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hydatid disease or cyst is a parasitic infection caused by the cestodes of genus , hence also known as echinococcosis .
cattle , pig , sheep , and occasionally humans are the intermediate hosts . hence , sheep and cattle raising regions have the highest incidence of this disease , especially in africa , new zealand , south america , central europe , and the middle east australia . the infestation is by direct contact with dogs commonly and ingestion by food contaminated with dog feces .
hydatid cysts affect humans , and the most frequent localizations are the liver and lungs ( 80% ) .
they have also been reported to occur in the peritoneum ( 20% ) , spleen ( 0.78% ) , kidney ( 7% ) , skin and muscles ( 4% ) , nervous system ( 0.23% ) , bones ( 2% ) , and heart ( 0.22% ) .
it is estimated that about 12% manifest in the head and neck region , involving the parotid and submandibular glands , tongue , maxillary sinus , infratemporal fossa , parapharyngeal space and pterygopalatine fossa as well as the posterior or anterolateral cervical regions have been reported in the literature .
this rare occurrence is even in countries where echinococcus infestation is endemic . in the past , this was an unusual disease but now it is no more considered to be restricted to a defined population in localized geographic regions and is reported to occur anywhere .
the need to be aware of its clinical presentation , diagnosis , and management is all more acute as the clinical features vary according to the location and size of the cysts .
only two cases of hydatid cyst involving buccal mucosa having been reported in the literature .
third case of an asymptomatic hydatid cyst localized in the buccal mucosa of the oral cavity in a 45-year - old male is reported here .
a 45-year - old male reported to the dental college for a regular dental checkup .
an accidental finding of a reddish brown swelling was revealed on clinical examination over the buccal mucosa . on inspection
, it was a well - defined solitary oval shaped swelling with bluish translucency and with no signs of inflammation , discharge or bleeding .
the patient was aware of the lesion but considered it insignificant due to its asymptomatic nature .
it was sessile , soft in consistency , fluctuant , and partially tender on palpation .
the hematoxylin and eosin stained sections revealed a cyst which was trilaminar made up of the outermost adventitial layer / pericyst , the innermost germinal layer / endocyst , and the intermediate avascular eosinophilic refractile chitinous layer / exocyst [ figure 3 ] .
the lumen was basophilic ( necrotic ) showed numerous vesicular projections on its germinal layer [ figure 4 ] .
the vesicles or the brood capsules contained scolices in various stages of maturation and hydatid sand demonstrating hooklets were seen [ figure 5 ] .
however , we could not identify any definitive scolices , and this made us difficult to identify the species .
the patient was then started on albendazole at 15 mg / kg / day for a month .
clinical image shows hydatid cyst of the buccal mucosa simulating a mucocele gross specimen of hydatid cyst histopathological image showing hydatid cyst of the buccal mucosa with capsule and contents ( h and e , 40 ) composite photomicrograph showing ( a ) three layers of the hydatid cyst ( h and e stain , 100 ) , ( b ) avascular eosinophilic refractile chitinous or laminated layer ( h and e , 400 ) and ( c ) germinal layer ( h and e , 100 ) histopathological image showing ( a ) brood capsule formation ( h and e stain , 400 ) , ( b ) hydatid sand demonstrating hooklets ( h and e , 400 ) and ( c ) hydatid cyst after rupture of the luminal contents ( h and e , 40 )
hydatid cysts are characteristically slow growing and asymptomatic benign cystic lesions affecting both men and women in equal proportions .
it is seen that the interval between the initial infection and symptoms clinically are variable and even though humans are affected during childhood , the prevalence is highest in second to fourth decades of life .
the incubation period is highly variable , and their expression of symptoms depends on the location , pressure , and size of the enlarging cyst .
patients usually show generalized urticaria and pruritus , which results from sensitivity caused due to echinococcal antigen from the cyst .
sometimes when there is a rupture of the cyst wall , unexpectedly leads to abscess formation and locally recurrent cysts . in the maxillofacial region , it accounts for only 2% of hydatid infections of the body and these signs and symptoms are not pathognomonic .
however , typically hydatid cyst presents as a solitary , unilocular cyst , and 2030% of cases may have several cysts in one organ or a single cyst in multiple organs .
involvement of the buccal mucosa is rare , and only two other cases have been reported in the literature .
the latter occurred in a 6-year - old male and was asymptomatic with no organ involvement .
the present case involved a daily wage laborer of low socioeconomic status and a history of association with sheep or animals could not be elicited .
is the first to report a hydatid cyst in a solitary organ without the involvement of liver and lungs , even though , the embryos have passed through these organs .
if no primary or hydatid cyst in other sites of the body have been found , the diagnosis of hydatid cyst localized to head and neck is pretty challenging for the clinicians .
it has a definitive host ( e.g. , dog ) which port the adult worms and the intermediate host ( sheep , pig , human etc . )
humans in close contact with dogs and sheep usually acquire this infection by ingesting eggs of e. granulosus through contaminated food .
the eggs hatch in the intestinal mucosa and inhabit for about 520 months , the larvae break through the mucosa and through portal vein they reach the liver and get trapped in the sinusoids . here , they develop into metacestodes or oncospheres and subsequently develop into unilocular cysts , 610 days after ingestion .
liver being the first filter is the most frequently involved organ ( 5570% ) followed by the lung ( 1835% ) . as the larvae reach lungs from the liver , they cause hydatid disease or cyst in any site or multiorgan involvement .
when these larvae escape the liver and lung barrier , it can get localized in any organ .
the larvae form small cysts reaching up to 15 cm in diameter / year . a fibrous capsule ( pericyst ) is formed surrounding these cysts at this stage .
this layer secretes a periodic acid - schiff positive polysaccharide - protein complex which is acellular laminated layer ( exocyst ) which forms the true wall of the cyst that can grow up to 2 mm in thickness and also protects the inner germinal layer ( endocyst ) . to keep the endocyst in close contact with the pericyst , the germinal layer produces clear fluid , also brood capsules which release protoscolices .
the head of the protoscolex evaginates after the ingestion by the primary host , and the larva is then referred to as scolex / scolices .
 as the cyst enlarges , the surface area of the laminated layer also increases and thickens .
these laminations are believed to be laid down to provide accommodation for growth and repair . at any stage of the life cycle of hydatid , the pericyst can get calcified .
daughter cysts are thought to develop from scolices and do not produce pericyst of their own as , usually they are in contact with the host tissue .
ultrastructurally , the cyst consists of an inner layer called as a germinal layer of cells which is supported by a middle layer , an acellular laminated membrane ( cuticular membrane / exocyst ) that are together referred to as endocyst .
the outer layer is a dense fibrous layer that is a reaction of the host to the parasite called as ectocyst ( pericyst ) .
life cycle of hydatid cyst computed tomography scan , ultrasonic scanning , and magnetic resonance imaging detects the cystic lesion in soft tissue areas and daughter cysts precisely .
fine - needle aspiration biopsy may show hooklets , scolices or remnants of the laminated membrane .
serological tests such as elisa , indirect hemagglutination test , latex agglutination , immunoelectrophoresis , and casoni skin tests are more sensitive where in , a decrease in the titer indicates resolution and increase in titer indicates recurrence of echinococcosis .
chemotherapy is usually followed in lesions that are inaccessible for surgery and patients with multiple organ involvement .
scolicidal agents or a combination of praziquantel , albendazole , and mebendazole are used against e. granulosus .
surgical pads soaked with 1.5% cetrimide and 1.5% of chlorhexidine gluconate can also be used .
0.5% silver nitrate and 20% hypertonic saline solutions can be used to prevent possible acute allergic reactions , secondary cyst formation , and also to inactivate the daughter cysts , scolices already present .
spillage of the cystic content , presence of daughter cysts , and leftover endocyst in the operated field are few reasons for the recurrence of the cyst .
hydatid disease or cyst is unusual as its sequelae are more important than the mass effect of the cyst , regardless of the immense size attained by the lesion .
hydatid cyst is a pseudocyst of head and neck region , considered to be very rare in nonendemic areas and the diagnosis of which is usually missed out .
therefore , it should be included in the different diagnosis while interpreting a single slow growing solid mass or cystic mass affecting the oral cavity .
dentists should be suspicious especially in the countries where hydatid disease is endemic , and patients must undergo a thorough systemic investigation to exclude the multiorgan involvement and the possible life - threatening occurrence with a long - term mandatory follow - up .
hydatid cyst is a parasitic cyst caused by the tapeworm echinococcus that occurs primarily in sheep grazing areas worldwide . 
 it is a chronic disease , and the cysts can be localized in unusual anatomical and geographic locations . 
 it is known to affect the head and neck region . 
 patients must undergo a thorough systemic investigation as 2030% show multiorgan involvement . 
 we report a case of hydatid cyst occurring in the buccal mucosa of a 45- year -old male presenting as a small asymptomatic lump and emphasize on its rarity and diagnostic issues .