A Sizeable Solitary Pedunculated Peripheral Osteoma of the Hard Palate: A Case Report

Abstract

Osteomas are benign, slow growing, usually sessile osteogenic tumors of unknown etiology. They arise from proliferation of either cancellous or compact bone. They can be central, peripheral or extra-skeletal based on their origin from endosteum, periosteum or extra-skeletal soft tissue respectively. They are commonly found in the skull and facial bones, the most common site in the maxillofacial region being paranasal sinuses. Among the jaw bones the most common site is the mandible. The hard palate is a rare site for such osteomas with a very few cases reported in literature. We report a case of large pedunculated peripheral osteoma of the hard palate in a 38 year old male. The tumor was excised with no recurrence after 3 years followup.

Introduction

Osteomas are benign, osteogenic, slow growing tumors that are composed of compact or cancellous bone. They are bosselated, round to oval sessile tumors. The exact etiology of these tumors is still unknown, though developmental, traumatic, infectious and neoplastic theories have been proposed [1, 2]. They can be solitary or multiple. Multiple osteomas are associated with Gardner’s syndrome. The solitary variety can be of central type arising from the endosteum, peripheral type arising from the periosteum or extra-skeletal soft tissue type arising from within a muscle [3, 4]. The most common site in the maxillofacial region are the paranasal sinuses and the mandible [5, 6]. Osteomas involving the hard palate are very rare [7, 8]. They are often asymptomatic but can occasionally present with facial disfigurement or functional impairment. Treatment is by complete surgical resection and recurrence is rare.

Case Report

A 38 years male patient presented to our OPD with complaints of swelling in the region of palate since 6 months which was insidious in onset and gradually progressive in size. He complained of foreign body sensation, difficulty in chewing and difficulty in articulation of certain words. There was no history of pain over the swelling. There was no history of trauma. No history of comorbidities. On clinical examination there was a huge swelling overlying the entire hard palate almost mimicking the hard palate on first look. The swelling was approximately 5 * 4 cm, margins well defined, surface was smooth and mucosa overlying the swelling was normal except for mild discolouration. On palpation there was no tenderness, the swelling was hard in consistency, immobile and there was no demarcation made out between the swelling and the adjoining mucosa of alveolus (Fig. 1). There were no other swellings elsewhere in the body. CECT was done which showed a homogenous, pedunculated, radio-opaque mass of 5 * 4 * 2 cm with only a small attachment to the palate on the right side (Fig. 1). Dental opinion was sought and they opined that tooth vitality is maintained.

Fig. 1.

Upper left—Clinical picture, Upper right—CT axial section, Lower left—Intraoperative showing the site of attachment, Lower right—Post excision defect sutured

Based on clinical and radiological examination a diagnosis of pedunculated osteoma arising from the hard palate was made and excision biopsy was planned under general anesthesia. Intraoperatively a plane was identified between the swelling and the palate all around except at the right border which was released using chisel and mallet (Fig. 1) and the mass was excised in total (Fig. 2). The mucosal defect was closed with 3-0 vicryl. The postoperative period was uneventful and the wound healed completely. Histopathological examination showed the lesion composed of bony lamella with osteocytes and intervening fibro-fat and calcification. No cellular atypia was seen (Fig. 2). Three years follow up showed no recurrence of the lesion.

Fig. 2.

Upper—Gross specimen, Lower—Histopathology

Discussion

Osteomas can occur in any age group. A mean age group of 40.5 years by Woldenberg et al. [4]. There is no specific gender predilection though various studies show mixed results [3]. In our case the patient was a 38 year, male. Peripheral osteomas of craniofacial region occur more commonly in the paranasal sinuses. Among the jaw bones mandible is the commonest site followed by maxilla. The hard palate is a rare site with a very few cases reported in literature. There are 20 cases of maxillary osteoma excluding that in the maxillary sinus reported in literature of which seven cases were found in the hard palate [8]. Our case was a hard palate osteoma of 5 * 4 * 2 cm which is a huge tumor for that site reported in literature till date. Radiographically the presence of an oval, radio-opaque, well circumscribed mass attached by a broad base or pedicle to the affected cortical bone is the hallmark of peripheral osteomas [8]. The closest differential diagnosis is exostoses, however they do not grow beyond puberty. The absence of lesions elsewhere ruled out Gardner’s syndrome. Asymptomatic osteomas are usually managed conservatively. In symptomatic cases complete surgical excision is the mainstay of treatment [9].

Conclusion

Osteomas of maxillofacial region are predominantly of the sinuses and mandible. Maxillary osteomas confined to hard palate and of such large sizes are rare with very few cases reported. These are well circumscribed lesions and complete surgical excision is the treatment of choice for symptomatic cases. There are hardly any recurrences following complete excision of lesion.

Compliance with Ethical Standards

Conflict of interest

All authors involved have no conflict of interest.

Ethical Approval

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from the participant included in the study.