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Giant palatal pyogenic granuloma.

A mucosal pypogenic granuloma is a reactive angiomatous proliferation with a higher preponderance for the maxillary gingiva. A giant growth within the oral cavity is rarely encountered. Tentative diagnosis is made by recognizing a rapidly growing pedunculated or sessile mass characterized by a friable surface, bleeding tendency, and an ulceration covered with whitish slough.

An 86-year-old man was referred for evaluation of an oral mass that was initially thought to be palatal carcinoma. The patient had been a smoker but had quit 10 years earlier. His caregiver mentioned that the lesion had shown rapid growth, with the patient suffering no predisposing trauma in the preceding 2 months. The lesion was associated with recurrent bleeding and occasional pain. Tracing the patient's medical history, we learned that he had symptomatic aortic valve stenosis with congestive heart failure (New York Heart Association classification III) and hypertension.

A comprehensive intraoral examination revealed an exuberant fleshy mass, scarlet in color, adhering to the hard palate (figure, A). Computed tomography (CT) with contrast disclosed an expansile tumor abutting the maxillary alveolar ridge (figure, B). Subsequent complete excision with electrodesiccation found a free-floating mass with a peduncle attached to the palatal gingiva (figure, C and D). Curettage with C[O.sub.2] laser photocoagulation of the raw base was performed later.

Microscopic examination demonstrated an aggregation of thin-walled capillaries in a lobulated pattern, confirming a diagnosis of pyogenic granuloma. The patient had no recurrence of the lesion for 15 months.

Pyogenic granuloma (lobular capillary hemangioma) is a benign, exophytic, vascular tumor, described in 1897 by Poncet and Dor as botryomycosis hominis. (1) Mucosal lesions have a tendency to occur in young adults and pregnant women. (1-4) The most common sites are areas rich in blood supply that are vulnerable to trauma, with a striking predilection for the gingiva. (1-6)

Although the exact pathogenesis of pyogenic granuloma is not clearly established, the lesion has been hypothesized to be a reactive process followed by an impaired wound healing response. (5) Imbalance between angiogenesis enhancers and inhibitors, as well as hormone changes, have been considered as essential factors in the development of this lesion. (5,6) The differential diagnosis should include hemangioma, bacillary angiomatosis, peripheral giant cell granuloma, peripheral ossifying fibroma, and some malignancies, such as Kaposi sarcoma, squamous cell carcinoma, and achromic melanoma.

Conservative surgical excision, cryotherapy, pulsed-dye laser therapy, and C[O.sub.2] laser therapy are all effective treatments. (1-3) Prevention depends on eliminating sources of repeated microtrauma. (1,4)

References

(1.) Bakshi J, Virk RS, Verma M. Pyogenic granuloma of the hard palate: A case report and review of the literature. Ear Nose Throat J 2009;88(9):E4-5.

(2.) Saravana GH. Oral pyogenic granuloma: A review of 137 cases. Br J Oral Maxillofac Surg 2009;47(4):318-19.

(3.) Ghodsi SZ, Raziei M, Taheri A, et al. Comparison of cryotherapy and curettage for the treatment of pyogenic granuloma: A randomized trial. Br J Dermatol 2006;154(4):671-5.

(4.) Giblin AV, Clover AJ, Athanassopoulos A, Budny PG. Pyogenic granuloma--the quest for optimum treatment: Audit of treatment of 408 cases. J Plast Reconstr Aesthet Surg 2007;60(9):1030-5.

(5.) Godlfaind C, Calicchio ML, Kozakewlch H. Pyogenic granuloma, an impaired wound healing process, linked to vascular growth driven by FLT4 and the nitric oxide pathway. Mod Pathol 2013;26(2):247-55.

(6.) Yuan K, Jin YT, Lin MT. The detection and comparison of angiogenesis-associated factors in pyogenic granuloma by immunohistochemistry. J Periodontol 2000;71(5):701-9.

Yu-Hsuan Lin, MD; Yaoh-Shiang Lin, MD

From the Department of Otolaryngology, Head and Neck Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr. YH Lin); and the Department of Otolaryngology, Head and Neck Surgery, National Defense Medical Center, Taipei, Taiwan (Dr. YS Lin).
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Article Details
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Title Annotation:HEAD AND NECK CLINIC
Author:Lin, Yu-Hsuan; Lin, Yaoh-Shiang
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Geographic Code:9TAIW
Date:Feb 1, 2015
Words:622
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