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Pulse granuloma in the wall of an inflammatory radicular cyst
Pulse granuloma in the wall of an inflammatory radicular cyst JOSE´ GARCI´A POLA, MD, PHD, ALBERTO DE LA CRUZ, MD, PHD, FRANCISCO BUSTILLO, MD, PHD, MERCEDES GALLAS, ´ N, MD, PHD, Oviedo, La Corun˜a, Ferrol, and Santiago de Compostela, Spain JUAN SEOANE LESTO
P ulse granuloma is a rare oral inflammatory lesion histologically characterized by the presence of giant cells, foreign body type, associated with hyaline rings and chronic inflammatory fibrous tissue. The pathogenesis of oral pulse granuloma is very controversial; thus, this condition has received the following designations: hyaline ring granuloma, chronic periostitis, granuloma in edentulous jaws, giant cell hyaline angiopathy, pulse granuloma, food-induced granuloma, and oral-vegetable granuloma.1 Clinically, it appears as a nonspecific mass, with an inflammatory aspect, that is asymptomatic, firm or fluctuating, painful to touch, and located in the oral cavity. The aim of this work was to present a rare and infrequent case of pulse granuloma located in the wall of a radicular cyst that, in our opinion, corroborates the extrinsic origin of the lesion. CASE REPORT Patient Data This case involved a 16-year-old boy with a clinical history of dental trauma in the right maxillary central incisor. This trauma resulted in an oblique crown fracture with pulpar exposure and subsequent root canal therapy. Four years later, he From the Department of Oral Medicine, School of Dentistry, University of Oviedo (Dr Pola), Oncology Regional Center (Dr De La Cruz), Dental Service, Navy Hospital (Dr Bustillo), Department of Comprehensive Dentistry, Faculty of Medicine and Dentistry, School of Dentistry, University of Santiago de Compostela (Dr Gallas), and Department of Oral Surgery, Faculty of Medicine and Dentistry, School of Dentistry, University of Santiago de Compostela (Dr Lesto´n). Reprint requests: Juan Manuel Seoane Lesto´n, MD, PhD, Facultad de Medicina y Odontologı´a, Ru´a Entrerrı´os, S/N, Santiago de Compostela, C.P. 15705, Spain; e-mail, [email protected]. Otolaryngol Head Neck Surg 2003;129:441-2. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/S0194-5998(03)00612-0
DDS, PHD,
and
presented with swelling over the anterior portion of the maxilla, pain, and inflammatory signs. A radiographic examination revealed a well-defined, 1-cm radiolucent lesion on the apex of the right central incisor (1.1). A clinical diagnosis of an apical inflammatory cyst was rendered, and cyst enucleation and apicoectomy were performed. Healing was uneventful, and there was no evidence of recurrence 2 years later. Pathologic Description During the histopathologic examination and through the use of electron microscopy, we observed a thick, cystic wall covered by squamous epithelium with variable areas of acanthosis. The wall is fibrous inflammatory tissue with thick— but not very cellular—fasces of collagens that have a prominent inflammatory infiltrate with a predominance of lymphocytes and plasma cells. In an area of the wall we observed various structures consisting of rings of hyaline material and multinucleated giant cells of the foreign body type. The relationship between these 2 components was variable, with areas in which they appeared closely mixed and other areas in which the giant cells seemed to phagocytose the hyaline material. At the same time, we observed minor vascular lumen lined with endothelium and a very thick, hyalinized wall in these areas (Fig 1). The immunohistochemical stains were negative for antibodies against stroma material and basal membrane (eg, laminin and type IV collagen). This ultrastructural study proves that hyaline structures are bodies of double membrane similar to walls of vegetable cells. DISCUSSION Even though the exact etiopathogenesis of these granulomas remains unknown, there are basically 2 opposing theories. The first researchers proposed that these lesions were extrinsic, resulting from the implantation of foreign material or body (vegetable material, legumes, pulses, therapeutic agents, or others that induced an unusual foreign body 441
Otolaryngology– Head and Neck Surgery October 2003
442 POLA et al
Fig 1. Multiple hyaline ring granulomas composed of eosinophilic, amorphous, dense hyalinized material with epithelioid cells and plasma cells; coarse granular areas of calcification are evident (hematoxylin-eosin stain; original magnification ⫻200). Insert, Complete hyaline ring containing cellular connective tissue and surrounded by multivariate giant cells (hematoxylin-eosin stain; original magnification ⫻100).
reaction).1,2 Experimental studies in animals have demonstrated that the lesions induced after the implantation of homogenized cooked lentils were very similar to the lesion described in human beings.3 The second theory proposed an intrinsic origin and established that the lesions represented a degeneration of collagenous structures, a degenerative change in the walls of blood vessels, extravasated and fibrosed serum proteins, or alterations in the natural process of resolution of periapical lesions.1 The etiologic factors that gave rise to these lesions are not known, but the lesions would appear to be inflammatory in nature and the clinical appearance and histologic features seem to support this theory.4 In light of the histopathologic features, pulse granuloma is basically a classic
foreign body granuloma irrespective of the clinical manifestations present.5 No presentation that could be considered clinically pathognomonic of pulse granuloma was found. Lesions of oral pulse granuloma presented with great clinical variety. Its preferred location was in the edentulous posterior alveolar ridge where tooth extractions had been performed. It appears to be less frequently associated with periapical lesions of teeth that had been subjected to endodontic treatment after a history of prolonged open drainage; in the walls of dentigerous, residual, and nasopalatine cysts; in association with retained tooth roots and impacted lower third molar teeth with a history of pericoronitis; and as a complication of periodontal surgery.1,2 Nevertheless, these lesions must always be viewed as the result of the introduction of foreign material into oral tissues probably through a postextraction socket or other defect, such as an open root canal or periodontal pocket. These mechanisms explain their extrinsic origin. REFERENCES
1. Chou L, Ficarra G, Hansen LS. Hyaline ring granuloma: a distinct oral entity. Oral Surg Oral Med Oral Pathol 1990; 70:318-24. 2. LaMear WR, Estrem SA, Spollen LE. Pulse granuloma presenting as a facial mass. Otolaryngol Head Neck Surg 1994;111:522-3. 3. Talacko AA, Radden BG. The pathogenesis of oral pulse granuloma: an animal model. J Oral Pathol 1988;17:99105. 4. McMillan MD, Kardos TB, Edwards JL, et al. Giant cell hyalin angiopathy or pulse granuloma. Oral Surg Oral Med Oral Pathol 1981;52:178-86. 5. Mincer HH, McCoy JM, Turner JE. Pulse granuloma of the alveolar ridge. Oral Surg Oral Med Oral Pathol 1979; 48:126-30.
P ulse granuloma is a rare oral inflammatory lesion histologically characterized by the presence of giant cells, foreign body type, associated with hyaline rings and chronic inflammatory fibrous tissue. The pathogenesis of oral pulse granuloma is very controversial; thus, this condition has received the following designations: hyaline ring granuloma, chronic periostitis, granuloma in edentulous jaws, giant cell hyaline angiopathy, pulse granuloma, food-induced granuloma, and oral-vegetable granuloma.1 Clinically, it appears as a nonspecific mass, with an inflammatory aspect, that is asymptomatic, firm or fluctuating, painful to touch, and located in the oral cavity. The aim of this work was to present a rare and infrequent case of pulse granuloma located in the wall of a radicular cyst that, in our opinion, corroborates the extrinsic origin of the lesion. CASE REPORT Patient Data This case involved a 16-year-old boy with a clinical history of dental trauma in the right maxillary central incisor. This trauma resulted in an oblique crown fracture with pulpar exposure and subsequent root canal therapy. Four years later, he From the Department of Oral Medicine, School of Dentistry, University of Oviedo (Dr Pola), Oncology Regional Center (Dr De La Cruz), Dental Service, Navy Hospital (Dr Bustillo), Department of Comprehensive Dentistry, Faculty of Medicine and Dentistry, School of Dentistry, University of Santiago de Compostela (Dr Gallas), and Department of Oral Surgery, Faculty of Medicine and Dentistry, School of Dentistry, University of Santiago de Compostela (Dr Lesto´n). Reprint requests: Juan Manuel Seoane Lesto´n, MD, PhD, Facultad de Medicina y Odontologı´a, Ru´a Entrerrı´os, S/N, Santiago de Compostela, C.P. 15705, Spain; e-mail, [email protected]. Otolaryngol Head Neck Surg 2003;129:441-2. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/S0194-5998(03)00612-0
DDS, PHD,
and
presented with swelling over the anterior portion of the maxilla, pain, and inflammatory signs. A radiographic examination revealed a well-defined, 1-cm radiolucent lesion on the apex of the right central incisor (1.1). A clinical diagnosis of an apical inflammatory cyst was rendered, and cyst enucleation and apicoectomy were performed. Healing was uneventful, and there was no evidence of recurrence 2 years later. Pathologic Description During the histopathologic examination and through the use of electron microscopy, we observed a thick, cystic wall covered by squamous epithelium with variable areas of acanthosis. The wall is fibrous inflammatory tissue with thick— but not very cellular—fasces of collagens that have a prominent inflammatory infiltrate with a predominance of lymphocytes and plasma cells. In an area of the wall we observed various structures consisting of rings of hyaline material and multinucleated giant cells of the foreign body type. The relationship between these 2 components was variable, with areas in which they appeared closely mixed and other areas in which the giant cells seemed to phagocytose the hyaline material. At the same time, we observed minor vascular lumen lined with endothelium and a very thick, hyalinized wall in these areas (Fig 1). The immunohistochemical stains were negative for antibodies against stroma material and basal membrane (eg, laminin and type IV collagen). This ultrastructural study proves that hyaline structures are bodies of double membrane similar to walls of vegetable cells. DISCUSSION Even though the exact etiopathogenesis of these granulomas remains unknown, there are basically 2 opposing theories. The first researchers proposed that these lesions were extrinsic, resulting from the implantation of foreign material or body (vegetable material, legumes, pulses, therapeutic agents, or others that induced an unusual foreign body 441
Otolaryngology– Head and Neck Surgery October 2003
442 POLA et al
Fig 1. Multiple hyaline ring granulomas composed of eosinophilic, amorphous, dense hyalinized material with epithelioid cells and plasma cells; coarse granular areas of calcification are evident (hematoxylin-eosin stain; original magnification ⫻200). Insert, Complete hyaline ring containing cellular connective tissue and surrounded by multivariate giant cells (hematoxylin-eosin stain; original magnification ⫻100).
reaction).1,2 Experimental studies in animals have demonstrated that the lesions induced after the implantation of homogenized cooked lentils were very similar to the lesion described in human beings.3 The second theory proposed an intrinsic origin and established that the lesions represented a degeneration of collagenous structures, a degenerative change in the walls of blood vessels, extravasated and fibrosed serum proteins, or alterations in the natural process of resolution of periapical lesions.1 The etiologic factors that gave rise to these lesions are not known, but the lesions would appear to be inflammatory in nature and the clinical appearance and histologic features seem to support this theory.4 In light of the histopathologic features, pulse granuloma is basically a classic
foreign body granuloma irrespective of the clinical manifestations present.5 No presentation that could be considered clinically pathognomonic of pulse granuloma was found. Lesions of oral pulse granuloma presented with great clinical variety. Its preferred location was in the edentulous posterior alveolar ridge where tooth extractions had been performed. It appears to be less frequently associated with periapical lesions of teeth that had been subjected to endodontic treatment after a history of prolonged open drainage; in the walls of dentigerous, residual, and nasopalatine cysts; in association with retained tooth roots and impacted lower third molar teeth with a history of pericoronitis; and as a complication of periodontal surgery.1,2 Nevertheless, these lesions must always be viewed as the result of the introduction of foreign material into oral tissues probably through a postextraction socket or other defect, such as an open root canal or periodontal pocket. These mechanisms explain their extrinsic origin. REFERENCES
1. Chou L, Ficarra G, Hansen LS. Hyaline ring granuloma: a distinct oral entity. Oral Surg Oral Med Oral Pathol 1990; 70:318-24. 2. LaMear WR, Estrem SA, Spollen LE. Pulse granuloma presenting as a facial mass. Otolaryngol Head Neck Surg 1994;111:522-3. 3. Talacko AA, Radden BG. The pathogenesis of oral pulse granuloma: an animal model. J Oral Pathol 1988;17:99105. 4. McMillan MD, Kardos TB, Edwards JL, et al. Giant cell hyalin angiopathy or pulse granuloma. Oral Surg Oral Med Oral Pathol 1981;52:178-86. 5. Mincer HH, McCoy JM, Turner JE. Pulse granuloma of the alveolar ridge. Oral Surg Oral Med Oral Pathol 1979; 48:126-30.