|Year : 2017 | Volume
| Issue : 2 | Page : 170-174
Differential diagnoses of elevated lesions of the upper lip: An overview
Gowri Pandarinath Bhandarkar1, Kushal Vasanth Shetty2
1 Department of Oral Medicine and Radiology, A.J. Institute of Dental Science, Mangalore, Karnataka, India
2 Department of Pedodontia, A.J. Institute of Dental Science, Mangalore, Karnataka, India
|Date of Web Publication||23-Jun-2017|
Gowri Pandarinath Bhandarkar
Department of Oral Medicine and Radiology, A.J. Institute of Dental Science, Kuntikan, Mangalore - 575 004, Karnataka
Source of Support: None, Conflict of Interest: None
This paper comes with a purpose to help the clinician as how to arrive at a logical differential diagnosis when an upper lip mass is encountered in day-to-day practice. The labial mucosa is commonly traumatized. One must be aware of the type of structures contained in the mucosa of the area of a lesion as well as the patients habits since they may relate to a lesion presented for diagnosis. It also helps them to procure a sound knowledge of the lesions by describing the lesions according to their clinical appearance and to aid the clinician in arriving at a differential diagnosis by considering that certain lesions have a predilection for the upper lip. All clinically similar appearing lesions are discussed according to their relative frequency of occurrence. This paper covers only a minority of plethora of elevated lesions that may appear on the upper lip since almost any soft tissue lesion or neoplasm (benign and malignant) may occur here.
Keywords: Benign tumor, differential diagnoses, elevated lesions, malignant tumor, upper lip
|How to cite this article:|
Bhandarkar GP, Shetty KV. Differential diagnoses of elevated lesions of the upper lip: An overview. J Can Res Ther 2017;13:170-4
| > Introduction|| |
The lips are two fleshy folds surrounding the oral orifice. The center of each lip contains a thick fibrous strand, consisting of parallel bundles of skeletal muscle fibers (orbicularis oris, together with incisivus superior and inferior). The free external surface of the each lip is covered by a thin keratinized epidermis and is continuous with mucosa at the vermilion (red) zone of the lip which has rich capillary plexus. The dermis is well vascularized and accommodates numerous hair follicles, sebaceous glands, and sweat glands. Subcutaneous adipose tissue is scanty.
Labial mucosa is nonkeratinized, stratified squamous epithelium. Lamina propria has long, slender papillae; dense fibrous connective tissue contains collagen and some elastic fibers. Rich vascular supply giving off anatomizing capillary loops into papillae is present. Submucosa contains mucosa firmly attached to the underlying muscle by collagen and elastin; dense collagenous connective tissue has fat, minor salivary glands and sometimes sebaceous glands. Lips have two zones:
- Vermilion zone has thin, orthokeratinized, stratified squamous epithelium. Lamina propria has numerous narrow papillae; some sebaceous glands are present in vermilion border
- Intermediate zone has thin, parakeratinized, stratified squamous epithelium with long, irregular papillae; elastic and collagen fibers are present in connective tissue. Minor salivary glands and fat are seen in the intermediate zone.
Normally, the texture of the labial mucosa is smooth, soft, and resilient. The color of the mucosa is pink to brown, depending on the presence of racial pigmentation.
| > Arterial Blood Supply (Subterminal Branches)|| |
Upper lip is supplied by the superior labial artery (anastomosis with buccal artery). The lower lip is supplied by inferior labial artery (anastomosis with buccal artery), mental artery, and branch of inferior alveolar artery.
| > Principal Sensory Nerve Fibers Supply (Innervation)|| |
The upper lip is innervated by the twigs from the infraorbital branch of maxillary nerve and lower lip by the mental branch of inferior alveolar nerve and buccal branch of mandibular nerve.
| > Development of the Differential Diagnosis|| |
The process of developing a differential diagnosis may be defined briefly as the rearranging of the list of possible diagnoses, with the most probable lesion ranked at the top and the least likely at the bottom.
Along with the usual (or characteristic) features of the specific lesions, signs, and symptoms produced by many diseases, it is particularly important that the clinician be aware of the relative incidences of individual lesions. In the completed differential diagnosis, the most commonly occurring lesions will usually be ranked above the least commonly occurring unless other features prompt a modification of this ranking in which case age, gender, race, country of origin, and anatomic location are considered.
It is imperative to be aware that discussions of entities described here are not envisioned to be meticulous portrayals of any disease but only to present germane facts that will curtail muddle and add to the development of a differential diagnosis. The intention of this paper is to offer the clinician with the germane features of relatively common upper lip masses that we consider indispensable to the differentiation of similar appearing lesions. A brief list of the more common elevated lesions of the upper lip is given below.
| > Differential Diagnosis of Elevated Lesions of the Upper Lip|| |
As certain lesions in the differential diagnosis list [Box 1] are quite rare and other common lesions are not enlisted, we rearranged the list describing the upper lip masses depending on its relative frequency of occurrence  as follows.
The acute form of periapical abscess when involving maxillary central incisors appears as upper lip swelling. Vitality tests of the teeth help in the differential diagnosis. Radiographs should also aid in ruling out pulp-related or odontogenic cysts.
Nodular fibrous hyperplasia(traumatic or irritation fibroma)
This nodular lesion of normal color is the most common soft tissue lesion encountered in the oral cavity and occurs commonly on the lips. Since the lesion is a fibrous hyperplasia, usually initiated by trauma such as lip biting, it is not a true neoplasm and has limited growth potential, rarely exceeding 1 or 2 cm in diameter. The lesion typically grows slowly and varies in consistency from very soft to firm.
Squamous cell papilloma
It is a common benign growth which may occur on lips although encountered intraorally. The lesion is classically an exophytic papillary mass either white or of a normal mucosal color. They may occur at any age but are common in adults.
Squamous cell carcinoma
It occurs commonly on the vermilion border of the lower lip and less commonly on the upper lip. The incidence is highest in men with histories of chronic exposure to excessive ultraviolet radiation. An advanced lesion is usually an indurated mass with a cratered, crusted, central area or produces an exophytic, proliferative growth of tumor tissue.
Basal cell carcinomas
They appear identical on clinical examination, but they arise only on the skin surface and extend to the mucosa.
Approximately, 75% of all mucoceles occur on the lower lip. As lip biting commonly occurs on the lower lip, the upper lip is an infrequent location. A fluctuation in size is characteristic of mucoceles.
Mucoceles appear suddenly and reach maximum size within several days. The typical lesion appears as an elevated vesicular or bullous lesion, which often has a slightly bluish or translucent appearance. However, if the lesions are situated more deeply in the tissues, they may be of normal color. The lesion is soft on palpation and often fluctuant.
It often involves only one lip and is characterized by edema and sudden, diffuse swelling. The swelling is edematous, firm, and nonpitting. However, the whole face occasionally may be swollen. Food and drugs are the most common causes, resulting in an immunoglobulin E-mediated hypersensitivity with mast cell degranulation. In some cases, the swelling may last only several hours, but in others, it may last as long as 3 days. Accompanying generalized urticaria may be present in approximately 50% of the cases. Recurrence is common.
It is a benign proliferation of blood vessels that occurs in the head and neck region in more than 50% of the cases. On clinical examination, they appear as flat or elevated, red, or bluish lesions, which usually blanch under pressure. The lips, buccal mucosa, and tongue are also common locations. The borders of the lesions are not usually well demarcated; therefore, though appears as a small, superficial lesion may have its bulk beneath the surface. Large lesions often pulsate.
It is a very common benign tumor of adipose tissue and rare intraorally, but it occasionally occurs on the mucosal aspect of the lips. It is slow growing and composed of mature fat cells. It is found in adults with no gender predilection. In most cases, the size of the lesion is <3 cm at the time of diagnosis but can increase up to 5–6 cm over period of years. It appears as a single or lobulated, painless lesion attached by either a sessile or a pedunculated base. There is a yellow surface discoloration, and swelling appears well-encapsulated and is freely movable. The lipoma is soft and fluctuant.
It is a slow-growing, encapsulated tumor that typically arises in association with a nerve trunk and derived from Schwann cells. It is usually of long duration at the time of presentation by the patient. It may arise at any age with no sex predilection. They are usually painless unless they are causing pressure on adjacent nerves rather than on the nerve of origin. The presenting symptom of the majority of patients is only the presence of tumor mass. It commonly affects the tongue although it can occur almost anywhere in mouth including lips. The soft tissue lesion is usually a single, circumscribed nodule of varying size that presents no pathognomonic features. It may resemble any of a number of benign oral soft tissue lesions.
It can occur at any age and is usually a slow-growing firm mucosal nodule. Most lesions are asymptomatic although occasional tumors can be painful. Solid leiomyomas are typically normal in color although vascular leiomyomas (angiomyxomas) may exhibit a bluish hue. The most common sites are the lips, tongue, palate, and cheek which together account for 80% of cases.
| > Minor Salivary Gland Tumors|| |
Tumors of the minor salivary glands occur most commonly on palate, buccal mucosa, and tongue. Occurrence on the lips appears to account for approximately 5% of these tumors, with most occurring on the upper lip. There is little difference in the clinical appearance of benign and malignant salivary gland tumors that occurs on lips. Salivary gland tumors appear as soft or firm masses, with most having a nodular, exophytic component. Ulceration of the nodular mass may occur, but the presence of ulcer gives no clues as to the tumor's benign or malignant nature. Those that are soft on palpation usually have large cystic cavities and abundance of mucin. The more solid tumors both benign and malignant (especially benign mixed tumors with large amounts of bone and cartilage) are firm. Most salivary gland tumors grow slowly and often exist for years. Rapid growth or a sudden change in growth is more consistent with malignant tumors or benign tumors that have undergone malignant change.
Pleomorphic adenoma is a benign tumor of salivary gland which is usually painless, slow-growing swelling of long duration. Intraorally, the mixed tumor most often occurs on the palate followed by upper lip and buccal mucosa.
Pleomorphic adenoma of the upper lip is relatively common in younger age group. Slight female predominance is noted. Pleomorphic adenoma of the upper lip exceeds that of the lower lip by the ratio of 6:1. There is a propensity for benign tumors to occur on the upper lip, whereas malignant lesions predominate on the lower lip. The reason for this difference has been thought to be due to the differences in embryonic development between the upper and lower lips.
Pleomorphic adenoma of the upper lip is circumscribed mobile nodule. Histologically, pleomorphic adenoma contains abundant ducts.
Myoepithelioma is a rare neoplasm of the salivary gland. Patients are generally over 50 years of age with both sexes being equally affected.
The parotid gland is most commonly involved, and the palate is the most frequent intraoral site of occurrence; Sciubba and Brannon reported lesions in retromolar glands and upper lip. Histologically, myoepitheliomas are composed completely or almost completely of myoepithelial cells.
Basal cell adenoma
Basal cell adenoma is an uncommon benign salivary gland neoplasm and the 70% of cases arise in the parotid gland of elderly patients (sixth decade) and has no capsule, and upper lip is the most common site for minor salivary glands.
There is a 2:1 female predilection. These tumors are usually painless and are characterized by slow growth and appear as a firm swelling which may be cystic and compressible and are clinically indistinguishable from mixed tumors, greatest dimension being <3 cm.
Canalicular adenomas are uncommon neoplasms predominantly occurring in persons older than 50 years of age and seen mostly in women. This lesion originates primarily in the intraoral accessory salivary glands , and almost 75% of canalicular adenomas occur on or near the upper lip and the majority are near the midline. The lesions are slow growing, movable, and asymptomatic.
Mucopidermoid carcinoma and mucous cell adenocarcinoma
Majority involves the parotid gland although the other major salivary glands and especially the intraoral accessory glands may also be the site of origin. It occurs with an equal distribution between men and women. It occurs primarily in the third to fifth decades of life but actually can occur in virtually all decades. It is the most common malignant salivary gland tumor of children.
The tumor of low-grade malignancy usually appears as a slowly enlarging, painless mass which simulates the pleomorphic adenoma. However, it seldom exceeds 5 cm in diameter, is not completely encapsulated and often contains cysts.
It appears as a blue lesion because pools of mucus are frequently present. Consequently, the tumor may resemble a mucocele on clinical examination. The palate, buccal mucosa, and upper lip may be involved whereas the lower lip is an uncommon site.
| > Minor Salivary Gland Calculi|| |
They are thought to be more common than reported in the literature. They occur primarily in the upper lip of patients in the fifth to seventh decades. Most appear as firm to hard, movable submucosal nodule. The lesions vary from 3 to 15 mm in diameter; the majority are <5 mm.
Nasolabial cyst (nasoalveolar cyst)
It is a nonodontogenic developmental cyst found in the upper lip or soft tissues of the face inferior to the nose in the nasolabial fold. It appears to be slightly more common in female patients, with no preference for the right or left sides. On clinical examination, the cyst appears as a fullness of the nasal vestibule. If it enlarges inferiorly, it may appear to originate in the lip. Or it may appear as a swelling in the floor of the nose. The cyst is usually asymptomatic.
The labial mucosa is commonly affected by the numerous agents associated with contact allergies of skin and mucosa. Clinically, there may be diffused erythema with or without swelling, vesicles, tissue sloughing, or thickened hyperkeratotic areas.
It is a multisystem granulomatous disease of unknown cause affecting young adults and presenting most frequently with hilar lymphadenopathy, pulmonary infiltration, and skin and eye lesions. Lesions of the sarcoid may be found to involve practically any site including the mouth. The disease is characterized by delayed-type hypersensitivity suggesting an impaired cell-mediated immunity and raised or abnormal serum immunoglobulins suggesting lymphoproliferation. Mild malaise and cough may be the chief features. Lesions on the lips manifested clinically as small, papular nodules or plaques or resembled herpetic lesions or “fever blisters.” The absence of its other manifestations or a negative Kveim–Siltzbach test may be an important aid in early and accurate diagnosis.
Crohn's disease (regional enteritis or regional ileitis)
It is a granulomatous inflammation of the intestine of unknown etiology which is also recognized as one form of gastrointestinal disturbance that may be associated with pyostomatitis vegetans. Crohn's disease may also have oral involvement. When lips were involved, they were found to be diffusely swollen and indurated. The absence of gastrointestinal symptom usually rules out Crohn's disease.
It is a relatively rare inflammatory disease primarily affecting the lower lip. In the early stages, mucosal surfaces reveal numerous dilated salivary duct orifices surrounded by a red macular area. As the condition progresses, the labial glands become enlarged, which may cause the lip to become everted. There may be a superficial inflammatory process or a deep-seated infection.
Chelitis granulomatosa and Melkersson–Rosenthal syndrome
Cheilitis granulomatosa (Miescher's syndrome) is characterized by a diffuse, soft swelling that develops slowly and may persist for months or years. It is seen most commonly on the upper lip, which is usually of normal color and is asymptomatic. It may occur alone or in association with facial paralysis and fissured (plicated tongue). This is referred to as Melkersson–Rosenthal syndrome.
Keratoacanthoma (self-healing carcinoma)
It occurs on the sun-exposed tissues of the face. 8.1% of the cases occurred on the lips, and vermillion border of both the upper and lower lip are affected with equal frequency. It resembles a squamous cell carcinoma on both clinical and microscopic examinations but is a benign lesion. It is predominantly seen in older men. The lesion begins as sometimes a painful nodule that rapidly increases in size. It is firm, raised, dome shaped, and flesh colored or slightly pink. The borders are rolled and firm and develops a central crater.
After reaching maximal growth which rarely exceeds 1.5 cm in diameter, the lesion begins to regress and heals. The entire process may take 3–4 months to several years.
The primary lesion of syphilis occurs at the site of inoculation. This site is most commonly on the genitalia; however, the oral cavity and especially lips are possible locations. The initial lesion or chancre usually begins as a papule at approximately 3 weeks after the contact. The papule eventually ulcerates, leaving a lesion. Serologic tests are usually positive during the secondary stages. Condyloma latum is another lesion of secondary syphilis that may occur on the lip. This papular wart-like lesion may be red or white and is more likely to be lobulated.
Tuberculous oral lesions
They are uncommon with most cases appearing as a chronic painless ulcer. Less frequent presentations include nodular, granular or (rarely) firm leukoplakic areas. When present, primary oral tuberculosis usually involves the gingiva, mucobuccal fold and areas of inflammation adjacent to teeth or in extraction sites; secondary oral lesions are mostly present on the tongue, palate, and lip.
It may occur on the labial mucosa as a single or multiple lesions particularly in individuals who test positive for the human immunodeficiency virus. Early lesions may be flat, appear as reddish, bluish, or purple macule (plaque stage) that later becomes raised (nodular stage) and may reach a large size with surface ulceration and necrosis. Less superficial lesions may be colorless. A biopsy is necessary for a definitive diagnosis.
All the above lesions must be ruled out by way of history and clinical findings. In addition, clinically similar lesions must be ruled out by histopathologic examination.
| > Conclusion|| |
Here, differential diagnoses of elevated lesions of the upper lip are discussed. The diagnosis and treatment of such cases should be based on correct history, clinical findings, and accurate histological identification of tumor necessary to detect malignant transformation. Since there is no good method of clinically differentiating salivary gland tumors from other soft tissue tumors, cysts or reactive lesions of the lip, biopsy is mandatory for diagnosis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Lawrence H. Bannister. Alimentary system. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 39th
ed. Philadelphia: Elsevier, Churchill Livingstone; 2005. p. 497-8.
Antonio Nanci. Ten Cate's Oral Histology, Development, Structure and Function. 7th
ed. St. Louis, Missouri: Mosby, Elsevier; 2008. p. 342-3, 347.
Wood NK, Goaz PW. Differential Diagnosis of Oral and Maxillofacial Lesions. 5th
ed. St. Louis, Missouri: Mosby, Elsevier; 2007. p. 202, 542, 562-4, 567, 571-6.
Pitak-Arnnop P, Dhanuthai K, Hemprich A, Pausch NC. Pleomorphic adenoma of the upper lip: Some clinicopathological considerations. J Cutan Aesthet Surg 2012;5:51-2. [Full text]
Shafer WG, Hine MK, Levy BM, Tomich CE. Shafer's Text Book of Oral Pathology. 5th
ed. India: Elsevier, Mosby, Saunders, Churchill Livingstone; 2006. p. 28, 116, 155, 194, 283, 316-8, 322, 547, 924.
Neville B, Damm D, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 3rd
ed. Philadelphia: Elsevier; 2011. p. 196, 406-20, 549.
Regezi JA, Scuibba JJ, Jordan RC. Oral Pathology: Clinical Pathologic Correlations. 5th
ed. St. Louis, Missouri: Saunders, Elsevier; 2009. p. 179-213.
Buchner A, Merrell PW, Carpenter WM. Relative frequency of intra-oral minor salivary gland tumors: A study of 380 cases from northern California and comparison to reports from other parts of the world. J Oral Pathol Med 2007;36:207-14.
Kataria SP, Tanwar P, Sethi D, Garg M. Pleomorphic adenoma of the upper lip. J Cutan Aesthet Surg 2011;4:217-9.
] [Full text]
Ferri E, Pavon I, Armato E, Cavaleri S, Capuzzo P, Ianniello F. Myoepithelioma of a minor salivary gland of the cheek: Case report. Acta Otorhinolaryngol Ital 2006;26:43-6.
Greenberg MS, Glick M. Burket's Oral Medicine: Diagnosis and Treatment. 10th
ed. Ontario, Canada: Elsevier, BC Decker Inc.; 2005. p. 262.