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An Exophytic Dorsolateral Tongue Mass in a Young Patient

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A young woman presented with a 1-year history of a right tongue mass that developed after initial bite trauma. The lesion waxed and waned but never completely healed; however, it greatly increased in size over 3 weeks before presentation. She reported constant, severe stabbing pain, right otalgia, and occasional swelling that caused oral dysphagia. She reported no constitutional symptoms or any history of tobacco or alcohol use. On examination, the mass was a 3 × 2-cm, exophytic and raised, plateaulike lesion on the right dorsolateral tongue with approximately 1 to 2 cm of surrounding induration (Figure, A).

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B. Schwannoma with a traumatic ulcerative granuloma with stromal eosinophilialike reaction

This case demonstrates a unique example of a lateral tongue schwannoma with an associated traumatic ulcerative granuloma with stromal eosinophilia (TUGSE)–like reaction that produced a large, exophytic mass mimicking more clinically concerning lesions, such as squamous cell carcinoma.

Schwannoma is a benign, peripheral nerve sheath tumor that can occur throughout the body, but most commonly develops in the head and neck.1 An oral tongue location has been a well-documented site for this tumor. The histologic features of schwannomas in an oral tongue location parallel those at other sites and consist of a spindled cell proliferation with hypercellular and hypocellular areas that refer to specific patterns known as Antoni A and Antoni B.1 In the hypercellular areas, there are foci with nuclear palisading known as Verocay bodies. Immunohistochemistry demonstrates that the spindled cells are strongly and diffusely positive for S-100 and SOX-10 and typically negative for markers of epithelial differentiation, such as cytokeratins.1 To our knowledge, a brisk inflammatory infiltrate, such as the kind seen with TUGSE, has not been reported to occur with schwannoma.

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Article Information

Corresponding Author: Joseph B. Meleca, MD, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A-71, Cleveland, OH 44195 (melecaj@ccf.org).

Published Online: May 23, 2019. doi:10.1001/jamaoto.2019.0935

Conflict of Interest Disclosures: None reported.

Meeting Presentation: This case report was presented as a poster at the Triological Society Conference 2018; January 18, 2018; Scottsdale, Arizona.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Butler  RT, Patel  RM, McHugh  JB.  Head and neck schwannomas: 20-year experience of a single institution excluding cutaneous and acoustic sites.  Head Neck Pathol. 2016;10(3):286-291. doi:10.1007/s12105-016-0680-2PubMedGoogle ScholarCrossref
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Butler  JN, Kobayashi  TT.  Traumatic ulcerative granuloma with stromal eosinophilia: a malignant-appearing benign lesion.  Cutis. 2017;100(2):E28-E31.PubMedGoogle Scholar
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Sarangarajan  R, Vaishnavi Vedam  VK, Sivadas  G, Sarangarajan  A, Meera  S.  Traumatic ulcerative granuloma with stromal eosinophilia—mystery of pathogenesis revisited.  J Pharm Bioallied Sci. 2015;7(suppl 2):S420-S423. doi:10.4103/0975-7406.163474PubMedGoogle ScholarCrossref
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Marszałek  A, Neska-Długosz  I.  Traumatic ulcerative granuloma with stromal eosinophilia: a case report and short literature review.  Pol J Pathol. 2011;62(3):172-175.PubMedGoogle Scholar
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Hirshberg  A, Amariglio  N, Akrish  S,  et al.  Traumatic ulcerative granuloma with stromal eosinophilia: a reactive lesion of the oral mucosa.  Am J Clin Pathol. 2006;126(4):522-529. doi:10.1309/AFHA406GBT0N2Y64PubMedGoogle ScholarCrossref
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Alobeid  B, Pan  LX, Milligan  L, Budel  L, Frizzera  G.  Eosinophil-rich CD30+ lymphoproliferative disorder of the oral mucosa: a form of “traumatic eosinophilic granuloma”.  Am J Clin Pathol. 2004;121(1):43-50. doi:10.1309/JQFXPND6DBLF6B9UPubMedGoogle ScholarCrossref
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Stevens  TM, Bishop  JA.  HPV-related carcinomas of the head and neck: morphologic features, variants, and practical considerations for the surgical pathologist.  Virchows Arch. 2017;471(2):295-307. doi:10.1007/s00428-017-2118-yPubMedGoogle ScholarCrossref
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Pytynia  KB, Dahlstrom  KR, Sturgis  EM.  Epidemiology of HPV-associated oropharyngeal cancer.  Oral Oncol. 2014;50(5):380-386. doi:10.1016/j.oraloncology.2013.12.019PubMedGoogle ScholarCrossref
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Tanna  N, Joshi  AS, Sidell  D, Misra  S, Santi  M, Collins  WO.  Pathology quiz case, 1: plexiform neurofibroma.  Arch Otolaryngol Head Neck Surg. 2007;133(3):302, 304-305. doi:10.1001/archotol.133.3.302PubMedGoogle ScholarCrossref
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Barbieri  M, Musizzano  Y, Boggio  M, Carcuscia  C.  Granular cell tumour of the tongue in a 14-year-old boy: case report.  Acta Otorhinolaryngol Ital. 2011;31(3):186-189.PubMedGoogle Scholar
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