A 44-year-old male presented to the oral and maxillo-facial surgery clinic at The Brooklyn Hospital Center.The patient’s chief complaint was an enlarging asymp-tomatic mass to the right side of his neck in thesubmandibular region, as shown in Figures 1 and 2.The patient noticed the mass 10 years ago but noticeda slow increase in size in the past 5 years. The pa-tient’s medical history was significant for hyperten-sion, asthma, and obesity. The patient denied anysurgeries in the past and any drug and alcohol use.However, the patient did admit to being a 25-yearpack-a-day cigarette smoker. The patient was afebrileand not in acute distress. A comprehensive head andneck examination showed a 6.5 � 4.5 � 2 cm doughyand well-circumscribed mass in the right submandib-ular region extending down into the neck. Ex-traorally, there was no discharge, no breakdown, andno erythema. The mass was not warm to the touchand the mandibular division of the fifth trigeminalnerve was intact bilaterally. There was no palpablelymphadenopathy omolateral or contralateral to thelesion. The patient had no complaints of restrictedneck movement. Intraorally, there was no trismus andno gross caries seen. The patient was missing teeth 30and 32, which were extracted many years ago. Thepatient’s uvula was at the midline; there was no floorof the mouth or vestibular swelling and no purulentdrainage noted intraorally. The patient showed nor-mal salivary flow. Routine hematologic and biochem-
Received from The Brooklyn Hospital Center, Department of Oral
and Maxillofacial Surgery, Brooklyn, NY.
*Senior Resident in Oral and Maxillofacial Surgery.
†Fellow in Oral and Maxillofacial Surgery.
‡Fellow in Oral and Maxillofacial Surgery.
§Chief Resident in Oral and Maxillofacial Surgery.
�Director.
¶Chairman.
Address correspondence and reprint requests to Dr Weiss: The
Brooklyn Hospital Center, Department of Oral and Maxillofacial
Surgery, 121 Dekalb Ave, Brooklyn, NY 11201; e-mail:
ical examinations, including thyroid hormonal evalu-ation, were within normal limits. The patient’s chestx-ray showed no abnormalities.
A panorex radiograph of the patient was taken andshowed no obvious odontogenic sources of infection.The patient was sent for a magnetic resonance imag-ing (MRI) study. A T1-weighted MRI of the facialbones, orbits, and paranasal sinuses was performedwithout contrast using 5-mm contiguous helically ob-tained axial images. As shown in Figures 3 and 4, theMRI showed a bright mass that was mostly lateral andinferior to the mandible; however, a projection of themass extended medially and superiorly compressingthe pterygoid muscle and displacing the right sub-mandibular gland inferiorly. A mass effect was notedparticularly on the lateral submandibular gland,which was deviated medially and was somewhat com-pressed. After gadolinium administration, no abnor-mal enhancement was seen.
Differential Diagnosis
A good rule of thumb when evaluating neck massesis to use the “rule of 80,”1 which pertains to adultsover the age of 40. This rule states that 80% of non-thyroid neck masses are neoplastic. Of the neoplasticmasses, 80% are malignant. Of the malignant masses,80% are secondary. Of the secondary masses, 80%occur above the clavicle. A secondary way of predict-ing the diagnosis based on duration would be to usethe “rule of 7’s.”1 If a mass has been present for 7
ays, it is likely inflammatory in nature; if present formonths, it is likely neoplastic in nature, and if
resent for 7 years, it would most likely be develop-ental. Despite these generalizations, it is important
o obtain an accurate history and perform a thoroughxamination when diagnosing neck masses. A thor-ugh examination of the oral cavity, nasopharynx,nd the larynx is critical. The clinician should evaluateoth sides of the neck to estimate the dimension ofhe mass. Determining the exact region of the neck inhich the mass is located is important and asking theatient to turn the head from left to right helpsssess painful versus nonpainful masses. The color
nd temperature of the skin overlying the mass may also
provide an important diagnostic clue. The age and gen-der of the patient and duration and rate of develop-ment, as well as palpation and auscultation, areprimary considerations in arriving at a differentialdiagnosis. A cranial nerve examination is also impor-tant because abnormal findings can indicate nerveinvolvement by tumor and a poorer prognosis. Fine-needle aspiration (FNA) biopsy is an inexpensive,rapid, and relatively accurate diagnostic tool for eval-uating neoplastic and nonneoplastic lesions, espe-cially in superficial or easily palpable masses. FNA isnot without error and should not replace sound clin-ical judgment.2
Neck masses can be categorized into the 3 follow-ing categories: inflammatory, neoplastic (benign, ma-lignant), and congenital.
Inflammatory masses are the most common causefor a neck swelling in children and young adults.Patients presenting with inflammatory neck massesoften present with a fever and complain of discom-fort. The neck mass with accompanying pain mayhave an odontogenic or nonodontogenic origin. Theneck masses can occur from acute or chronic lymph-adenitis, may have a viral origin (cytomegalovirus andmononucleosis), bacterial origin (parotid sialadenitis,cat scratch disease), parasitic origin (toxoplasmosis),or can be a manifestation of a granulomatous disease(sarcoidosis, scrofula).
In individuals over the age of 40, neck masses are
FIGURE 1. Preoperative presentation showing large mass in theright submandibular region.
Weiss et al. Large Unilateral Neck Mass in Submandibular Re-gion. J Oral Maxillofac Surg 2012.
most commonly neoplastic in nature. Both benign
and malignant neck masses can be encountered. Li-pomas are a type of benign neoplasm frequently en-countered in the neck region.3 Neurofibromas in the
eck may occur as solitary tumors or as part ofeurofibromatosis (von Recklinhausen’s disease).chwannomas can appear very similar clinically toolitary neurofibromas. The main difference betweenhese 2 tumors is that the nerve usually enters aeurofibroma centrally, whereas the schwannoma tu-or cells always stay on the outside of the nerve.4
Benign salivary gland tumors, such as pleomorphicadenoma, usually appear as a unilateral, asymptomaticmass that generally is solitary, freely mobile, and slowgrowing. Desmoplastic fibromas usually occur in theposterior cervical triangle. They originate from theroots of the first or second cervical nerves and arehard, fixed lesions. The clinician may also encountera carotid body tumor, which is a painless lateral neckmass that is more movable laterally than vertically.This compressible mass may be pulsatile or presentwith a bruit.5 Glomus jugulare are solid, fixed tumorsand are usually found in the bifurcation of the carotidartery.6 This can actually displace the internal andxternal carotid arteries.
FIGURE 2. Preoperative presentation showing large mass in theright submandibular region.
Weiss et al. Large Unilateral Neck Mass in Submandibular Re-
gion. J Oral Maxillofac Surg 2012.
ns
gmt
tt
W n. J Or
844 LARGE UNILATERAL NECK MASS IN SUBMANDIBULAR REGION
Malignant tumors of the neck can originate fromtissues in the surrounding region or may present as ametastasis from a tumor from a distant site. Some ofthe common primary malignant tumors causing cer-vical nodal distant metastases are those originatingfrom the thyroid, breast, lungs, and colon. It is criticalto examine the cervical lymph nodes during the headand neck examination when malignancy is suspected.Metastatic lesions may present in the neck regionwith an unknown primary lesion. These unknownhead and neck primaries are generally squamous cellcarcinomas. Also, squamous cell carcinomas of thetonsillar region are frequently manifested as solitaryneck masses with cystic lesions that affect the lymphnode. Patients with malignant cervical adenopathywith no immediately apparent primary tumor repre-sent 3% to 10% of all head and neck cancers.7
Hodgkin’s lymphoma and non-Hodgkin’s lym-phoma are frequently found as neck masses. Clinicallyit is very hard to make a distinction between the 2.Neck lymphomas usually present with fever, fatigue,and malaise and are often found in the posteriortriangle.8 Lymphomas can occur on both sides of the
eck and can be either small and hard or large and
FIGURE 3. T1-weighte
eiss et al. Large Unilateral Neck Mass in Submandibular Regio
oft on palpation. Lymphomas may present in any age
roup, but they are the most common malignant tu-ors of the head and neck in the pediatric popula-
ion, representing 10% of all malignancies.9
Salivary gland tumors are another category of ma-lignant tumors that can present as neck masses. Themost common that present as a primary or metastaticlesion in the neck are mucoepidermoid carcinomaand adenoid cystic carcinoma. Mucoepidermoid car-cinoma is the most common salivary gland malig-nancy and the second most common malignancy ofthe submandibular gland. Adenoid cystic carcinoma isthe second most common malignant salivary glandtumor and the most common in the submandibulargland.
Skin cancers can also spread and present as neckmasses. These are the most common malignancies inthe United States. Like other head and neck malignan-cies, lymphatic spread is associated with decreasedsurvival.10 Cutaneous head and neck and rarely in-raoral melanomas also frequently give regional me-astases to the neck.11
Finally, the third category that can be divided intocongenital and developmental neck masses are therarest. Examples of congenital cysts that can present
aken in the axial view.
al Maxillofac Surg 2012.
d MRI t
as neck masses include dermoid cysts, epidermoid
vddbpdbra
fch
W n. J Or
WEISS ET AL 845
cysts, and teratomas. Dermoid and epidermoid cystsare mostly found at the midline of the floor of themouth.12 Teratomas are rare, usually found at birth,can cause respiratory difficulty, and can occur any-where on the neck. Lymphangiomas or cystic hygro-mas present as soft, diffuse, multicystic compressiblemasses. These masses are usually found during in-fancy and are rarely seen during adulthood. Branchialcleft cysts of the neck are usually developed from thesecond branchial arch. They are often found antero-laterally to the jugular vein and carotid artery and aretypically located anterior to the sternocleidomastoidmuscle. Usually present as asymptomatic unless in-fected, they therefore can achieve a considerable sizebefore they are diagnosed.13 The most common de-elopmental cyst found in the neck is the thyroglossaluct cyst. The typical presentation of the thyroglossaluct cyst is a large mass in the midline of the neckelow the hyoid bone that moves with swallowing orrotrusion of the tongue. Cysts of the thyroglossaluct can be found from the foramen cecum at thease of the tongue to the pyramidal lobe of the thy-oid gland.14 Hemangiomas are often present at birth
FIGURE 4. T1-weighted
eiss et al. Large Unilateral Neck Mass in Submandibular Regio
nd rapidly proliferate in the first years of life, usually
ollowed by a slow involution. These lesions are moreommon in females (3:1) and 60% are located in theead and neck region.15
Surgery Performed and SubsequentCourse
The risks, benefits, and alternative treatments werediscussed with the patient. Treatment options in-cluded doing nothing or excision of the lesion, andbenefits included removal of source of discomfort.Risks were discussed with the patient, including par-esthesia, motor nerve paralysis, bleeding, swelling,pain, and infection. The patient elected to have thelesion excised under general anesthesia.
The patient was brought to the operating room andplaced under general endotracheal anesthesia. Thepatient was prepped and draped in a sterile fashion. Ano. 15 blade was used to make the initial submandib-ular skin incision extending to the most inferior por-tion of the extended lesion. Blunt dissection wasperformed down to the level of the lesion as shown inFigure 5. Dissection was then performed down to the
ken in the sagittal view.
al Maxillofac Surg 2012.
MRI ta
level of the lesion capsule at which point intracapsu-
Fsci
Wg
W
846 LARGE UNILATERAL NECK MASS IN SUBMANDIBULAR REGION
lar dissection was performed until the mass was freedin all aspects, medially, laterally, inferiorly, and supe-riorly. The mass was dissected from the right subman-dibular gland, which it displaced inferiorly and medi-ally, as shown in Figure 6. No attempt was made toevacuate the contents of the lesion. The mass wasremoved in total and measured approximately 9 cm inlength and 5 to 6 cm in width, as shown in Figure 7.As seen in Figure 8, the mass was submerged informalin and floated, confirming the diagnosis of alipoma. The specimen was sent to pathology for fur-ther study. The surgical site was irrigated with copi-ous amounts of sterile saline. A no. 7 Jackson Prattdrain was inserted and secured with silk sutures.Closure was completed and a telfa dressing and bac-itracin was applied to the wound. The patient wasextubated and transported to the recovery room instable condition. The patient was admitted and stayed
Weiss et al. Large Unilateral Neck Mass in Submandibular Re-gion. J Oral Maxillofac Surg 2012.
FIGURE 6. Intraoperative photograph showing the relationship ofmass to right submandibular gland.
Weiss et al. Large Unilateral Neck Mass in Submandibular Re-
gion. J Oral Maxillofac Surg 2012. g
overnight for observation. A noneventful postopera-tive course was observed and the patient was dis-charged the day after the surgery was performed.
Pathology Diagnosis
The histological diagnosis of this mass was a li-poma. Lipomas have a characteristic histological ap-pearance. These benign tumors are histologically sim-ilar to adipose tissue; however, they are differentiatedby the presence of a fibrous capsule.16 As shown inigure 9 representing the histology of the sampleubmitted from our case, lipomas are composed mi-roscopically of mature white adipose tissue arrangedn lobules, many of which are surrounded by a deli-
FIGURE 7. Surgical specimen.
eiss et al. Large Unilateral Neck Mass in Submandibular Re-ion. J Oral Maxillofac Surg 2012.
FIGURE 8. Specimen shown floating in formalin solution.
eiss et al. Large Unilateral Neck Mass in Submandibular Re-
ion. J Oral Maxillofac Surg 2012.
wmtgTbpmmcf
b
ttl
tdi
rstaaneuctt“
WEISS ET AL 847
cate fibrous capsule. These tumors frequently exhibitvarying numbers of collagen strands coursing throughthe lesion and one will occasionally observe smallblood vessels as well. When this fibrous connectivetissue forms a more significant portion of the tumor,the lesion is then described as a fibrolipoma.
Discussion
The lipoma has rarely been reported in the oralcavity, larynx, and pharynx. It occurs more frequentlyin other areas, in particular, the subcutaneous tissuesof the neck.17 Lipomas are slow growing, nearly al-
ays benign tumors that are well-circumscribed tu-ors of mature adipose tissue. On gross examination,
hey are smooth, well circumscribed, lobulated,reasy to the touch, and yellow to orange in color.he epithelium is usually very thin and the superficiallood vessels are readily visible over the surface. Li-omas are the most common neoplasms of mesenchy-al origin, arising in any location where fat is nor-ally present. Solitary lipomas are generally more
ommon in women, whereas multiple tumors (re-erred to as lipomatosis) are more common in men.18
Benign lipomatous tumors have been subclassifiedaccording to their histological features and growthpattern into classic lipomas (solitary or multiple), fi-brolipoma, angiolipoma, infiltrating lipoma, intramus-cular lipoma, hibernoma, pleomorphic lipoma, lipo-
lastomatosis, and diffuse lipoblastomatosis.19,20
Lipomas can also be further classified based on eithersize or weight. A tumor is classified as a giant lipomaif the size is greater than 10 cm in 1 dimension or the
FIGURE 9. Microphotograph of specimen shown at high powerview showing mature adipose tissue arranged in lobules.
Weiss et al. Large Unilateral Neck Mass in Submandibular Re-gion. J Oral Maxillofac Surg 2012.
weight is greater than 1,000 g.21
Lipomas are rare in the first 2 decades of life,usually developing in the fifth and sixth decadeswhen fat begins to accumulate in inactive, underex-ercised individuals. In general, this tumor is morecommonly found in obese people and can increase insize during a period of rapid weight gain.22 Accordingo Das Gupta,23 obesity and local growth of adiposeissue may both be responsible for the formation of aipoma.
This is known as the hypertrophy theory. In con-rast, the metaplasia theory holds that lipomatousevelopment represents the abnormal differentiation
n situ of mesenchymal cells into lipoblasts.24 How-ever, others have suggested that trauma and chronicirritation may cause the proliferation of soft tissue andplay a part in the formation of a lipoma.25
Lipomas usually occur sporadically, but rarelythey can be associated with several inherited disor-ders, including hereditary multiple lipomatosis,Gardner’s syndrome, and Madelung’s disease.26 He-editary multiple lipomatosis is characterized by wide-pread, symmetric lipomas appearing most often overhe extremities and trunk.27 Gardner’s syndrome is anutosomal-dominant disorder that can also be associ-ted with lipomatosis and is characterized by intesti-al polyposis, cysts, and osteomas.26 Madelung’s dis-ase or benign symmetric lipomatosis involves annusual distribution of fatty tissue surrounding theervical region, shoulders, and proximal upper ex-remities. Patients with this disease are often long-erm alcoholics and present with the characteristichorse-collar” cervical appearance.28
There are different imaging modalities that can beused in confirming the preoperative diagnosis of alipoma. The computed tomography (CT) can distin-guish cystic from solid lesions. A CT scan provides adefinitive diagnosis of lipoma in almost all cases bycalculating the actual density of the suspected mass(via the CT attenuation number). Fat, being the onlysoft tissue with a density less than water, has a nega-tive CT attenuation number. A lipoma will character-istically appear as a homogeneous mass with fewseptations, low CT attenuation number, and no con-trast enhancement. MRI and CT not only show thelipomatous nature of the tumor preoperatively butalso accurately determine its exact size, location, andextensions. This is critical in determining a preoper-ative surgical plan. The MRI as used on the patientdescribed in our case has an advantage over a CT in itssoft tissue capabilities and it is useful when the dis-tinction between the mass and surrounding soft tissueis poor. It is important to understand that neither CTnor MRI can differentiate a lipoma from a liposar-coma.29 This distinction can only be made with cer-tainty by a careful histopathological examination. Ul-
trasound is another study that is readily available,
3Lt
al4iytptlgm
tirdhqomptp
wao
6ia3smwfig
4ith
848 LARGE UNILATERAL NECK MASS IN SUBMANDIBULAR REGION
inexpensive, noninvasive, and accurate that can beused in determining the nature of unknown neckmass.30
Lipomas may present in the neck as large isolatedmasses present for long periods without muchchange over the years. The treatment of these benigntumors is a simple excision. The recurrence of thesetumors is rare.31 True lipomas recur in only 1% to 2%of cases after adequate excision, so a recurrenceshould raise the suspicion of a liposarcoma, especiallyif the tumor is not superficially located.32 Lipomastend to form in the subcutaneous tissue, which is incontrast to the liposarcoma that forms from thedeeper tissues, an important clinical distinction.
Upon performing a PubMed search for head andneck lipomas, it is evident that literature on head andneck lipomas is limited and has mostly been in theform of separate case reports. We have highlighted afew of the cases published in the literature to showthe variability in size, location, and type that thesetumors can present with in the head and neck region.
There is a report of a 55-year-old obese female thatpresented with soft, nontender chin swelling.33 In-traoral examination showed a large fixed mass fillingthe lower sulcus between the right lateral incisor andthe left second molar covered by slightly inflamedmucosa. The tumor was resected and the diagnosiswas submucosal and intramuscular benign lipoma.
Rarely, a lipoma has been known to infiltrate sur-rounding tissues, most notably skeletal muscle, inwhich case it is referred to as an infiltrating lipoma.
Do et al34 reported a case of a 22-month-old boywith a history of painless swelling in the right sub-mandibular area for 2 months that rapidly enlarged.CT showed a 5 � 5-cm expansive mass with a clearlydemarcated low density at the right submandibulararea. The histopathologic diagnosis was a lipoblas-toma. Lipoblastoma is a rare, benign tumor arisingfrom embryonic white fat cells and usually occurs ininfants younger than 3 years or in childhood.35 Thistype of tumor typically presents as a rapidly enlarging,painless mass and the clinical symptoms are mostlyassociated with tumor size and anatomical location.36
There are also several reports of lipomas of theparotid gland. One such report involves a 44-year-oldfemale with a 3-year history of a slowly enlarging leftpreauricular mass that suddenly had become painfuland tender.37 The lipoma was not attached to theoverlying skin and appeared to be in the superficiallobe of the left parotid gland. Another case reportdescribes a 47-year-old male with a deep lobe parotidgland lipoma.38 A physical examination showed a 4 �-cm soft and painless mass in the left parotid region.ipomas account for 2% to 3% of the benign parotidumors.39 Interestingly, Rosado et al report a case of a
73-year-old woman with a 2-year history of a gradually i
enlarging, painful mass located in the left parotidregion.40 Surgical excision was performed, obtaininga red-wine-colored mass located in the upper periph-eral part of the superficial parotid lobe. Immunohis-tochemical analysis led to the diagnosis of an angio-myolipoma of the parotid gland. Angiomyolipomasare benign mesenchymal tumors, commonly found inthe kidneys, but rare in the head and neck region.41
No recurrences have been reported after head andneck angiomyolipoma excision.
Lipomas constitute 4.4% of all intraoral tumors. Thecheek is the most common location of intraoral lipo-mas, accounting for 32% to 50% of cases.42 Our liter-ture search came up with a rare case of an intraoralipoma of the tongue and submandibular space.42 A5-year-old Nigerian tribesman presented with swell-
ng of the lower jaw and tongue for approximately 10ears. The patient had a grossly enlarged tongue andhe dorsum of the tongue consisted of areas of normalapillae interrupted by exophytic, smooth, and fluc-uant outgrowths. The facial examination showed bi-ateral symmetrical swelling of the submandibular re-ion that would enlarge and regress depending on theovements of the tongue.A patient can on occasion present with a lipoma
hat can be very troublesome and even life-threaten-ng if left unattended. One case report describes aetropharyngeal lipoma causing sleep apnea syn-rome.43 A 56-year-old man presented with a 2-yearistory of upper airway obstruction, snoring, and fre-uent episodes of sleep apnea. An examination of theropharynx showed a soft, nonpulsating, submucosalass, covered by normal mucosa, bulging from theosterior pharyngeal wall, mainly on the left side. Theumor extended from the inferior part of the naso-harynx as far as the margin of the epiglottis.Unfortunately, lipomas of the retropharyngeal areaill usually grow to a large size before they are found,
nd the initial symptom is often related to the airwaybstruction.Additionally, we found a case study describing a
2-year-old female that presented with a sialolipoman the right submandibular region.44 This patient hadswelling in the right submandibular region for 2 toyears. The mass was palpable and movable in the
ubmandibular triangle. Microscopically, the tumorass was mainly composed of mature adipocytes andas separated from the normal salivary gland by abrous capsule. The normal acinar cells of the salivaryland were infiltrated with mature adipocytes.Another interesting case in the literature involves a
0-year-old man who presented with a painless tumorn the left submandibular region.45 The 7 � 4-cmumor was removed by surgical excision. There was aard formation extracted from the fatty mass measur-
ng 3.5 � 2 cm. This is an extremely rare case in
aaggpamgduslmttodtbo
WEISS ET AL 849
which a hard mass of osseous metaplasia was foundwithin the lipoma.
Fanburg-Smith et al presented a clinicopathologicstudy in 2002 of 18 cases of liposarcoma of the oraland salivary gland region.46 In adults it is the mostcommon soft tissue sarcoma but it is rare in andaround the mouth. Only 3% of all liposarcomas occurin the head and neck region.46 It normally appears in
middle-aged person as a slowly enlarging, painless,nd nonulcerated submucosal mass but some lesionsrow rapidly and become ulcerated early in theirrowth. Development from a pre-existing benign li-oma is very rare and most cases arise de novo.46 Theuthors found that these rare tumors occur most com-only in the buccal mucosa, tongue, and parotid
land. Most of the tumors in their study were wellifferentiated. These tumors were composed of lob-les of mature fat, with thickened or widened fibrousepta and scattered atypia. The atypical nuclei werearge, hyperchromatic, and prominent even at lower
agnifications. No patients in this review had metas-ases or died because of the liposarcoma. The onlyumors that locally recurred in this study, regardlessf subtype, were greater than 5.0 cm in maximalimension. Complete local excision and careful pa-ient follow-up, without adjuvant therapy, appears toe the best treatment for liposarcomas found in theral and salivary gland regions.46
The case report of a large lipoma in the right sub-mandibular region of the neck presented in this arti-cle showed the importance of approaching masses ofthe neck in a systematic fashion. A mass of the neckhas a very extensive differential diagnosis so an accu-rate and complete examination is essential. An accu-rate history and complete head and neck examinationoften narrows the diagnostic possibilities, thus obvi-ating the need for excessive testing and invasive pro-cedures. There is always the possibility for malig-nancy in any age group; therefore, close follow-upand an aggressive approach are best for long-termfavorable outcomes. As shown in this case of a largelipoma, information regarding the slowly growingmass, absence of fixity and cranial nerve involvement,lack of intracranial extension, and no lymphadenopa-thy, along with normal peripheral blood examination,reduced the likelihood of a malignant lesion. Addition-ally, FNA, CT, and MRI imaging can each be usedalone or all the tests can be used in conjunction indetermining a preoperative diagnosis of a neck mass.
The Embrylogic and Anatomic Basis of Modern Surgery. Pas-chalidis Medical Publications. McGraw-Hill Publishing, Greece,
2004
2. Spearman M, Curtin H, Dusenbury D, et al: Computed tomog-raphy directed fine needle aspiration of the skull base parapha-ryngeal and infratemporal fossa masses. Skull Base Surg 5:199,1995
3. Rapidis AD: Lipoma of the oral cavity. Int J Oral Surg 11:30,1982
4. Apostolidis C, Anterriotis D, Rapidis AD, Angelopoulos AP:Solitary intraosseous neurofibroma of the inferior alveolarnerve: Report of a case. J Oral Maxillofac Surg 59:232, 2001
5. Perskey MS, Setton A, Niimi Y, et al: Combined endovascularand surgical treatment of head and neck paragangliomas—ateam approach. Head Neck 24:423, 2002
7. Adams JR, O’Brien CJ: Unknown primary squamous cell carci-noma of the head and neck: A review of diagnosis, treatmentand outcomes. Asian J Surg 25:188, 2002
8. Daskalopoulou D, Papanastasiou C, Markidou S, et al: Thediagnostic value of fine needle aspiration cytology in Waldey-er’s ring lymphomas. Eur J Cancer [Oral Oncol] 37:36, 2001
9. Bonilla JA, Healy GB: Management of malignant head and necktumors in children. Pediatr Clin North Am 36:1443, 1989
10. Rowe DE, Carroll RJ, Day CL Jr: Prognostic factors for localrecurrence, metastasis, and survival rates in squamous cellcarcinoma of the skin, ear, and lip. Implications for treatmentmodality selection. J Am Acad Dermatol 26:976, 1992
11. Rapidis AD, Apostolidis C, Vilos G, et al: Primary malignant mel-anoma of the oral mucosa. J Oral Maxillofac Surg 61:1132, 2003
12. Rapidis AD, Angelopoulos AP, Skouteris CA: Dermoid cyst of thefloor of the mouth. Report of a case. Br J Oral Surg 19:43, 1981
13. Rapidis AD, Faratzis G, Lagogiannis G, et al: Large swelling ofthe lateral neck. J Oral Maxillofac Surg 63:820, 2005
14. Al-Khateeb TH, Al Zoubi F: Congenital neck masses: A descrip-tive retrospective study of 252 cases. J Oral Maxillofac Surg65:2242, 2007
15. Enjolras O, Riche MC, Merland JJ, Escande JP: Management ofalarming hemangiomas in infancy: A review of 25 cases. Pedi-atrics 85:491, 1990
16. Kim YH, Reiner L: Ultrastructure of lipoma. Cancer 50:102,1982
17. Messeguer H, Ortega G, Galvez M: Pharyngeal iipoma: An ORLIbero. America 3:247, 1994
18. Koh HK, Bhawan J: Tumours of the skin, in Moschella SL,Hurley HJ (eds): Dermatology (ed 3). Philadelphia, PA, WBSaunders, 1992, pp 1721-1808
19. Salvatore C, Antonio B, Del Vecchio W, et al: Giant infiltratinglipoma of the face: CT and MR imaging findings. AJNR Am JNeuroradiol 24:283, 2003
28. Schuler FA, Graham JK, Horton CE: Benign symmetrical lipo-matosis (Madelung’s disease): Case report. Plast Reconstr Surg57:662, 1976
29. Rosell A, Garcia-Arranz G, Llavero MT, et al: Imaging case studyof the month. Lipoma of the retropharyngeal space. Ann Otol
Rhinol Laryngol 107:726, 1998
850 LARGE UNILATERAL NECK MASS IN SUBMANDIBULAR REGION
30. Knappe M, Louw M, Gregor RT: Ultrasonography-guided fine-needle aspiration for the assessment of cervical metastases.Arch Otolaryngol Head Neck Surg 126:1091, 2000
31. Lee J, Fernandes R: Neck masses: Evaluation and diagnosticapproach. Oral Maxillofac Surg Clin North Am 20:321, 2008
32. Das Gupta TK: Tumors and tumor-like conditions of the adiposetissue, in Ravitch MM, Ellison EH, Julian OC, et al (eds): CurrentProblems in Surgery. Chicago, IL, YearBook Medical, 1970
33. Pilissier A, Sawaf M, Shabana AM: Infiltrating (intramuscular)benign lipoma of the head and neck. J Oral Maxillofac Surg49:1231, 1991
34. Do NY, Cho SI, Park JH, Choi JY: Lipoblastoma arising from thesubmandibular region. J Pediatr Surg 43:E13, 2008
35. Sakaida M, Shimizu T, Kishioka C, Majima Y: Lipoblastoma ofthe neck: A case report and literature review. Am J Otolaryngol25:266, 2004
36. Rasmussen IS, Kirkegaard J, Kaasbol M: Intermittent airwayobstruction in a child caused by cervical lipoblastoma. AetaAnaesthesiol Scand 41:945, 1997
37. Malave DA, Ziccardi VB, Greco R, et al: Lipoma of the parotidgland: Report of a case. J Oral Maxillofac Surg 52:408, 1994
38. Ozcan C, Unal M, Talas D, Görür K: Deep lobe parotid glandlipoma. J Oral Maxillofac Surg 60:449, 2002
39. Waltz AE, Perzik SL: Lipomatous lesions of the parotid area.Arch Otolaryngol 102:230, 1976
40. Rosado P, Villalain L, De Vicente JC, et al: Angiomyolipoma ofthe parotid gland: Report of a case and review of the literature.J Oral Maxillofac Surg 68:2609, 2010
41. Farrow GM, Harrison EG Jr, Utz DC, et al: Renal angiomyoli-poma. A clinicopathologic study of 32 cases. Cancer 22:564,1968
42. Daltilo D, Taiige J, Nwanas EJ: Intraoral lipoma of the tongueand submandibular space: Report of a case. J Oral MaxillofacSurg 54:915, 1996
43. Girolamo S, Marine L, Galli A, et al: Retropharyngeal lipomacausing sleep apnea syndrome. J Oral Maxlllofac Surg 56:1003,1998
44. Jang YW, Kim SG, Hyunkyung P, et al: Sialolipoma: Case reportand review of 27 cases. Oral Maxillofac Surg 13:109, 2009
45. Dutescu N, Georgescu L, Hary M, et al: Lipoma of submandib-ular space with osseous metaplasia. J Oral Surg 35:611, 1973
46. Fanburg-Smith J, Furlong M, Childers E: Liposarcoma of the oraland salivary gland region: A clinicopathologic study of 18 cases
with emphasis on specific sites, morphologic subtypes, andclinical outcome. Mod Pathology 15:1020, 2002
