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CORRESPONDENCE COLUMN |
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| Year : 2005 | Volume
: 50
| Issue : 3 | Page : 174-175 |
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| Diagnosing lip swelling |
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Omar Al Al Akloby, Iqbal A Bukhari
College of Medicine, Dermatology Dept. King Faisal University, Alkhobar, Saudi Arabia
Correspondence Address:
Omar Al Al Akloby
College of Medicine, Dermatology Dept. King Faisal University, Alkhobar
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
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How to cite this article:
Akloby OA, Bukhari IA. Diagnosing lip swelling. Indian J Dermatol 2005;50:174-5 |
Orofacial granulomatosis describes a clinical entity including Melkersson-Rosenthal syndrome More Details (MRS), granulomatous cheilitis, and sarcoidosis.[1],[2] The condition may manifest as diffuse swelling of the buccal mucosa, lips, cheeks, nose, eyelids, and forehead. In Melkersson-Rosenthal syndrome a triad of recurrent orofacial edema, peripheral facial palsy, and fissured tongue is usually present with labial swellings being reported in more than 80% of patients with this syndrome.[3] Recently we came across a case with painful lip swelling without any evidence of odontogenic focus which turned out to be caused by bacterial infection of the soft tissue of the lower lip.
A 12 year old Saudi girl presented to our dermatology clinic with painful swelling of her lower lip for the past 5 days. The condition started gradually and over few days the lower lip became swollen, tense and painful with no discharge or bleeding. She denied any associated facial swelling or change in the facial features. She is a known case of bronchial asthma and any suggestive family history or drug history was negative. On examination, the patient showed tender firm non-flucutuant swelling of the lower lip which limited her lip movement. The buccal mucosa and tongue were normal and signs of facial nerve palsy or fissured tongue were not present. She had significant right cervical lymphadenopathy but no fever. Our differential diagnosis included herpes labialis, bacterial soft tissue infection and Melkersson-Rosenthal syndrome. Baseline laboratory investigations were normal including complete blood count, serum bio-chemistry and urinalysis. ESR was elevated (40mm/hr), C reactive protein was reactive and IgM antibody titre to Herpes simplex virus was negative. We consulted the dental surgeon to rule out odontogenic infections who suggested evacuation of the lesion under local anesthesia which showed large collection of pus in the lower lip without any evidence of odontogenic infection. Culture of the pus showed Staphylococcus aureus . The final diagnosis came out to be bacterial infection of the soft tissue of the lip. At presentation, the patient was treated with topical antibiotic with no significant improvement, rather her condition worsened. The patient was put on ciprofloxacin 250 mg twice a day for one week after which the condition resolved and the lip swelling completely disappeared.
Orofacial granulomatosis describes a clinical entity including Melkersson-Rosenthal syndrome, granulomatous cheilitis, and sarcoidosis.[1],[2] Food and contact allergy, tuberculosis, leprosy, and tooth-associated infections also have been implicated.[1],[4] The condition may manifest as diffuse swelling of the buccal mucosa, lips, cheeks, nose, eyelids, and forehead.[1] Specifically Melkersson-Rosenthal syndrome (MRS) is a rare neuromucocutaneus disorder characterized by a triad of recurrent orofacial edema, peripheral facial palsy, and fissured tongue but most cases have been reported with incomplete expression such as mono symptomatic and oligosymptomatic forms.[5] However, orofacial edema has been accepted as the dominant symptom of MRS and the most important diagnostic feature.[6] In the literature, labial swelling has been reported in more than 80% of patients with this syndrome.[3] In addition, patients may complain of burning sensation, speech and eating disturbances.[5] MRS may start at any age but it peaks in the second decade of life, and has equal sex distribution. Histologically, non-caseous lymphoepithelial and giant cell granulomas are present which is sometimes indistinguishable from lymphoma, sarcoidosis or tuberculosis. The cause of this syndrome is unclear but several associated conditions have been reported including diabetes mellitus, hypertension, obesity and Chrohn's disease . Several therapeutic measures including corticosteroid therapy, nonsteroidal anti-inflammatory agents, antibiotics, and surgical reduction, have been suggested for MRS, but all of these may produce only temporary success.[7] However, elimination of odontogenic infectious foci has been accepted as an important step in the management of these patients. Interestingly, our patient had painful lip swelling with no evidence of odontogenic focus. It is possible that the condition was due to unnoticed minor trauma to the lip area which was secondarily infected with staphylococcal organisms. So It is very important to take a careful history to reach correct diagnosis and to institute proper treatment without any delay.
 References | |  |
| 1. | Wiesenfeld D, Ferguson MM, Mitchell DN, Macdonald DG, Scully C, Cochran K, et al. Orofacial granulomatosis: a clinical and pathological analysis. Q J Med 1985;54:101-13.  |
| 2. | Rogers RS. Melkersson-Rosenthal syndrome and orofacial granulomatosis. Dermatol Clin 1996;14:371-90. |
| 3. | Sheridan PJ, Minn R. Orofacial manifestations of Melkersson-Rosenthal syndrome. Oral Surg Oral Med Oral Pathol 1992;74:610-9. |
| 4. | Sweatman MC, Tasker R, Warner JO, Ferguson MM, Mitchell DN. Orofacial granulomatosis: response to elemental diet and provocation by food additives. Clin Allergy 1986;16:331-8. |
| 5. | Tadokoro T, Ozawa K, Muso Y, Ito H, Itami S, Yoshikawa K. Melkersson-Rosenthal syndrome caused by Saprodontia: a case report. J Dermatol 2003;30:679-82. |
| 6. | Daoud MS, Rogers III RS. Melkersson-Rosenthal syndrome. Seminars in Dermatology 1995;14:135-9. |
| 7. | Camacho F, Garcia-Bravo B, Carrizosa A. Treatment of Miescher's cheilitis granulomatosa in Melkersson-Rosenthal syndrome. J Eur Acad Dermatol Venereol 2001;15: 546-9. |
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