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Shishir N. Sheth, MD; Carmen Gomez, MD; Gary D. Josephson, MD
From the Departments of Otolaryngology–Head and Neck Surgery (Dr Sheth) and Pathology (Dr Gomez), Division of Pediatric Otolaryngology–Head and Neck Surgery (Dr Josephson), University of Miami School of Medicine, Miami, Fla. Dr Sheth is now with the Department of Otolaryngology–Head and Neck Surgery, Cleveland Clinic Florida, Ft Lauderdale. Dr Josephson is now with the Nemours Children's Clinic, Jacksonville, Fla.

Arch Pediatr Adolesc Med. 2001;155:1065-1066.

A 6-WEEK-OLD girl with no other medical problems was brought to the otolaryngology clinic for a mass on her tongue causing mild difficulty in feeding. A history of neonatal meconium delivery was reported for which the child was hospitalized for a week. During the hospitalization, she was noted to have a whitish, scooped-out lesion on the dorsum of the tongue in the same area as her current lesion; this was felt to be a fungal infection and was treated with antifungals. The tumor had grown in the area from the time of birth to the time of presentation. There were no associated respiratory problems.

Examination revealed a bilobed, pale, 2 x 1-cm mass on the midline dorsum of the tongue, centrally located (Figure 1). This was firm and rubbery in texture and had no obvious tenderness. Findings from the remainder of the head and neck examination were normal. Intraoperative biopsy findings are shown in Figure 2.

Figure 1.

Figure 2.

Diagnosis and Discussion: Pyogenic Granuloma of the Tongue

Figure 1. A 2 x 1-cm mass on the midline of the tongue.

Figure 2. Endothelial proliferation with formation of vascular spaces. Note the lymphocytic infiltration of the lesion (hematoxylin-eosin, original magnification x40).

First described in humans by Poncet and Dor,¹ pyogenic granuloma is relatively common and accounts for 1.85% to 7% of all biopsy findings from oral cavity lesions.^2-3 Females are slightly more affected than males,^2-6 and the age at presentation ranges from 18 months to 93 years. Our patient, at age 6 weeks, is the youngest reported case to our knowledge.

The pathogenesis of this benign lesion is not well understood. Trauma is felt to be the most common initiating event but is not always present in the history.⁴ The occasional presence of microorganisms has led to speculation of an infectious cause. This has not been proven. There is a higher incidence of pyogenic granuloma in women during pregnancy, and this is felt to be caused by the raised levels of progesterone and estrogen; the tumor usually regresses postparturition.^7-8 The underlying problem seems to be an exaggerated tissue response and vascular proliferation secondary to local irritation.

The most common symptom of oral cavity pyogenic granuloma is the presence of a mass. The tumor may grow rapidly in size and then remain stable for indefinite periods of time.^{4, 6} The most common sites within the oral cavity according to several large series^{2, 4, 6} are gingiva (61%), lip (14%), tongue (9%), and buccal mucosa (7%). Pain, aside from the local mass effect, may or may not be present. The tumors are often vascular and can bleed either spontaneously or in response to trauma. Adjacent bone resorption may occur.^6-9

On gross examination, the tumor appears as an elevated, often lobulated and ulcerated mass that could be either sessile (as in our case; Figure 1) or pedunculated.⁴ Some^{4, 6} feel that younger tumors are soft in consistency, progressing to a rubbery texture on maturation. The color may range from pink to bright red to purple or brown.

An extreme endothelial proliferation with formation of vascular spaces is histopathologically visible (Figure 2); renaming this lesion to lobular capillary hemangioma has been proposed.¹⁰ The tumor is covered by a thin epithelium that is usually ulcerated.^{2, 4} There is often a lymphocytic infiltration; bacteria may be present, especially if ulcerated.

The only curative treatment is conservative local excision. Recurrence rates after excision range from 0% to 16%.^2-3,5 Because the pyogenic granuloma of pregnancy often regresses postparturition, they need not be excised unless symptomatic.^7-8,11 After complete excision, our patient has been symptom- and disease-free for a follow-up period of 1 year.

AUTHOR INFORMATION
Accepted for publication August 15, 2000.

Reprints: Gary D. Josephson, MD, Division of Pediatric Otolaryngology–Head and Neck Surgery, Nemours Children's Clinic, 807 Nira St, Jacksonville, FL 32225 (e-mail: gjosephs{at}nemours.org).

REFERENCES
1. Poncet A, Dor L. Botryomycose humaine. Rev Chir Orthop. 1897;18:996. 2. 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. PUBMED 3. Lawoyin JO, Arotiba JT, Dosumu OO. Oral pyogenic granuloma: a review of 38 cases from Ibadan, Nigeria. Br J Oral Maxillofac Surg. 1997;35:185-189. PUBMED 4. Kerr DA. Granuloma pyogenicum. Oral Surg. 1951;4:158-176. PUBMED 5. Leyden JJ, Master GH. Oral cavity pyogenic granuloma. Arch Dermatol. 1973;108:226-228. FULL TEXT | PUBMED 6. Angelopoulos AP. Pyogenic granuloma of the oral cavity: statistical analysis of its clinical features. J Oral Surg. 1971;29:840-847. PUBMED 7. Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med. 1996;41:467-470. PUBMED 8. Manus DA, Sherbert D, Jackson IT. Management considerations for the granuloma of pregnancy. Plast Reconstr Surg. 1995;95:1045-1050. PUBMED 9. Goodman-Topper ED, Bimstein E. Pyogenic granuloma as a cause of bone loss in a twelve-year-old child: report of case. J Dent Child. 1994;61:65-67. 10. Mills SE, Cooper PH, Fechner RE. Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma. Am J Surg Pathol. 1980;4:471-479. 11. Goette DK, Carpenter WM. Pyogenic granuloma of the oral cavity. South Med J. 1977;70:1358-1360. PUBMED

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