Pyogenic granuloma (PG) is a hyperplastic and inflammatory lesion found in the oral cavity. Exuberant tissue response to trauma or local irritation is believed to cause PG. In the second decades of their life, it is commonly seen in young women, owing to vascular hyperplasia caused by female hormones. The clinical presentations are smooth or lobulated exophytic mass and sessile or pedunculated red to pink. The size of the PG may vary from a few millimeters to several centimeters. Gingiva is the common site for PG in the oral cavity. PG very rarely involves the hard palate. However, there is a high chance of PG in the oral cavity during pregnancy. Therefore, complete surgical excision of the lesion is the treatment of choice. Here, this case report presents PG in the hard palate region of an 18-year-old female, a scarce location for this lesion.
Keywords: Complete excision, hard palate, oral cavity, pyogenic granuloma
| Introduction|| |
Pyogenic granuloma (PG) is a type of inflammatory hyperplasia that affects the oral cavity's mucosal lining and the skin. It can affect the pediatric age group and young adults. PG is a reactive and nonneoplastic soft-tissue lesion in the oral cavity. Although the name is PG, it is not associated with pus and histologically no granulomatous lesion. Sometimes, the word lobular capillary hemangioma is used for PG. PG commonly involves the gingiva in the oral cavity. It rarely affects lips, tongue, palate, or buccal mucosa. PG is often solitary, but multiple satellite lesions may be seen. Although PG is a relatively common clinical entity in the oral cavity, it is found mainly in the gingival area (75%), particularly in the upper gingival region. Buccal mucosa, lips, tongue, and palate are rare sites for PG.
| Case Report|| |
An 18-year-old female complained of a large reddish lesion on her hard palate for 4 months. She said that she did not have any ear, nose, or throat problems. She had no notable medical history. She was not addicted to smoking and alcohol. The lesion size was almost negligible when the patient found it 4 months back. However, the lesion size has increased since the past month to the present extent. Clinical examination showed a sessile and friable lesion with a smooth surface (3.5 cm × 2.5 cm) [Figure 1]. The palatal mass was red-colored, consistent, nonblanching, nontender, and crispy. In addition, the patient's dental hygiene was poor. Computed tomography (CT) scan revealed a homogeneously enhancing mass at the hard palate with evidence of adjacent bony erosion. A small piece of tissue from the palatal mass was sent for histopathological study. The histopathological examination showed granulation tissue with the nonneoplastic proliferation of endothelial cells with infiltration of acute and chronic inflammatory cells in collagenous, which established the diagnosis of PG [Figure 2]. Complete surgical excision of the mass was done. The healing of the wound occurred effectively with no evidence of recurrence at the follow-up visits at 6 months and 1 year.
|Figure 1: Oral cavity examination showing a giant pyogenic granuloma in the hard palate|
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|Figure 2: Histopathological microphotograph showing granulation tissue: chronic inflammatory cells, blood vessels, and collagen fibers (H and E, ×400)|
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| Discussion|| |
PG is a benign soft-tissue tumor affecting the mucosal membranes and skin, also known as lobular hemangioma. The oral cavity is a common site for PG. It is a reactive inflammatory process caused by several stressors such as low-grade and long-term local irritation, traumatic injury, altered hormones, and few medicines, which results in granulation tissue overgrowth. The exact cause of PG is still unknown. Initially, botryomycotic infection was thought to be the cause of PG. At present, PG is believed to be originated due to a long-standing minor injury and prolonged irritation. The pathogenesis of the PG is still debatable. PG often grows slowly with no symptoms or sometimes pain. In some patients with PG, the symptoms such as pain during swallowing, bleeds on touch, and ulcers over the mass covered with white scab as per the progress of the disease. It may confuse malignant lesions and create a challenge for the clinicians to diagnose.
Patient of PG often presents with a single nodular mass or sessile papule, and the surface is smooth or lobulated. Its size varies from millimeters to several centimeters. As the lesions of the PG progress, the vascularity of the lesion reduces, and the appearance is more collagenous and pinkish. Gingiva in the oral cavity is the most standard site for PG and presents a wide range of clinical presentations. PG often delivers a painless, soft-to-firm, and red-to-reddish-purple appearance. Because of these factors, making an accurate clinical diagnosis of PG at the hard palate is often difficult. To begin with, PG is relatively uncommon on the hard palate. Second, because the hard palate can be affected by a wide range of pathologic entities, differential diagnosis based on physical appearance and imaging findings can be problematic.
The differential diagnosis of the PG includes cavernous hemangioma, minor salivary gland neoplasms, such as pleomorphic adenoma, malignant lesions such as squamous cell carcinoma, peripheral ossifying fibroma, and peripheral giant-cell granuloma (non-Hodgkin lymphoma), Kaposi sarcoma, and other types of soft-tissue sarcomas., The pleomorphic adenoma arising from minor salivary glands is often found in the posterior part of the hard palate as minor salivary glands are more distributed in the rear part of the palate. The overlying mucosa of the pleomorphic adenoma is usually smooth. PG differs from cavernous hemangioma histologically, where the hemangioma shows proliferation of endothelial cells with no infiltration of inflammatory cells. Because of its aggressive development style, squamous cell carcinoma is a frequent malignant tumor discovered in the palatal region, particularly the hard palate. In the histopathological study, multinucleated giant cells in the absence of infection distinguish the peripheral giant-cell granuloma.
CT scan and magnetic resonance imaging are helpful investigations for PG, which delineate the extent of neoplasm and any involvement of the bone. The biopsy and histopathological examination are beneficial to confirm the diagnosis., There are different modalities of treatment for PG. The effective treatment for PG includes excision, laser surgery, sclerotherapy, electrodesiccation, curettage, and a combination of different techniques. Other treatment options include cryosurgery, intralesional injection of ethanol or corticosteroid, and sodium tetradecyl sulfate. The standard treatment modality is complete surgical excision under local/general anesthesia. There is approximately a 15% chance of recurrence following simple excision of the PG. The prevention measures include maintaining proper oral hygiene. Maintaining good oral hygiene, cleaning dental plaque, and using soft toothbrushes are helpful in pregnancy to prevent PG.
| Conclusion|| |
The PG is rarely seen in the hard palate. Clinicians should keep in mind about PG when making a differential diagnosis for a tumor on the hard palate. A histopathological study confirms the diagnosis. Complete excision of the mass is the definitive treatment of PG. Although PG in the oral cavity is a nonneoplastic pathology, proper diagnosis with appropriate treatment is essential for clinicians. Maintaining good oral hygiene is an important preventive measure for PG.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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Santosh Kumar Swain,
Department of Otorhinolaryngology and Head and Neck Surgery, IMS&SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
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