The patient also complained about shortness of breath and tiredness, while her face was pale and her legs were swollen.
Q1What is the cause of her lip discoloration?
1 Hemangioma
2 Heart failure induced
3 Blue nevus
4 Hematoma
5 Melanoma
Answers:
1 No
2 Congestive heart failure is the cause of the bluish color of her lips (cyanosis), skin and other mucosae and appears when the level of deoxygenated hemoglobin level is above of 5 g/dl. Cyanosis is more obvious in an acute crisis of asthma.
3 No
4 No
5 No
Comments: In heart failure, the cyanosis is mixed (central and peripheral) and differs clinically from similar lesions such as hemangiomas, blue nevus, melanoma, or even hematomas. The stable blue color on the patient's lips regardless of its duration or absence of bleaching changes seen with local pressure exclude hematoma, hemangiomas, and blue nevus respectively. The fact, that her blue discoloration was diffuse, without over‐growths or satellite lesions or color variations equally found on both lips, rules out melanoma from diagnosis.
Q2 Cyanosis is more obvious in patients with:
1 Dark complexion
2 Vitamin C deficiencies
3 Anemia
4 Post‐inflammatory pigmentation
5 Bullous disorders
Answers:
1 No
2 Vitamin C deficiency causes scurvy, a condition that leads to abnormally pale skin and therefore the cyanosis is more obvious.
3 Anemia is characterized by cyanosis when the oxygen saturation falls below hemoglobin levels. Cyanosis appears when the oxygen saturation in patients without anemia drops to <80–85 per cent and even lower than 60 per cent in patients with severe anemia (Hb < 6 g/dl).
4 No
5 No
Comments: The blue color is the result of deoxyhemoglobin's optical properties and especially its porphyrin rings; therefore it is more difficult to be seen in patients with dark skin due to racial or post‐inflammatory pigmentation.
Q3 The differences between peripheral and central cyanosis are based on:
1 Location of cyanosis
2 Degree of cyanosis
3 Temperature of affected parts
4 Response to oxygen
5 Duration of cyanosis
Answers:
1 In central cyanosis the discoloration is generalized and affects the skin, oral and other mucosae while the peripheral cyanosis is localized only on the skin.
2 No
3 The limb temperature is unaffected in central, but is lower in peripheral cyanosis.
4 The application of pure oxygen improves the central but not peripheral cyanosis.
5 No
Comments: The duration of cyanosis reflects on the severity rather than the type of cyanosis. Cyanosis of a few seconds seems benign, while a prolonged or unresolved cyanosis may raise concerns of serious complications such as seen in heart, lungs, or brain.
Case 2.7
CO: A healthy young man of 18 years of age presented to the Emergency Dental Clinic for a bluish swelling on his lower lip.
HPC: The lesion appeared, one week ago, following a facial injury during a basketball game as a small, asymptomatic soft lump. The lesion has become bigger over the last three days when the patient bit accidentally his lip during eating again.
PMH: He has no serious medical problems apart from an atopic dermatitis, since the age of six, which was treated with topical glucocorticoid cream. Being a basketball player, his regular blood check‐up did not reveal any bleeding conditions, while his habits do not include smoking or drinking.
OE: A large soft swelling of the inner surface of the lower lip. The swelling was painless and fluctuant with bluish color and with a size of 2 cm maximum in diameter and a superficial ulcer on top (Figure 2.7). It was associated with swollen minor salivary glands and topical ecchymosis due to previous trauma. No bruises or ecchymoses in other parts of his mouth and skin were found.
Q1 What is his most likely diagnosis?
1 Hemangioma
2 Mucocele
3 Hematoma
4 Fibroma (traumatic)
5 Lip abscess
Answers:
1 No
2 Mucocele is a common soft, cystic‐like swelling seen on both lips but mainly in the lower caused by an extravagation of saliva into the submucosa due to the damage of minor salivary glands after a local injury. A repeated trauma increases mucocele size and changes its color from translucent to bluish, due to the accumulation of blood within the saliva and hematoma formation at the base of lesion as is exactly seen in this patient.
3 No
4 No
5 No
Comments: In contrast to the mucocele, hemangioma appears very early in the patient's lifewhile the hematoma is a blue discoloration which faints over the time; Fibroma is a soft but not fluctuated lesion; while abscess is a fluctuated, inflamed swelling containing pus and therefore its color ranges from red to yellow but rarely blue.
Q2 Which is/are the histological difference(s) between a mucous extravasation and retention mucocele?
1 Inflammation (type/density)
2 Epithelial
