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Pyogenic granuloma (lobular capillary hemangioma) of the tongue
International Journal of Pediatric Otorhinolaryngology 58 (2001) 239– 241 www.elsevier.com/locate/ijporl
Case report
Pyogenic granuloma (lobular capillary hemangioma) of the tongue M. Umut Akyol a,*, Elif Gu¨lin Yalc¸iner a, A. Is¸in Dog˘an b a
Department of Otorhinolaryngology, Hacettepe Uni6ersity School of Medicine, Ankara, Turkey b Department of Pathology, Hacettepe Uni6ersity School of Medicine, Ankara, Turkey
Received 28 September 2000; received in revised form 12 January 2001; accepted 13 January 2001
Abstract A patient with a pyogenic granuloma which occurred in an unusual location and at an earlier age is presented. Pyogenic granuloma is not an uncommon entity which may occur on oral mucosa, face and fingers. The most frequent location encountered for oral cavity pyogenic granuloma is the gingiva and the tongue is a rare location for its occurrence. These lesions are usually seen between 11 and 40 years age. Surgical excision and removal of etiological factors are needed for treatment. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Pyogenic granuloma; Lobular capillary hemangioma; Tongue; Infant
1. Introduction Pyogenic granuloma of the oral cavity is a relatively common entity first described by Poncet and Dor in 1897 as ‘human botryomycosis’ [1]. Then, Hartzell [2] introduced the term ‘pyogenic granuloma’ and some authors use the term ‘lobular capillary hemangioma’[3]. Clinically they usu-
* Corresponding author. Present address: Iran cad 47/10, Gaziosmonpasa, Ankara 06700 Turkey. Tel.: + 90-3124276246; fax: + 90-312-3113500. E-mail address: [email protected] (M.U. Akyol).
ally present as red, soft and single nodules and may be seen in any size from a few millimeters to several centimeters. A review of 835 cases in the literature showed that the prevalent age for the development of pyogenic granuloma appears to lie between 11 and 40 years (60%) although all age groups may be affected [4]. In the literature, the earliest age reported was 1.5 years [5]. They are mostly seen on oral mucosa, the face and fingers. Oral pyogenic granulomas are usually seen on the gingiva (almost 75%) [5–7] and less frequently at other sites like the tongue. Our case is the youngest case with an unusual location and presentation that has been reported.
0165-5876/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 0 1 ) 0 0 4 2 5 - 6
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M.U. Akyol et al. / Int. J. Pediatr. Otorhinolaryngol. 58 (2001) 239–241
2. Case report A 4-month old male infant was referred to the ENT Department for evaluation and treatment of a mass on his tongue. His mother stated that the lesion appeared when he was 45 days old as a yellowish discoloration on his tongue, and had grown slowly. Examination revealed a soft, solitary, lobular and broad based mass with whitepinkish color including yellowish areas on the middle 1/3 of the dorsal side of the tongue. The lesion was non-tender and approximately 0.8 cm in diameter and 1 cm in height and was covered with normal mucosa (Fig. 1). The patient was operated on under general anesthesia and the lesion was easily and completely dissected from the underlying muscular layer. After
Fig. 2. Lobulated proliferation of widely dilated capillaries with intervening fibrous septa within a collagen rich matrix beneath an intact mucosal layer (H&E, 25 ×).
Fig. 1. A pale white, yellow and pinkish, soft, lobular, broad based, non-tender mass approximately 1 cm in diameter on the middle 1/3 of the dorsal side of the tongue which was covered with normal mucosa
excision the wound was closed with primary sutures. The functions of the tongue remained normal after operation. The postoperative course was uneventful. On pathological examination, it was found to be a fragment of grayish-brown nodular mass measured 1×0.8× 0.8 cm. When sectioned, the cut surface was brown in color and spongy. On histological examination, closely packed blood vessels of capillary size with open lumens were detected within a collogen rich matrix beneath an intact mucosal layer. The lumens of these capillaries contained erythrocytes and were lined with endothelial cells and pericytes in peripheral areas. Capillary lumens were widely dilated. Lobulated proliferation of capillaries with intervening fibrous septa was the basic histological pattern of this lesion. These fibrous septi and matrix were found to be collagen rich when stained with Masson’s trichrom stain (Fig. 2).
M.U. Akyol et al. / Int. J. Pediatr. Otorhinolaryngol. 58 (2001) 239–241
3. Discussion Pyogenic granuloma accounts for approximately 1.5– 2% of all biopsies from the oral cavity. Being the most common site of oral pyogenic granuloma, gingival lesions are suggested to be due to calculus or foreign material within the gingival sulcus. Pyogenic granulomas are uncommonly seen elsewhere in the mouth but may appear in areas of frequent trauma such as the lower lip, the buccal mucosa and the tongue [8]. The floor of the mouth has not been reported as a site of this tumor in the literature. The reason is suggested to be due to the protection of this region from traumatic injuries by the tongue and the absence of a sufficient amount of connective tissue in the mucosa of floor of the mouth. The surface of the tumor frequently ulcerate in areas subjected to trauma and occasional bleeding may occur especially during mastication [4]. In the pediatric age group this tumor occurs most frequently in early childhood, rarely in adolescents and affects males more than females [9]. The consistency of the tumor gets firmer both with aging of the lesion and removal of its etiological factors [4]. The pathogenesis of the pyogenic granuloma is unclear. Etiologically many factors such as trauma, infection, and hormonal influences have been frequently suggested. The hormonal influence is suggested on the basis of the observation that a pregnancy tumor, which is also called granuloma gravidarum, occurs in the gingiva of pregnant women with the same microscopic appearance [5]. Hormonal changes of puberty and pregnancy may modify the gingival repairative
.
241
response to injury. In this case there is no trauma history. Can the maternal hormones explain the occurrence of this lesion in a 45 days old baby? A higher apoptotic activity was found in infantile capillary hemangiomas than in pyogenic granulomas, therefore, some authors suggest that apoptosis might be a cause of spontaneous involution in infantile capillary hemangiomas. Since the pyogenic granulomas do not spontaneously involute, they should be surgically excised [3]. Recurrence is rare in non-pregnant individuals [6] and is believed to be due to incomplete excision, or failure to remove etiologic factors or reinjury to the area [6]. References [1] A. Poncet, L. Dor, Botryomycose humaine, Rev. Chir. (Paris) 18 (1897) 996. [2] M.B. Hartzell, Granuloma pyogenicum (botryomycosis of French authors), J. Cutan. Dis. 22 (1904) 520 – 523. [3] J. Iwata, H. Sonobe, M. Furihata, E. Ido, Y. Ohtsuki, High frequency of apoptosis in infantile capillary haemangioma, J. Pathol. 179 (1996) 403 – 408. [4] A.P. Angelopoulos, Pyogenic granuloma of the oral cavity: statistical analysis of its clinical features, J. Oral Surg. 29 (1971) 840 – 847. [5] S.N. Bhaskar, J.R. Jacoway, Pyogenic granuloma-clinical features, incidence, histology, and result of treatment: report of 242 cases, J. Oral Surg. 24 (1966) 391 – 398. [6] E.J. Butler, D.R. Macintyre, Oral pyogenic granulomas, Dent. Update 19 (1991) 194 – 195. [7] K. Goette, W.M. Carpenter, Pyogenic granuloma of the oral cavity, South. Med. J. 70(11) (1977) 1358 – 1360. [8] G.H. Zalzal, K. Patterson, R.T. Cotton, Cogenital tumors of the dorsum of the tongue, Int. J. Pediatr. Otorhinolaryngol. 28 (1994) 219 – 227. [9] S.J. Patrice, K. Wiss, J.B. Mulliken, Pyogenic granuloma (lobular capillary hemangioma):a clinicopathological study of 178 cases, Pediatr. Dermatol. 8 (1991) 267 – 276.
Case report
Pyogenic granuloma (lobular capillary hemangioma) of the tongue M. Umut Akyol a,*, Elif Gu¨lin Yalc¸iner a, A. Is¸in Dog˘an b a
Department of Otorhinolaryngology, Hacettepe Uni6ersity School of Medicine, Ankara, Turkey b Department of Pathology, Hacettepe Uni6ersity School of Medicine, Ankara, Turkey
Received 28 September 2000; received in revised form 12 January 2001; accepted 13 January 2001
Abstract A patient with a pyogenic granuloma which occurred in an unusual location and at an earlier age is presented. Pyogenic granuloma is not an uncommon entity which may occur on oral mucosa, face and fingers. The most frequent location encountered for oral cavity pyogenic granuloma is the gingiva and the tongue is a rare location for its occurrence. These lesions are usually seen between 11 and 40 years age. Surgical excision and removal of etiological factors are needed for treatment. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Pyogenic granuloma; Lobular capillary hemangioma; Tongue; Infant
1. Introduction Pyogenic granuloma of the oral cavity is a relatively common entity first described by Poncet and Dor in 1897 as ‘human botryomycosis’ [1]. Then, Hartzell [2] introduced the term ‘pyogenic granuloma’ and some authors use the term ‘lobular capillary hemangioma’[3]. Clinically they usu-
* Corresponding author. Present address: Iran cad 47/10, Gaziosmonpasa, Ankara 06700 Turkey. Tel.: + 90-3124276246; fax: + 90-312-3113500. E-mail address: [email protected] (M.U. Akyol).
ally present as red, soft and single nodules and may be seen in any size from a few millimeters to several centimeters. A review of 835 cases in the literature showed that the prevalent age for the development of pyogenic granuloma appears to lie between 11 and 40 years (60%) although all age groups may be affected [4]. In the literature, the earliest age reported was 1.5 years [5]. They are mostly seen on oral mucosa, the face and fingers. Oral pyogenic granulomas are usually seen on the gingiva (almost 75%) [5–7] and less frequently at other sites like the tongue. Our case is the youngest case with an unusual location and presentation that has been reported.
0165-5876/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 0 1 ) 0 0 4 2 5 - 6
240
M.U. Akyol et al. / Int. J. Pediatr. Otorhinolaryngol. 58 (2001) 239–241
2. Case report A 4-month old male infant was referred to the ENT Department for evaluation and treatment of a mass on his tongue. His mother stated that the lesion appeared when he was 45 days old as a yellowish discoloration on his tongue, and had grown slowly. Examination revealed a soft, solitary, lobular and broad based mass with whitepinkish color including yellowish areas on the middle 1/3 of the dorsal side of the tongue. The lesion was non-tender and approximately 0.8 cm in diameter and 1 cm in height and was covered with normal mucosa (Fig. 1). The patient was operated on under general anesthesia and the lesion was easily and completely dissected from the underlying muscular layer. After
Fig. 2. Lobulated proliferation of widely dilated capillaries with intervening fibrous septa within a collagen rich matrix beneath an intact mucosal layer (H&E, 25 ×).
Fig. 1. A pale white, yellow and pinkish, soft, lobular, broad based, non-tender mass approximately 1 cm in diameter on the middle 1/3 of the dorsal side of the tongue which was covered with normal mucosa
excision the wound was closed with primary sutures. The functions of the tongue remained normal after operation. The postoperative course was uneventful. On pathological examination, it was found to be a fragment of grayish-brown nodular mass measured 1×0.8× 0.8 cm. When sectioned, the cut surface was brown in color and spongy. On histological examination, closely packed blood vessels of capillary size with open lumens were detected within a collogen rich matrix beneath an intact mucosal layer. The lumens of these capillaries contained erythrocytes and were lined with endothelial cells and pericytes in peripheral areas. Capillary lumens were widely dilated. Lobulated proliferation of capillaries with intervening fibrous septa was the basic histological pattern of this lesion. These fibrous septi and matrix were found to be collagen rich when stained with Masson’s trichrom stain (Fig. 2).
M.U. Akyol et al. / Int. J. Pediatr. Otorhinolaryngol. 58 (2001) 239–241
3. Discussion Pyogenic granuloma accounts for approximately 1.5– 2% of all biopsies from the oral cavity. Being the most common site of oral pyogenic granuloma, gingival lesions are suggested to be due to calculus or foreign material within the gingival sulcus. Pyogenic granulomas are uncommonly seen elsewhere in the mouth but may appear in areas of frequent trauma such as the lower lip, the buccal mucosa and the tongue [8]. The floor of the mouth has not been reported as a site of this tumor in the literature. The reason is suggested to be due to the protection of this region from traumatic injuries by the tongue and the absence of a sufficient amount of connective tissue in the mucosa of floor of the mouth. The surface of the tumor frequently ulcerate in areas subjected to trauma and occasional bleeding may occur especially during mastication [4]. In the pediatric age group this tumor occurs most frequently in early childhood, rarely in adolescents and affects males more than females [9]. The consistency of the tumor gets firmer both with aging of the lesion and removal of its etiological factors [4]. The pathogenesis of the pyogenic granuloma is unclear. Etiologically many factors such as trauma, infection, and hormonal influences have been frequently suggested. The hormonal influence is suggested on the basis of the observation that a pregnancy tumor, which is also called granuloma gravidarum, occurs in the gingiva of pregnant women with the same microscopic appearance [5]. Hormonal changes of puberty and pregnancy may modify the gingival repairative
.
241
response to injury. In this case there is no trauma history. Can the maternal hormones explain the occurrence of this lesion in a 45 days old baby? A higher apoptotic activity was found in infantile capillary hemangiomas than in pyogenic granulomas, therefore, some authors suggest that apoptosis might be a cause of spontaneous involution in infantile capillary hemangiomas. Since the pyogenic granulomas do not spontaneously involute, they should be surgically excised [3]. Recurrence is rare in non-pregnant individuals [6] and is believed to be due to incomplete excision, or failure to remove etiologic factors or reinjury to the area [6]. References [1] A. Poncet, L. Dor, Botryomycose humaine, Rev. Chir. (Paris) 18 (1897) 996. [2] M.B. Hartzell, Granuloma pyogenicum (botryomycosis of French authors), J. Cutan. Dis. 22 (1904) 520 – 523. [3] J. Iwata, H. Sonobe, M. Furihata, E. Ido, Y. Ohtsuki, High frequency of apoptosis in infantile capillary haemangioma, J. Pathol. 179 (1996) 403 – 408. [4] A.P. Angelopoulos, Pyogenic granuloma of the oral cavity: statistical analysis of its clinical features, J. Oral Surg. 29 (1971) 840 – 847. [5] S.N. Bhaskar, J.R. Jacoway, Pyogenic granuloma-clinical features, incidence, histology, and result of treatment: report of 242 cases, J. Oral Surg. 24 (1966) 391 – 398. [6] E.J. Butler, D.R. Macintyre, Oral pyogenic granulomas, Dent. Update 19 (1991) 194 – 195. [7] K. Goette, W.M. Carpenter, Pyogenic granuloma of the oral cavity, South. Med. J. 70(11) (1977) 1358 – 1360. [8] G.H. Zalzal, K. Patterson, R.T. Cotton, Cogenital tumors of the dorsum of the tongue, Int. J. Pediatr. Otorhinolaryngol. 28 (1994) 219 – 227. [9] S.J. Patrice, K. Wiss, J.B. Mulliken, Pyogenic granuloma (lobular capillary hemangioma):a clinicopathological study of 178 cases, Pediatr. Dermatol. 8 (1991) 267 – 276.