A clinicopathologic discussion on a case of asymptomatic swelling on the ventral tongue Thomas S, Velayudhannair V, Thomas J, Lekha SB

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CASE REPORT

Year : 2019 | Volume : 8 | Issue : 3 | Page : 191-193

A clinicopathologic discussion on a case of asymptomatic swelling on the ventral tongue

Sunila Thomas, Vivek Velayudhannair, Jincy Thomas, Saranya Balachandran Lekha
Department of Oral Medicine and Radiology, PMS College of Dental Science and Research, Thiruvananthapuram, Kerala, India

Date of Web Publication

9-Dec-2019

Correspondence Address:
Dr. Sunila Thomas
Department of Oral Medicine and Radiology, PMS College of Dental Science and Research, Vattapara, Thiruvananthapuram - 695 028, Kerala
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/sjhs.sjhs_128_19

Abstract

The tongue is a complex structure composed of muscles, nerve fibers, blood vessels, salivary glands, etc. A swelling on the ventral tongue can arise from any of these tissues. We report a case and clinicopathologic discussion of asymptomatic swelling on the ventral surface of the tongue in a 13-year-old female patient under orthodontic treatment, diagnosed as extravasation mucocele. Oral mucocele is a benign minor salivary gland lesion which occurs due to trauma or obstruction. Extravasation mucocele seen in this case resembles mucocele developing from the glands of Blandin and Nuhn. This article emphasizes the importance of clinicopathological correlation in diagnosing common lesions in uncommon locations.

Keywords: Minor salivary gland, mucocele, tongue

How to cite this article:
Thomas S, Velayudhannair V, Thomas J, Lekha SB. A clinicopathologic discussion on a case of asymptomatic swelling on the ventral tongue. Saudi J Health Sci 2019;8:191-3

How to cite this URL:
Thomas S, Velayudhannair V, Thomas J, Lekha SB. A clinicopathologic discussion on a case of asymptomatic swelling on the ventral tongue. Saudi J Health Sci [serial online] 2019 [cited 2021 Jan 16];8:191-3. Available from: https://www.saudijhealthsci.org/text.asp?2019/8/3/191/272438

Introduction

Swellings on the ventral surface of the tongue are rare clinical presentations. The tongue is a complex organ composed of muscles, minor salivary glands, papillae, sensory and motor nerve fibers, blood vessels, adipose tissues, etc., This wide variety of tissues poses challenges in the diagnosis of tongue lesions.^[1] A case report of large mucocele on the ventral tongue is presented. The most common site for mucocele is the lower lip, and 2.25% of mucoceles arose from the minor salivary glands on the tongue.^[2] Mucoceles are well-circumscribed, asymptomatic swelling of deep blue to normal mucosal color and size ranges from 0.2 mm to 2 cm and are common among females and children.^[3] This case report intended on comprehensive review of tongue swellings, ranging from an innocuous benign lesion like mucocele to malignant lesions.

Case Report

A 13-year-old female patient undergoing orthodontic treatment presented with asymptomatic swelling of 2 weeks on the ventral tongue, lateral to the lingual frenum. Similar swelling was noted at the same site 3 months back, which ruptured draining clear fluid. Intraoral examination revealed well-defined ovoid swelling of 2 cm × 1.5 cm with well-defined borders, extending 2 cm from the tip of the tongue and lateral to the lingual frenum. The swelling was bluish-pink, smooth surfaced with prominent capillaries but no visible pulsation [Figure 1]. Palpation revealed soft-to-firm consistency, nontender, nonpulsatile, fluctuant, fixity to the underlying tissues with no evidence of induration. Diascopy was negative. Excisional biopsy under local anesthesia was performed. Histopathological examination showed no evidence of epithelial lining and presence of inflamed fibrovascular connective tissue exhibiting a cavity space with focal areas of mucin, salivary gland mucous acini, and ductal spaces. Muscle fibers, nerve bundles, adipocytes, and extravasated red blood cell (RBC) were also noted [Figure 2]. These features suggested extravasation-type mucocele.

Figure 1: Intraoral photograph of the patient exhibiting well-defined swelling on the ventral surface of the tongue

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Figure 2: Photomicrograph of the lesion exhibiting a cavity space with focal areas of mucin, salivary gland mucous acini, and ductal spaces

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Discussion

The presence of muscles, nerve fibers, blood vessels, and salivary glands in the tongue invites the possibility of a lesion developing from any of these structures. In the present case, clinicopathological discussion includes lesions ranging from benign minor salivary gland lesion mucocele to smooth, nodular submucosal lesions such as fibroma, lipoma, hemangioma, lymphangioma, neurofibroma, neurilemoma, and leiomyoma. Malignant salivary gland lesion low-grade mucoepidermoid carcinoma was also considered in the differential diagnosis.

Mucocele usually occurs in teenage females on lower labial mucosa; they may also be found in association with minor salivary glands of the tongue, buccal mucosa, superior lip, and palate. Superficial mucocele is asymptomatic with a characteristic blue hue, frequently traumatized, and drain fluid when ruptured.^[2] These clinical features were observed in our case along with a history of rupture, and the drainage of clear fluid made the diagnosis of mucocele more preferential.

Fibroma occurs secondary to trauma, frequently seen on the tongue, buccal mucosa, and labial mucosa.^[1] This patient under orthodontic treatment was susceptible to trauma. The lack of normal mucosal color and history of rupture of the swelling were against the diagnosis of fibroma.

Oral hemangioma develops during late fetal stages or infancy with a female predilection. It arises in the lips, tongue, buccal mucosa, gingiva, and palate.^[4] Appearance as a soft mass with smooth surface and bluish discoloration with prominent capillaries in the present case can be compared to hemangioma, but the absence of pulsation and blanching was considered for exclusion.

Mucoepidermoid carcinoma is the most common malignant salivary gland tumor of children, presenting as slow-growing mass. Low-grade lesions present as asymptomatic cystic swellings with a blue or red hue in the lower lip, floor of mouth, tongue, and retromolar pad often mimic mucocele.^[5] The presence of epithelium-lined cystic spaces, mucin pools, and mucin-filled mucocytes in low-grade mucoepidermoid carcinoma bears histopathological similarity to mucocele. However, the absence of epithelial lining in this case helps in differentiating mucoepidermoid carcinoma from mucocele.^[6]

Lipoma, a benign soft-tissue neoplasm, even though rare intraorally, could be considered in the diagnosis of asymptomatic tongue swellings. A lack of yellowish color with no-slip sign^[7] indicated lipoma to be kept below mucoepidermoid carcinoma.

Lymphangioma, a congenital malformation of lymph vessels, involves females on the tongue, palate, gingiva, and lips.^[8] Deeper lesions which present as asymptomatic, soft, nodular masses with normal color were also considered.

Neurilemoma, a benign tumor, arising from the nerve sheath's Schwann cells is seen on the tongue, as circumscribed firm submucosal mass. Large lesions present as asymptomatic slow-growing swelling with paresthesia^[9] which was not seen here even though the lesion was considerably large.

Neurofibromas are benign tumors of nerve cell origin, rare intraorally. They are common in females on the buccal mucosa, palate, tongue, and lips. It appears as sessile or nodular tumors, painless with gradual growth.^[10] Nodularity and slow growth were absent in our case.

Leiomyoma is a benign smooth muscle, presents as asymptomatic, slow-growing submucosal mass with a smooth surface and normal mucosal color. Oral vascular leiomyomas are usually painless with slow growth, but those on the tongue are symptomatic.^[11]

After considering the lesions in the differential diagnosis, this case on the ventral tongue diagnosed as extravasation mucocele based on clinicopathologic features is considered a rarity. In 1970, Heimansohn first reported a case of Blandin and Nuhn mucocele in a 14-year-old female.^[3] De Camarago Moraes found mucoceles on the ventral tongue as the second most frequent with 15.4%.^[2] Tegginamani et al. studied 50 cases of mucocele, with 4% on the ventral tongue, which accounts for the third position.^[6] Spencer et al. reported female-male ratio for mucocele as 4:1.^[12] Harrison reported that mucoceles develop most commonly from 3 weeks to 3 months, which was similar to our case with a duration of 3 months.^[2]

Mucocele involving glands of Blandin and Nuhn located on the ventral tongue are often histologically diagnosed as extravasation type. Mucin surrounded by a layer of inflammatory cells encapsulated with granulation tissue, with no epithelial covering,^[2] was observed in our case. As Blandin and Nuhn mucoceles are embedded in the muscles of the ventral tongue, it shows muscle fibers and nerve bundles, adipocytes, and extravasated RBC similar to our observation.

This case report emphasizes the importance of clinicopathological correlation in diagnosing common lesions in unusual locations. Blandin and Nuhn mucocele, although rare, should be considered in the differential diagnosis of asymptomatic ventral tongue lesions. Surgical excision and histopathological confirmation is mandatory to avoid misdiagnosis and recurrence.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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