Loading

Osteoblastoma of the Jaw: Juggling Jepardy!

Case Report | Open Access | Volume 9 | Issue 6

  • 1. Oral and Maxillofacial Surgery, Karpaga Vinayaga Institute of Medical and Dental Sciences, India
  • 2. Head and Neck Oncological Services, Karpaga Vinayaga Institute of Medical and Dental Sciences, India
+ Show More - Show Less
Corresponding Authors
Yash Merchant, Oral and Maxillofacial Surgery, Karpaga Vinayaga Institute of Medical and Dental Sciences, Chennai, Tamil Nadu, 402, The Great Eastern Retreat, Lakaki Road, Model Colony, Pune 411016, India, Tel: 91-9881075160
ABSTRACT

Clinical facts along with radiological and histological findings are imperative to appropriately diagnose lesions of the jaws. Osteoblastoma is an uncommon, benign, primary lesion of the bone that rarely occurs in the
jaw. It presents in the body/ramal region of the posterior mandible and mimics several other swellings which may present at this site. Clinico-pathologically and radiographically there are several lesions that present
with almost similar features. The authors present one such case of a large osteoblastoma in an elderly female stressing the importance of correctly diagnosing these lesions.

KEYWORDS

Osteoblastoma, Diagnostic dilemma, Benign jaw pathology, Bone pathology/swelling

CITATION

Merchant Y, Mohan AM, Balaguhan B, Karthikeyan G (2022) Osteoblastoma of the Jaw: Juggling Jepardy! Ann Otolaryngol Rhinol 9(6): 1304.

INTRODUCTION

Osteoblastoma is a relatively uncommon benign lesion of the bone that accounts for less than 1% of all bone tumors [1]. It commonly involves the spine and sacrum of younger individuals with less than 10% localised to skull [2]. This primary lesion of the bone occurs in young adults with a male predilection (2:1) [1]. In 1956, the lesion was definitely separated from osteoid osteoma and recognised as a separate entity by Jaffe and Lichtenstein under the name ‘benign osteoblastoma’ and subsequently this has been adopted by the World Health Organisation Classification of Bone Tumours [3]. Osteoblastoma of the jaws was first reported in English literature by Borello and Sedano in 1967 [4]. Clinically, the lesion often presents with a bony hard swelling with an obvious facial asymmetry in long-standing lesions. Patients may or may not be symptomatic with pain or discomfort [1]. Radiological evaluation reflects variable features usually exhibiting mixed radiolucency/radio-opacity with relatively defined borders. Reactive sclerosis surrounding the lesion is not generally present. Some lesions present a calcified plaque within the radiolucent area, and some may display considerable calcification [3]. Clinical case capsule, detailed relevant history and radiological findings must be assessed in tandem to appropriately diagnose lesions of the jaws. The authors present a large long-standing asymptomatic osteoblastoma in an elderly female patient that was excised in toto.

CASE PRESENTATION

A 62-year-old female reported to the Out-patient Department of our institute with the chief complaint of a bony hard swelling over the left pre-auricular region extending beyond the left angle of the mandible. She reported mild discomfort over the left side of the face and facial asymmetry since the last 1 year. She did not complain of any accompanying pain. On inspection extra-orally, the swelling measured approximately 6 x 4 x 2 cm and extended from the tragus of the left ear to 1cm below albeit in continuity with the left angle of the mandible. Anteroposteriorly it extended from the left buccal region of the face to the skin below and behind the pinna of the left ear. The ear lobe was slightly elevated. The skin over the lesion appeared intact and normal in texture and pigmentation. On palpation, the swelling was bony hard in consistency, immobile and non-tender. The temperature of the overlying skin was normal. No palpable cervical lymphadenopathy was noted. Intra-orally, there were no anomalies/swelling and the buccal mucosa appeared normal. Mouth opening was within normal limits. On palpation the mucosa was pliable with no fibrosis and all findings of inspection were confirmed. A contrast-enhanced CT was advised which revealed a large well-defined high density (HU~1400) bony lesion with a lobulated outline arising from the left ramus and projecting into the masticator and para pharyngeal space. Lesion appeared to be displacing the left Internal Carotid Artery medially and extending up to the styloid posteriorly. Laterally the lesion seemed to be abutting the parotid. Trachea, thyroid and cricoid cartilage appeared normal.

CT scan depicting 3d reconstruction, axial, sagittal and coronal view.

Figure 1: CT scan depicting 3d reconstruction, axial, sagittal and coronal view.

(Figure 1) Left posterior segmental resection of the mandible with disarticulation was planned under General Anaesthesia after routine investigations and anaesthetic fitness. All routine investigations were within normal limits. A modified median lip split incision was made after infiltration with lidocaine and adrenaline (1:2,00,000). The incision was extended along the cervical crease (apron extension) for access (Figure 2a).

a: Incision marking b: Intra-operative view of lesion after reflection of flap c: Intra-operative view of defect post excision d: Flap sutured back in place

Figure 2 a: Incision markingb: Intra-operative view of lesion after reflection of flapc: Intra-operative view of defect post excisiond: Flap sutured back in place

Flap was reflected and the left hemi-mandible was exposed (Figure 2b).Mandible was resected posterior to the last molar under copious irrigation. The lesion was excised in toto. The internal maxillary artery was severed during the procedure and subsequently ligated. Wound was closed in layers with 3-0 polyglactin 910 and 4-0 polyamide after achieving haemostasis. (Figure 3c&d) Sutures were removed on the 7th post-operative day and healing was uneventful. Histopathological examination revealed irregular woven bone like tissue within areas of hypercellular and loose fibrovascular connective tissue stroma Woven bone showed large osteocytes within, along with plump osteoblastic rimming in some sections (Figure 3).

H&E light microscopy.

Figure 3: H&E light microscopy.

(Figure 4).

Post OP.

Figure 4: Post OP.

DISCUSSION

Although it is unequivocally agreed that the osteoblastoma is a benign lesion, the true nature of the lesion and the underlying pathophysiology remain an enigma. Some authors regard this entity as an abnormal local response of the tissues to injury or a localised alteration in bone physiology. Osteoblastomas may be classified into cortical, medullary and periosteal types. Osteoblastomas of jaws are either medullary or periosteal and not cortical which are common in extra-gnathic sites [5]. Differential diagnosis’ ranges from cementoblastoma, osteoid osteoma, fibrous dysplasia, ossifying fibroma, focal cementoosseous dysplasia to low grade osteosarcoma. Microscopically and radiographically benign cementoblastoma mimics osteoblastoma.

The feature to differentiate it from osteoblastoma is the merging of the lesion and the radicular surface of the tooth. Osteoid osteoma and osteoblastoma are similar on histopathological examination. However a discerning pathologist would note that the bony trabeculae of osteoblastoma are slightly wider than those of osteoid osteoma and there is less irregularity in their arrangement; the number of osteoblasts is much greater in osteoblastoma but osteoid osteoma lacks giant cells and is not as well vascularized. The most prominent clinical symptom of osteoid osteoma is frequent and severe night pain that responds to nonsteroidal anti-inflammatory drugs (NSAID). Clinically, osteoblastoma may be asymptomatic or present with pain which is refractory to NSAID. It presents with neurological pain if the surrounding neurovascular structure is compressed. Osteoblastoma by definition exceed 1 cm in its greatest diameter and is not associated with characteristic oval radiolucency (nidus) with surrounding sclerosis bon sclerosis typical of osteoid osteoma [6]. Osteoid osteoma and osteoblastoma are bone-forming tumors shown to harbour
FOS (87%) and FOSB (3%). FOS immunohistochemistry and / or FISH can be used as an auxiliary tool for osteoid osteoma and osteoblastoma in short decalcified tissue where distinction is difficult fromt their histological mimics since there are no specific antibodies or molecular tests for osteosarcoma. [7,8] However, FOS immunohistochemistry should not be used after long decalcification, and the low-level focal expression found in other lesions and tissues, especially reactive bone, might be confusing. Under these circumstances, the use of FISH for FOS could be diagnostically useful, for cases where it is difficult
to distinguish osteoid osteoma and osteoblastoma from their histologic mimics [7]. Ossifying fibroma and fibrous dysplasia of bone may share many similarities with osteoblastoma but are less mineralised lesions, revealing fine calcifications rather than large clusters of mineralised material. Fibrous Dysplasia is not circumscribed radiologically and is usually multi-focal [1]. Focal cemento-osseous dysplasia (COD) does not typically expand the cortex and microscopically does not depict large numbers of plump, actively proliferating osteoblasts. COD consists of easily fragmented and gritty tissue that can be curetted easily but does not separate cleanly from the adjacent normal bone. In contrast, ossifying fibromas tend to separate easily from the bone [9]. Histopathological examination is the crux to differentiate osteoblastomas from low grade osteosarcomas. Under light microscopy, osteosarcoma is marked by the lack of tumour maturation at the margins, with permeation of tumour into adjacent tissues, in contrast to osteoblastoma which depicts
maturation at the margins and lack of permeation into adjacent bone. In summary, conservative but comprehensive surgical excision of the lesion is the definitive treatment. Recurrence is a rare event (13.6%) and is almost always attributed to incomplete excision. No adjuvant therapy is necessary post excision. It is clear that this benign lesion is unpredictable with behaviour varying from case to case and apparently no special histological features exist that provide clues to the biological behaviour of this neoplasm. Appropriate diagnosis is arrived at in consultation with a radiologist, submission of representative sections to the
histo-pathologist and astute clinical examination.

REFERENCES

1. Huvos AG. Bone tumors - diagnosis, treatment and prognosis. Philadelphia, Pa: WB. Saunders Co. 1979.
2. Mirra JM, Picci P, Gold RH. Bone tumors. Clinical, radiologic and pathologic correlations. Philadelphia: Lea and Febiger; 1989; 389–430.
3. Capelozza ALA, Dezotti MSG, Alvares LC, Fleury RN, Sant’Ana E. Osteoblastoma of the mandible: Systematic review of the literature and report of a case. Dentomaxillofac Radiol. 2005; 34: 1–8.
4. Borello ED, Sedano HO. Giant osteoid osteoma of the maxilla. Oral Surg Oral Med Oral Pathol. 1967; 23: 563–6.
5. Farman AG, Nortje CJ, Grotepass F. Periosteal benign osteoblastoma of the mandible: report of a case and review of the literature pertaining to benign osteoblastic neoplasam of the jaws. Br JOral Surg. 1976; 14: 12-22.
6. Natasja Franceschini, Suk Wai Lam, Anne-Marie Cleton-Jansen, Judith V M G Bovée. What’s new in bone-forming tumours of the skeleton?. Virchows Arch. 2020; 476: 147–157.
7. Lam SW, Cleven AHG, Kroon HM, Briaire-de Bruijn IH, Szuhai K, Bovée JVMG. Utility of FOS as diagnostic marker for osteoid osteoma and osteoblastoma. Virchows Arch. 2020; 476: 455-463.
8. Baumhoer D, Amary F, Flanagan AM. An update of molecular pathology of bone tumors. Lessons learned from investigating samples by next generation sequencing. Genes Chromosomes Cancer. 2018; 1–12.
9. Salvi AS, Patankar S, Desai K, Wankhedkar D. Focal cemento-osseous dysplasia: A case report with a review of literature. J Oral Maxillofac Pathol. 2020; 24: S15-S18.

Merchant Y, Mohan AM, Balaguhan B, Karthikeyan G (2022) Osteoblastoma of the Jaw: Juggling Jepardy! Ann Otolaryngol Rhinol 9(6): 1304.

Received : 17 Nov 2022
Accepted : 29 Nov 2022
Published : 29 Nov 2022
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X