Sublingual pyogenic granuloma of pregnancy

Granuloma gravidarum, or "pregnancy tumour," is a lesion that is histologically and clinically similar to a pyogenic granuloma of the oral cavity. The granuloma gravidarum is a form of pyogenic granuloma that occurs during pregnancy. It is a benign hemorrhagic lesion involving skin or mucous membranes, consisting predominantly of blood vessels with areas of ulcerations.1

These growths have been described as occurring on the gingiva of pregnant patients in areas involved by an inflammatory process. Lesions located on the tip or lateral portions of the tongue have also been described.2 We present a previously unreported case of a large pyogenic granuloma of pregnancy presenting sublingually.

Case Report

A 20-year-old gravida 3, para 1 female who was 24 weeks pregnant presented with a slowly expanding, nontender mass sublingually and submentally (Fig. 1). The patient was prompted to seek medical attention because the mass had begun to interfere with her ability to chew and speak. She denied any trauma or infection of her oral cavity. This mass measured 4.0 x 3.0 cm submentally, and was elevating the tongue sublingually (Fig. 2). Several attempts at fine-needle aspiration were nondiagnostic. Magnetic resonance imaging (MRI) of the neck revealed a sublingual mass, with pushing margins, that was most likely benign (Fig. 3). The growth of the mass stabilized about 2 months prior to delivery and began to slowly regress over a 4-month period after delivery. Open biopsy was performed 3 weeks postpartum. Histologic evaluation was diagnostic of pyogenic granuloma of pregnancy.

Histology

The biopsy specimen was fixed in formalin and embedded in paraffin following routine processing. Fivemicrometer sections were cut and stained with hematoxylin and eosin. Microscopy revealed a proliferation of endothelial lined vascular channels in a markedly edematous stroma, with numerous neutrophils, lymphocytes, and occasional multinucleated giant cells (Fig. 4). No epithelium was represented in the biopsy. The histologic appearances were those of a pyogenic granuloma (lobular capillary hemangioma), also known, in this context, as a pyogenic granuloma of pregnancy.

Discussion

Pyogenic granulomas are benign, painless, nonulcerated, capillary-rich lesions that occur on the skin and mucous membranes.3 Pyogenic granulomas of pregnancy histologically mimic pyogenic granulomas of the oral cavity occurring in nonpregnant individuals. These are rapidly growing lesions of the oral cavity that occur in up to So/o of pregnancies,4 which are most often found on the gingiva but have also been described on the palate, lip, and buccal surfaces. In a review of the literature, 76% occurred on the gingiva, 5% involved the tongue, and the remainder were found on the lip, cheek, mucobuccal fold, and the frenulum.4 The tongue lesions were found to involve the lateral border, dorsal and ventral surfaces, and the tip.4

Figure

These tumours most often develop during the first trimester of pregnancy, and may arise from a combination of trauma and circulating hormones present during pregnancy. They often occur in patients with inflammatory gingivitis secondary to poor oral hygiene, and form via a chronic healing reaction and granuloma formation.' The rapid growth parallels the rise in circulating estrogens and progestins in pregnancy,6 and regression occurs following parturition, although not always completely. Pyogenic granulomas are also seen in patients taking oral contraceptives with high progestin activity.7

The treatment has been expectant management if they are small and painless. These tumours tend to regress following pregnancy and have a high incidence of recurring if removed during pregnancy. Therefore, observation and reassurance have been recommended during pregnancy, and excision after parturition if the mass persists.4 If excision is warranted, several methods have been reported, including cold-knife excision, sclerotherapy, and laser excision.4

Figure 2 Figure 3

Figure 4

References

References

1. Bhaskar SN, Jacoway JR. Pyogenic granuloma-clinical features, incidence, histology, and result of treatment: report of 242 cases. J Oral Surg 1966; 24:391-398. 2. Angelopoulos AP. Pyogenic granuloma of the oral cavity: statistical analysis of its clinical features. J Oral Surg 1971; 29:840-847.

References

3. Cummings CW, ed. Otolaryngology-head and neck surgery. St. Louis: Mosby, 1986:1265,1439.

4. Sills ES, Zegarelli DJ, Hoschander MM. Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med 1996; 41: 467-470.

References

5. Ojanotko-Harri AO, Harri MP, Hurttia HM, Sewon LA. Altered tissue metabolism of progesterone in pregnancy gingivitis and granulomas. J Clin Periodontol 1991; 18:22-26. 6. Fenton JE, Timon CI, McShane DP. Lingual granuloma gravidatum. Otolaryngol Head Neck Surg 1996; 114:682-83. 7. Goette DK, Carpenter WM. Pyogenic granuloma of the oral cavity. South Med J 1977; 70:1358-1360.