagnoses of the nonodontogenic orofacial tumors showed overall a female predilection with a female to male ratio of 3.5:1 for the benign lesions, 2:1 for reactive lesions, and 1.2:1 for the malignant lesions. Among the malignant lesions, there was a male predilection for the non-Hodgkin lymphomas (male to female ratio 1.4:1), a female preponderance for the salivary adenocarcinomas (female to male ratio 2.5:1) and equal occurrence in both genders for squamous cell carcinoma. The malignant lesions mostly occurred in multiple sites, whereas the benign lesions were mostly in solitary sites. The malignant lesions (n = 20, 50%) were associated with painful swellings, whereas the nonmalignant lesions (benign and reactive lesions) were mostly painless (n = 6, 15%). Constitutional symptoms were associated with the malignant lesions (n = 11, 27.5%), especially the non-Hodgkins lymphoma (n = 6, 15%) and squamous cell carcinoma (n = 4, 10%). There was significant association between constitutional symptoms of the swellings and histological diagnosis of the nonodontogenic tumors (P = 0.016). Most of the malignant swellings were rapidly growing (n = 18, 45%). Most of the benign (n = 8, 20%) were slow growing swellings. The growth rate was observed to be significantly associated with the histopathological diagnosis of the nonodontogenic tumors (P = 0.013).
Most of the malignant lesions were firm swellings (n = 26, 65%), especially the lymphomas (n = 12, 30%), whereas the benign lesions were mostly soft swellings (n = 5, 12.5%), especially the hemangiomas. There was a statistically significant association between consistency of the swellings and histological diagnosis of the nonodontogenic tumors (P = 0.002). Most of the malignant lesions were nonmobile swellings (n = 24, 60%). The mobile swellings were mostly the benign (n = 5, 12.5%) lesions. There was a statistically significant association between nonmobility and mobility of the swelling and the histological diagnosis of the malignant and benign nonodontogenic tumors, respectively (P = 0.004). A similar significant association between lymphadenopathy and histological diagnosis of the nonodontogenic tumors was also observed. Most of the malignant lesions (n = 17. 42.5%), especially the lymphomas (n = 9, 22.5%) and squamous cell carcinoma (n = 3, 7.5%) presented with lymphadenopathy. There were ulcers in 11 (27.5%) cases of the malignant lesions seen mostly in the salivary adenocarcinomas (n = 5, 12.5%) and squamous cell carcinoma (n = 4, 10%). BSTF was mostly aspirated from the malignant lesions (n = 24, 60%), whereas bloody aspirate was mostly found in benign lesions (n = 5, 12.5%), mostly the hemangiomas (n = 2, 5%). The nature of aspirate was significantly associated with histological diagnosis of the nonodontogenic tumors (P = 0.005) [Table 5].
|Table 5: Association of clinical features with the histopathological features of the nonodontogenic orofacial tumors|
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There was a statistically significant difference in the duration of the malignant and nonmalignant (benign and reactive) tumors (P = 0.006). The mean duration for the malignant nonodontogenic tumors was 49 weeks and that of nonmalignant nonodontogenic tumors was 129 weeks. A significant difference was also observed between the size of the malignant and that of the nonmalignant nonodontogenic tumors (P = 0.001). The mean size (in diameter) for malignant nonodontogenic tumors was 7.7 cm and that of the nonmalignant tumors was 6 cm [Table 6]. The predictors of malignancy in this study were the rapid rate of growth of the swelling, the presence of lymphadenopathy, nonmobility of the mass, firm consistency, the nature of aspirates (BSTF), shorter duration, and size of the mass (large diameter). They were observed to be highly significant in the histopathological diagnosed nonodontogenic tumors. These features were further tested for the strength of association using the adjusted odd ratio, and the absolute predictors of malignancy after serial elimination using binary logistic regression were presence of lymphadenopathy (P = 0.035) and nonmobility of the swellings (P = 0.029) [Table 7].
|Table 7: Adjusted odd's ratio: predictors of malignancy after serial elimination using binary logistic regression|
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| > Discussion|| |
Orofacial tumors cause morbidity and mortality for people globally. Accurate diagnosis is essential for proper management of cases. This study focused on the nonodontogenic tumors, a group of tumors known to be frequent in the orofacial region as shown by previous reports.,,
In this study, the peak age groups of the nonodontogenic tumors seen were in the first and fifth decades of life. A study  reported the 4th decade as the peak age group of orofacial tumors in their series. A younger mean age of 36 years was observed in this study, which is in contrast to that done by Parkins et al., who observed a mean age of 40 years for all orofacial tumors studied. The younger mean age of the patients with nonodontogenic tumors observed in this study compared to previous studies on orofacial tumors , was probably due to the clinical and demographic setting and also because most of the lesions in this study were malignant, the patients were more likely to present earlier for the treatment. There was a female predilection for orofacial nonodontogenic tumors, which agrees with the report by Lasisi et al. on orofacial tumors. This may be due to the fact that females are more concerned with their facial appearance and present for treatment early because of the facial disfigurement associated with this swellings. The mandible and the preauricular area were the most common solitary sites in this study. Similarly, several studies ,,, have reported that the mandible is the site most commonly affected. A finding from a study  reported that the preauricular area is the most common site for the soft tissue tumors and the posterior parts of the mandible were the most common sites for intrabony tumors.
Twenty-five (62.5%) patients complained of painful swellings which may be attributed possibly to secondary infections or malignant lesions as shown by the presence of regional lymphadenopathy, constitutional symptoms, ulcers, or malignancy infiltrating nerves in the local sites. A study  reported pain in 41% of patients in their study of orofacial tumors. Moreover, another study  stated that the most common cause of pain is local tumor invasion and that the pain develops via inflammatory and neuropathic mechanisms. In another study, ulcers were reported in 29% of patients which is similar to the observation in the present study. They further observed the presence of regional lymphadenopathy in 9% of cases which is in contrast to the 45% reported in this study. The majority of the tumors in this study were malignant lesions which may explain the relatively higher occurrence of lymphadenopathy and this agrees with reports in scientific literatures that lymphadenopathy are associated with malignancies.,
The predominant radiological (imaging) pattern of the nonodontogenic tumors, especially the malignant type in this study, were radiolucent masses (45%) consisting mostly of radiolucent jaw tumors. A study  observed more of radiolucent masses which accounted for 87% of the malignant lesions studied. Huang et al. reported that all the malignant jaw lesions in their study showed radiolucent features.
Histopathological diagnosis of malignant lesions was the predominant finding in this study accounting for 72.5% of the cases consisting mostly of non-Hodgkins lymphomas (30%) with the non-Burkitt type accounting for 20% and Burkitt's lymphoma accountings for 10% of the non-Hodgkins lymphomas. These findings agree with an East African study  which reported the predominance of malignant lesions (74.5%) among the orofacial tumors seen. Furthermore, Jaafari-Ashkavandi and Ashraf  reported non-Hodgkins lymphomas (Burkitt's and the non-Burkitt types) as the most common malignant lesion in their study. Salivary adenocarcinomas (22.5%) were the second most common malignant lesion in this study, consisting mostly of mucoepidermoid carcinoma (15%). Squamous cell carcinoma (10%) was the third most common malignant tumor found in this study. In contrast, Arotiba et al. found squamous cell carcinoma as the most common malignant lesion accounting for 46% of the patients studied. Parkins et al. also reported squamous cell carcinoma (64%) as the most common malignant tumor followed by the lymphomas (17%), whereas Gupta et al. found squamous cell carcinoma and adenocarcinomas to be more frequent than non-Hodgkin's lymphoma in their study.
Among the nonmalignant, nonodontogenic tumors were the benign and reactive lesions. The benign lesions were more commonly seen (12.5%), consisting mostly of vascular tumors with hemangioma and lymphangioma accounting for 5% each. Similarly, a study  reported hemangioma as the most common benign lesion among the orofacial tumors studied. In contrast, a study  reported fibromas as the most common benign lesion accounting for 26.7% of their series. The reactive tumors were rare in this study (7.5%), consisting of one case each of peripheral giant cell granuloma, lymph node hyperplasia, and orofacial granulomatosis.
In this present study, clinical indicators of Burkitt's lymphoma were a rapidly growing swelling in a young patient with expansile radiolucent jaw mass and dental anarchy, whereas the non-Burkitt types are associated more with lesions in the older patients. This is in agreement with Bosco et al., who did a clinicoradiological review of 19 cases of Burkitt's lymphoma. It also agrees with the assertion by a study  that observed from their clinical findings that young patients with rapidly expanding nodal and extranodal masses in endemic areas suggest Burkitt's lymphoma. They also stated that if these clinical presentations are seen in adults, with lymphadenopathy, a clinical suspicion of lymphoma possibly non-Burkitt type of non-Hodgkin's lymphoma should be made. Clinical indicators of squamous cell carcinoma of the orofacial region in this study were a history of a short duration, with painful ulcers, associated lymphadenopathy, and radiolucent masses. These features are consistent with reports by Müller and Slootweg  that correlated the clinical and radiological aspects of squamous cell carcinomas of the oral cavity to their histological findings. Our study also show that palpable swellings arising from a salivary gland having a possible history of initial slow growth in some cases and recent rapid growth that are nonmobile, with or without pain and lymphadenopathy and with or without nerve involvement or numbness is more likely to be a salivary adenocarcinomas. This is comparable to other reports.,, Lesions clinically suspected and then histopathologically diagnosed as vascular tumors in this study were associated with bloody aspirates., The benign lesions however were characterized by slow growing painless masses that are usually mobile. Lymphadenopathy is not a feature except in the reactive lymph node hyperplasia.,
Some authors have related clinical features of orofacial tumors to histopathological diagnosis.,, With respect to the above findings, this study has identified clinical indicators that may be useful as index of suspicion in the histopathological diagnosis of nonodontogenic orofacial tumors. Therefore, observations from this present study suggest the need to classify such clinical indicators as follows:
- Clinical indicators which were not significantly associated with the histological diagnosis of the nonodontogenic tumors. These include the patients' gender, sites of the lesion, presence or absence of pain, discharge, numbness, effect on the teeth, ulcers, and radiological patterns of the tumors
- Clinical indicators that were significantly associated with the histological diagnosis of the nonodontogenic tumors. These include the duration, rate of growth, constitutional symptoms, size of the tumor, consistency of the swelling, and the nature of aspirate
- Clinical indicators that were significant and strongly associated with histopathological diagnosis of the nonodontogenic tumors. These were lymphadenopathy and mobility of the swelling. The presence of lymphadenopathy and nonmobility of the swellings are very strong indicators for the diagnosis of malignant nonodontogenic tumors.
| > Conclusion|| |
This study showed that nonodontogenic tumors occur mostly in younger patients with a female preponderance. The mandible and the preauricular region were the most common sites of the tumors and malignant tumors were the most common histopathological diagnosis, especially the non-Hodgkins lymphomas (non-Burkitt type) and mucoepidermoid carcinoma. Lymphadenopathy and nonmobility of the swellings were strong clinical indicators for the diagnosis of malignant nonodontogenic tumors in this study.
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.
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Conflicts of interest
There are no conflicts of interest.
| > References|| |
Jaafari-Ashkavandi Z, Ashraf MJ. A clinico-pathologic study of 142 orofacial tumors in children and adolescents in Southern Iran. Iran J Pediatr 2011;21:367-72.
Arotiba JT, Adebola RA, Ajike SO, Adeola DS, Ladeinde A. Orofacial tumours and tumour-like lesions in Kano, Nigeria. Niger J Surg Res 2003;5:134-9.
Theodorou DJ, Theodorou SJ, Sartoris DJ. Primary non-odontogenic tumors of the jawbones: An overview of essential radiographic findings. Clin Imaging 2003;27:59-70.
Seta AS. Benign non odontogenic tumours in children and adolescents (analysis of 77 cases). Egypt Dent J 2010;56:1169-72.
Oji C. Late presentation of orofacial tumours. J Craniomaxillofac Surg 1999;27:94-9.
Cochran WG. Sampling Techniques. 3rd
ed. New York: John Wiley and Sons; 1977. p. 190-205.
Arotiba GT. A study of orofacial tumors in Nigerian children. J Oral Maxillofac Surg 1996;54:34-8.
Sepideh S, Nasibeh K, Mohaddeseh M. Oral and jaw lesions in adults: A 19-year retrospective study in Northern Iran. Iran J Pathol 2013;8:159-64.
Oti AA, Larsen-reindorf R, Nii R, Laime L, Donkor P. Review of orofacial biopsies at komfo anokye teaching hospital, Ghana. Stand Sci Res Essays 2013;1:28-31.
Parkins GE, Armah G, Ampofo P. Tumours and tumour-like lesions of the lower face at Korle Bu Teaching Hospital, Ghana – an eight year study. World J Surg Oncol 2007;5:48.
Lasisi TJ, Adisa AO, Olusanya AA. Appraisal of jaw swellings in a Nigerian tertiary healthcare facility. J Clin Exp Dent 2013;5:e42-7.
Riaz N, Warraich RA. Tumors and tumor-like lesions of the Orofacial region at Mayo hospital, Lahore – A five year study. Ann of King Edward Med Uni 2011;17:2-5.
Saxena S, Kumar S, Pundir S. Pediatric jaw tumors: Our experience. J Oral Maxillofac Pathol 2012;16:27-30. [Full text]
Epstein JB, Elad S, Eliav E, Jurevic R, Benoliel R. Orofacial pain in cancer: Part II – clinical perspectives and management. J Dent Res 2007;86:506-18.
Allhiser JN, McKnight TA, Shank JC. Lymphadenopathy in a family practice. J Fam Pract 1981;12:27-32.
Sambandan TL, Christeffi M. Cervical lymphadenopathy. A review. JIADS 2011;2:31-3.
Kaffe I, Ardekian L, Peled M, Machtey E, Laufer D. Radiological features of primary intra-osseous carcinoma of the jaws. Analysis of the literature and report of a new case. Dentomaxillofac Radiol 1998;27:209-14.
Huang JW, Luo HY, Li Q, Li TJ. Primary intraosseous squamous cell carcinoma of the jaws. Clinicopathologic presentation and prognostic factors. Arch Pathol Lab Med 2009;133:1834-40.
Kamulegeya A, Kalyanyama BM. Oral maxillofacial neoplasms in an East African population a 10 year retrospective study of 1863 cases using histopathological reports. BMC Oral Health 2008;8:19.
Gupta N, Banik T, Rajwanshi A, Radotra BD, Panda N, Dey P, et al.
Fine needle aspiration cytology of oral and oropharyngeal lesions with an emphasis on the diagnostic utility and pitfalls. J Cancer Res Ther 2012;8:626-9.
Bosco JI, Appaji L, Aruna K, Raghuram P, Rama-Rao C, Vidhya A. Clinical and radiological features of paediatric Burkitt's lymphoma – A four year study. Indian J Med Paediatr Oncol 2007;28:14-7.
Ayers LW, Tumwine LK. Diagnosis of Burkitt Lymphoma. Burkitt's lymphoma. Current Cancer Research. New York: Springer Science; 2013. p. 35-52.
Müller H, Slootweg PJ. Mandibular invasion by oral squamous cell carcinoma. Clinical aspects. J Craniomaxillofac Surg 1990;18:80-4.
Spiro RH, Huvos AG, Strong EW. Cancer of the parotid gland. A clinicopathologic study of 288 primary cases. Am J Surg 1975;130:452-9.
Bussu F, Parrilla C, Rizzo D, Almadori G, Paludetti G, Galli J. Clinical approach and treatment of benign and malignant parotid masses, personal experience. Acta Otorhinolaryngol Ital 2011;31:135-43.
Boahene DK, Olsen KD, Lewis JE, Pinheiro AD, Pankratz VS, Bagniewski SM. Mucoepidermoid carcinoma of the parotid gland: The Mayo clinic experience. Arch Otolaryngol Head Neck Surg 2004;130:849-56.
Rossiter JL, Hendrix RA, Tom LW, Potsic WP. Intramuscular hemangioma of the head and neck. Otolaryngol Head Neck Surg 1993;108:18-26.
Narayanan CD, Prakash P, Dhanasekaran CK. Intramuscular hemangioma of the masseter muscle: A case report. Cases J 2009;2:7459.
Weiss LM, O'Malley D. Benign lymphadenopathies. Mod Pathol 2013;26:S88-96.
Osborne BM, Butler JJ, Variakojis D, Kott M. Reactive lymph node hyperplasia with giant follicles. Am J Clin Pathol 1982;78:493-9.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]