|Year : 2018 | Volume
| Issue : 4 | Page : 123-128
Lip lesions: A 10-year retrospective analysis from a Nigerian tertiary healthcare institution
Benjamin Fomete1, Rowland Agbara2, Ezekiel T Adebayo3, Davis S Adeola1
1 Maxillofacial Surgery Department, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Dental and Maxillofacial Department, University Teaching Hospital, Jos, Nigeria
3 Army Dental Center, Bonny Camp, Lagos, Nigeria
|Date of Web Publication||20-Sep-2019|
Dr. Benjamin Fomete
Maxillofacial Surgery Department, Ahmadu Bello University Teaching Hospital, Zaria
Introduction: Lip lesions can be acquired or congenital, benign, or malignant. They can also form as a result of systemic manifestation or infection such as cancrum oris or gangrenous stomatitis. Lesion can affect the upper, lower, or both lips together. Patients and Methods: A retrospective study of patients attending the oral and maxillofacial clinic of a tertiary health institution between January 2006 and December 2015 was undertaken. Results: The majority of the patients were from 2nd to 5th decades of life with a ratio of 1.54:1. The age ranged from 1.5 to 78 years. The lower lip (64%) was the most affected, and the unspecified represented 7.8%. The upper-to-lower lip ratio was 1:2.85. Conclusion: Acquired lesions formed the bulk of the lesions seen.
Keywords: Acquired, benign, lip, lesions, malignant
|How to cite this article:|
Fomete B, Agbara R, Adebayo ET, Adeola DS. Lip lesions: A 10-year retrospective analysis from a Nigerian tertiary healthcare institution. Sub-Saharan Afr J Med 2018;5:123-8
|How to cite this URL:|
Fomete B, Agbara R, Adebayo ET, Adeola DS. Lip lesions: A 10-year retrospective analysis from a Nigerian tertiary healthcare institution. Sub-Saharan Afr J Med [serial online] 2018 [cited 2020 Jan 24];5:123-8. Available from: http://www.ssajm.org/text.asp?2018/5/4/123/267128
| Introduction|| |
The lips comprise two mobile structures that represent the anterior boundaries of the oral cavity. The lips function dynamically in deglutition, speech, aesthetic balance, and facial expression. They are the dynamic center of the lower third of the face and thus an important part of the facial complex. In addition, a variety of acquired conditions such as infections, trauma, autoimmune, and benign and malignant tumors may be related to this anatomic site.
Traumatic injuries to the soft tissues of the cranio-maxillofacial region, especially the lips, are still the most common group of pathological problems encountered in the accident and emergency room of every healthcare facility. Their pattern and distribution vary depending on the etiology that includes road traffic accidents (RTAs), and animal and human bites. Among inflammatory conditions of the lip, recurrent aphthae constitute the most common oral mucosal disease in otherwise normal patients affecting 10% to 25% of the population, 5% to 50% when ethnic or socioeconomic groups are considered., A previously fatal stomatitis affecting the lips was cancrum oris or gangrenous stomatitis. Among tumors, the squamous cell carcinoma (SCC) of the lip is relatively common; it is responsible for over 30% of all oral SCCs, with over 80% in the lower lip., Vascular lesions encompass a wide range of conditions throughout the body that results in an abnormal number of structures or position of blood vessels. They are grouped into hemangiomas and vascular malformations.
However, despite the relative importance of the lip, reports on acquired and vascular lesions of the anatomic region are scarce, whereas more attention has been on congenital lesions of the lips, such as cleft lip. This has necessitated this retrospective analysis. The aim of this report is to analyze acquired and vascular lesions of the lips based on cases seen at the foremost tertiary healthcare institution in Northern Nigeria for comparison with relevant literature.
| Patients and methods|| |
A retrospective study of patients attending the oral and maxillofacial surgery clinic of the Ahmadu Bello University Teaching Hospital, Zaria, between January 2006 and December 2014 was undertaken. Patients with lesions of the lip (n = 124) were further selected for data collection. Data collected were age, sex, site(s), type of lesion, histopathology results, where needed, and other ancillary results. A total of 35 patients were excluded for incomplete record with majority (n = 27) as no site of the lesion was specified. Patients having cleft lips were also excluded from this study.
| Results|| |
There were more male (n = 54, 60.7%) than female (n = 35, 39.3%) with the majority from 2nd to 5th decades of life. The male-to-female ratio was 1.54:1. The age range was between 1.5 and 78 years with a mean of 33.92 years. The lower lip was the most affected (n = 57, 64%) followed by the upper lip (n = 20, 22.4%), both lips (n = 5, 5.6%), and unspecified (n = 7, 7.8%). The upper-to-lower lip ratio was 1:2.85. [Table 1] shows the pattern of acquired and vascular lip lesions seen at a Nigeria tertiary health institution.
|Table 1 Pattern of acquired and vascular lip lesions seen at a Nigerian tertiary health institution|
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As seen from [Table 1], trauma caused the most acquired lip lesions (n = 30, 33%) followed by malignancies that were responsible for 19 cases (21.3%).
In [Table 2], trauma caused 33.7% of acquired and vascular lip lesions consisting of those from RTA, human, and animal bites. RTA accounted for 26 cases resulting in lacerations (n = 16 cases) and avulsion [Figure 1] (n = 10 cases). The lower lip was more involved (n = 19 cases, 61.3% of traumatic lip injuries) than the upper lip (n = 7 cases, 22.6% of traumatic lip lesions) or both lips (n = 5, 16.1%). There were more males than females with traumatic lesions overall (ratio was 2.75:1), with the highest occurrence between the 3rd and 5th decades. Treatment included primary closure, debridement with secondary closure, dressing and skin grafting, and forehead flap reconstruction.
|Table 2 Age distribution of the lip lesions seen at a tertiary health institution|
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|Figure 1 A male patient with a healed upper lip avulsion secondary to trauma|
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All neoplasms of the lip seen were malignancies, accounting for 22.5% of lip lesions seen in this study because of SCC (n = 17 cases), rhabdomyosarcoma and fibrosarcoma (one case each), and one case of adenoidcystic carcinoma. The lower lip was more involved (n = 14 cases, 70% of malignancies) than the upper lip (n = 2 cases, 10% of malignant lip lesions) or both lips 5% or even unspecified 15%. There were more males than females with malignant lesions overall (ratio was 1.5:1) with the highest occurrence between the 6th and 7th decades. Treatment included excision with immediate reconstruction, excision with delayed reconstruction, shaving down, and chemoradiation.
Vascular lesions caused 15.7% of lip lesions with causes due to hemangioma (13 cases) and one case of lymphangioma. The lower lip again was more involved (n = 8, 57.2%) than the upper lip (n = 6, 42.8%). There were few males than females with vascular lesions on the whole (ratio was 1:2.5) with the highest occurrence between the 1st and 2nd decades. Treatments conducted included sclerotherapy, excision, and reconstruction.
Cancrum oris caused 7.9% of acquired lip lesions with seven cases. Both lips were more involved (n = 3, 42.8%) than either the upper or lower lip (n = 2, 28.6% each). There were fewer males than females on the whole (1:1.3) with the maximum occurrence in the 1st and 2nd decades. Types of lesions based on Montandon classification were type I (n = 3 cases), type II, and type III (n = 2 cases each). None of the patients tested positive to human immunodeficiency virus on enzyme-linked immunosorbent assay (ELISA) screening using the western blot technique. They had low hemoglobin (less than 10 g), and all presented at an active/acute stage. Therefore, treatment was basically debridement and daily dressing. The patients also benefited from the nutritional rehabilitation such as “kwashi pap,” a specially made diet for malnourished patients. By the time many of them were out of the active stage, they requested to go home to source for funds for reconstructive surgery having spent all they had. Most of them never returned except for two of those with type I defects.
Aphthous ulcers caused 9% (n = 8 cases) of the acquired and vascular lip lesions, which were on the lower lip in all cases. Overall, there were more males than females (7:1). The maximum occurrence was in the 3rd to 4th decades. They all presented with pain and ulcer and volunteered going through one stress or the other. The treatment was supportive with tetracycline mouth rinse and topical application of analgesics.
| Discussion|| |
This retrospective study of acquired and vascular lesions of the lip recorded 89 cases between 1.5 and 78 years (mean ± 33.9 years). There were more males than females, and the ratio was 1.54:1, almost no sex predilection, male-to-female ratio was 1.01:1. Higher male predilection could be related to greater exposure in our environment due to cultural/religious factors. They reported an age range of 2 to 96 years (mean = 40.1 years), and a peak incidence in the 5th decade, whereas ours was in the 4th decade. The lower lip was the most affected (n = 57, 64%) followed by the upper lip (n = 20, 22.4%). Upper-to-lower lip ratio was 1:2.85. Ntomouchtsis et al., and Osterne et al. also found that the lower lip is being more affected than the upper lip, with 56.42% and 65.9%, respectively.
Lip lesions due to trauma
Akinbami et al. stated that contact with sharp objects in RTAs and use of such objects in cases of assault contributed to the high incidence of lacerations. Among the cases shown in [Table 1] and [Table 2], trauma accounted for most cases (33.7%) with laceration (16 cases, 51.6%) followed by avulsion (10 cases, 32.6%) and then human (four cases, 12.9%) and animal bites (one case, 3.2%). Fundamental reconstructive principles include three-layered closure for full-thickness lip lacerations. In addition, special care is required to ensure an aesthetic repair of the cosmetically complex and important vermillion border, philtrum, and Cupid’s bow. The keys to proper lip injury management are correct alignment of lip landmarks and a layered, tension-free closure to ideally restore the motor, aesthetic, and sensory functions of the lip. When there is less than 30% of lip involvement, primary closure should be considered, and this should be performed in layers. Central upper lip defect and primary closure may interrupt the normal anatomy. Mobilization of local tissue for closure of wounds that cannot be closed primarily is most appropriate. Larger defects can be repaired using Abbe flap or similar lip-switch procedures or even local advancement flaps. In our cases, we used forehead flap to reconstruct some avulsive injuries, and others were treated using primary closure, debridement with secondary closure, dressing and skin grafting, and forehead flap reconstruction.
Trauma from human [Figure 2] and animal bites accounted for 4.5% and 1.12% of lip lesions, respectively. All bites are (potentially) contaminated with animal bites carrying the risk of rabies infection, through verification of rabies status of the animal, thorough wound exploration, irrigation, and timely closure of the wound. Penetrating wounds should be irrigated to their depths, kept open, and seen frequently to spot infection. All animal bites result in severe but momentary inflammation and subsequently subside. Human bites are more challenging due to the presence of virulent and defiant organisms. Wounds should be meticulously cleansed, then approximated, but not completely closed, if there is any concern over tissue viability. The infectious status of the offender should be ascertained and documented and suitable management should be commenced. Both animal and human bites are usually polymicrobial with both aerobic and anaerobic organisms and also with time of presentation (first 24 h and after 24 h). It is the practice in our center to debride and irrigate the wound thoroughly with saline and close primarily, and then place the patient on prophylactic antibiotics. This is in agreement with the previous literature.
Lip lesions due to neoplasms
SCC of the lip [Figure 3] is the most common malignancy of the lips with 80% in the lower lip. The main cause of SCC of the lip is chronic exposure to ultra violet (UV) light with outdoor activities and skin color. Other important factors are alcohol intake, smoking, human papilloma virus (HPV), and chronic irritation. SCC of the lip can be seen at all ages; people aged 45 years and above are at high risk. It affects males more than females. In our study, SCC cases ranged from 35 to 78 years with a mean of 50.9 years. More males than females (ratio was 1.5:1) were affected, and the lower lip was more affected than the upper (70% versus 10%). The male preponderance was comparable to the literature., Salihu et al. noted that 57% of their patients were outdoor workers. In our study, the majority of our patients were peasant farmers.
|Figure 3 A female patient with SCC of the lower lip and angle of the mouth|
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Fibroma is the most common connective tissue and benign soft tissue neoplasm. It accounted for 9.28% of lip lesions in the study of Ntomouchtsis et al., whereas it represented 1.12% in our study [Table 1]. In the paper from Turkey, fibroma accounted for 5% of lip lesions. Clinically, it appears as an elevated lesion of normal color with a smooth surface and a sessile or pedunculated base. It is slow growing and can occur at any age, although it is more common in 3rd and 4th decades. Conservative excision is the treatment with very little or no recurrence.
Lip lesions from infections/inflammations
Cancrum oris or gangrenous stomatitis initially was very fatal but now has increased survival because of availability of antimicrobial agents. The age ranged between 3 and 56 years with a mean of 20.28 years, with more female (57.2%) than male (42.8%) and both lips more than upper or lower lip. None of our patients tested positive to retroviral screening, but they had low hemoglobin. They all presented at an active/acute stage with abundant salivation, marked fetor oris, and facial edema. Treatment conducted at this center followed the earlier paper by Adekeye and Ord. By the time many of them were out of the active stage, they requested to go home to prepare for reconstructive surgery haven spent all they had. Most of them never returned except for a few who had closure of the defect with release of ankylosis. In their study, Adekeye and Ord recorded the lip involvement as the second highest site (24.29%). In this study, cancrum oris was 7.8% of acquired and vascular lip lesions. In the earlier study from our center, 87% of patients with cancrum oris were in the 1st decade of life. This contrasts with a lower frequency (43%) in the 1st decade and 28.6% in the 2nd decade seen in this study and shown in [Table 1]. The difference could be that patients with the condition are now seeking care later. It could also be to the availability of specialist care, improved understanding of the disease, and availability of antibiotics. The occurrence of this condition could again highlight the prevalent poverty, presence of malnutrition, poor health seeking behavior, and inadequate oral health practices in this part of Nigeria. There is need for continuous advocacy to improve the socioeconomic lot of the masses of Northern Nigeria coupled with increased health education.
Pyogenic granuloma could present as a sessile or pedunculated, elevated hemorrhagic mass with a smooth surface that occurs most frequently on the gingiva but may also be found on the lip., It has a strong tendency to recur after simple excision because the lesion is not encapsulated among lip lesions; Arslan et al. had 5.63% of pyogenic granuloma, whereas this study found 1.12% in [Table 1]. Chronic irritation as a causative factor for these lesions may sometimes be hard to identify, but the fact that they are usually located close to the gingival margin suggests that calculus could be a cause, as it seems to be tissue response to a nonspecific infection. When excising the lesion, care should be taken to scale the adjacent teeth. The age group incidence is not significant nor is there any significant difference between the sexes.
Vascular lip lesions
Vascular lesions encompass a wide range of conditions throughout the body that results in an abnormal number of structures or position of blood vessels. They can be grouped into hemangiomas and vascular malformations. Hemangioma [Figure 4] was the most common lesion in the series of Ntomouchtsis et al. with 19.28%, and in our case, it was 14.6% as in [Table 1]. Hemangioma of the lip is second to that of the tongue. Various methods of treatment have been proposed including cryotherapy, primary surgical resection, laser treatment, and steroids. Excision, although effective, is not widely used because of the complications of scarring and bleeding. Cryotherapy is effective in certain cases but prone to cause unsightly scarring. Our patients were treated using sclerotherapy, excision, and reconstruction.
Autoimmune lip lesions
Recurrent aphthae constitute the most common oral mucosal disease in otherwise normal patients affecting 10% to 25% of the population., In our study, it accounted for 9% of the acquired and vascular lip lesions in [Table 1]. There were more males than females in overall (7:1) unlike the report by Cawson and Odell. They are classified into minor, major, and herpetiform.
The current concept is that RAS is a clinical syndrome with several possible causes. The main contributing factors are genetic predisposition, exaggerated response to trauma, infections, immunological abnormalities, gastrointestinal disorders, hematological deficiencies (serum iron, vitamin B12, or folate), hormonal disturbances, stress, allergy to food, and anxiety., Children with RAS-positive parents have 90% possibility to develop RAS compared to 20% of RAS-negative parents. None of our patients volunteer a history of trauma, nor did investigation reveal any hematological/ immunological abnormality. The majority of them accepted being stressed up by one situation or the other and some degree of anxiety at the time of presentation. Pain was the main complaint of the patients (100%) followed by ulcer (75%). This is in agreement with Greenberg, who also stated that they interfere with feeding and speech.
Cystic lip lesions
Prevalence of mucocoele was 3.37% in this study, whereas it was 7.14% in the study by Ntomouchtsis et al., the most common reactive/inflammatory lesion in Brazil, and most common benign lesion in Turkey. Yamasoba et al. reported that 75% of all oral mucocoele occur in the lower lip. In this study, all the three cases were on the lower lip. They also stated that surgical excision was the treatment of choice and had recurrence in only two cases. They had equal gender distribution. The age range was between 2 and 63 years with the highest occurrence in the 2nd decade. We had more male (66.66%) than female and the age ranged between 11 and 40 years. The other salivary gland tumors have been reported in our previous studies.,
| Conclusion|| |
Acquired and vascular lesions of the lips presented in the form of neoplasm, trauma, inflammation/infection, autoimmune, and even cystic lesions. Acquired lesions were more than vascular lesions and trauma formed the bulk of the cases.
BF and RA collected data, ETA analyzed them, BF, RA, DSA designed the study. All of them read through.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]