Dysphagia

https://doi.org/10.1007/s00455-019-10057-2

CLINICAL CONUNDRUM

A Huge Oropharyngeal Pyogenic Granuloma in a Patient Presenting

with Dysphagia
Ilker Burak Arslan1 · Samira Abdurahmanova Ozkara1 · Engin Baser1 · Ibrahim Cukurova1

Received: 1 May 2019 / Accepted: 21 August 2019

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
A 39-year-old woman experienced dyspnea and progressive dysphagia for 1 year. Dysphagia appeared for solid foods at
the beginning but advanced for liquids. She described 17 kg weight loss in the past 6 months and her current weight was
38 kg [body mass index (BMI) 16 kg/m2]. Dyspnea presented with effort and lying was included after 1 month. There was
no disease or surgery except chronic hepatitis C in her medical history. Physical examination revealed hyponasal speech and
a mass beside the tongue base. A smoothly surfaced 4 × 3-cm vascular mass in oropharynx was determined in endoscopic
examination. The mass was mobile and occupied 80% of oropharyngeal area. Contrast-enhanced computed tomography
revealed hypervascular 4 × 4 × 3 cm pedunculated (8 × 13 mm) mass arising from the right tongue base. The mass and the
surrounding mucosa with a thin layer of tongue musculature were excised using cold instrumentation and bipolar cautery.
Histologically the mass was reported as pyogenic granuloma (PG). This is the first study to report on oropharyngeal PG
causing obvious weight loss in literature.

Keywords  Dysphagia · Dyspnea · Pyogenic granuloma · Oropharynx

Clinical Conundrum tomography revealed a hypervascular, 4 × 4 × 3-cm pedun-

A 39-year-old female presented with dyspnea and increasing
dysphagia, 1 year in duration. Initially, she was unable to
take solid foods; the dysphagia later included an inability to
take liquids. She had lost 17 kg in the past 6 months; her cur-
rent weight was 38 kg [body mass index (BMI) 16 kg/m2].
One month prior, dyspnea developed with effort, and when
she lay on her back. She had no history of any disease except
chronic hepatitis C infection; she had never undergone sur-
gery. Physical examination revealed hyponasal speech and
a mass beside the tongue base. Endoscopic examination
revealed a smoothly surfaced 4 × 3-cm vascular mass in the
oropharynx. The mass was mobile and occupied 80% of the
oropharyngeal area (Fig. 1). Contrast-enhanced computed
culated (8 × 13 mm) mass arising from the right tongue base
(Fig. 2). The mass abutted the base of the tongue anteriorly
and the posterior pharyngeal wall posteriorly. The mass
extended to the tongue base and the petioles of the epiglot-
tis, and pushed the epiglottis anteriorly (Fig. 3). Excision
via the transoral route was planned. With the patient under
local anaesthesia, tracheotomy was initially performed.
General anaesthesia was induced via the tracheotomy. The
oropharynx was visualised with the aid of a Davis–Boyle
mouth gag. The mass, the surrounding mucosa, and a thin
layer of tongue musculature were excised using cold instru-
mentation and bipolar cautery. The tongue was sutured with
polygalactin. The specimen was sent for histopathological
examination (Fig. 4, 5).

Electronic supplementary material  The online version of this What is the Diagnosis?

article (https​://doi.org/10.1007/s0045​5-019-10057​-2) contains
supplementary material, which is available to authorized users.
Histologically, the mass was found to be a pyogenic granu-
* Ilker Burak Arslan loma (PG). The tracheotomy was closed on day 2 postop-
ilkerburakarslan@hotmail.com eratively. No complication was observed and the lesion did
not recur during follow-up. She gained 17 kg during the first
1
University of Health Science, Izmir Tepecik Egitim ve 12 months postoperatively (BMI 23.2 kg/m2).
Arastirma Hastanesi KBB Klinigi, Izmir, Turkey

13
Vol.:(0123456789)

Fig. 1  A transoral endoscopic view of a smoothly surfaced 4 × 3-cm
hypervascular mass in the oropharynx
Fig. 2  Contrast-enhanced axial images of the neck showing mild
homogenous enhancement but serious narrowing of the oropharyn-
geal airway
Discussion
A PG is an inflammatory vascular lesion that generally
presents as a red polypoid mass of (apparently) granula-
tion tissue that bleeds easily [1]. The aetiology remains
unknown, although the lesion was originally believed to
be a site of actinomycotic infection. It was thought that
a PG formed after an exaggerated, localised, connective
tissue reaction to minor trauma and/or chronic low-grade
13
İ. B. Arslan et al.: A Huge Oropharyngeal Pyogenic Granuloma in a Patient
Fig. 3  Reformatted sagittal CT images showing the mass protruding
into the Rima glottis and pushing the epiglottis anteriorly
Fig. 4  Ulceration, inflammation, and regenerative epithelium on the
surface epithelium (HE × 20)
irritation, thus opening a pathway for invasion of non-
specific microorganisms [2]. Also, bacterial and viral
infections, hormonal stimuli, drugs (retinoids, antiretro-
virals, and oncological agents), and iatrogenic stimulation
were thought to be in play. In the case series of Lin et al.,
chronic hepatitis C infection was associated with gastric
PG [1]. The underlying fibrovascular connective tissue
became hyperplastic, and proliferation of granulation tis-
sue triggered the formation of a PG.
İ. B. Arslan et al.: A Huge Oropharyngeal Pyogenic Granuloma in a Patient
Fig. 5  Epidermal collarette overlying the lobular arrangement of cap-
illary proliferation (HE × 40)
A PG may develop at any age, but is most common in the
second decade of life in females. The lesional size varies,
but rarely exceeds 2.5 cm in diameter. PG of the alimen-
tary tract is extremely rare, except in the oral cavity [1].
An oropharyngeal lesion is very rare [3]. Clinically, a PG
manifests as a smooth or lobulated exophytic lesion exhibit-
ing low-level, red erythematous growth on a pedunculated
(or sometimes sessile) base that is usually haemorrhagic.
Definitive diagnosis requires histopathological examination,
which reveals variably sized capillaries arranged in lobules
within a connective tissue stroma [4].
The most common complaints of PG patients are pain
and associated bleeding. Other symptoms include painless
swelling, dysphagia, odynophagia, voice changes, and short-
ness of breath [3, 5]. This is the first study to report on an
oropharyngeal PG that caused major weight loss.
We report a huge PG in a very rare site; the patient pre-
sented with dyspnea and weight loss. We found no possible
aetiological factor except a history of chronic hepatitis C
infection. At the 12-month clinical follow-up, the lesion had
disappeared.
References
1. Lin CY, Hsieh YC, Hsu CM, Chu YY, Yeh HC, Chen TD, Chiu
CT. Clinical and endoscopic features of gastric pyogenic granu-
loma. Adv Dig Med. 2014;1:118–25.
2. Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: vari-
ous concepts of etiopathologies. J Oral Maxillofac Pathol.
2012;16:79–82.
3. Ramasundram S, Mohamad I, Kumarasamy S, Ambu VK. Case
report unusual site of pyogenic granuloma: case report. Egypt J
Ear Nose Throat Allied Sci. 2017;18:83–5.
4. Udoji TN, Bechara RI. Pyogenic granuloma of the distal trachea
a case report. J Bronchol Interv Pulmonol. 2011;18(39):281–4.
https​://doi.org/10.1097/lbr.0b013​e3182​28f3b​1.
5. Krishnapillai R, Punnoose K, Angadi PV, Koneru A. Oral pyo-
genic granuloma—a review of 215 cases in a South Indian Teach-
ing Hospital, Karnataka, over a period of 20 years. Oral Max-
illofac Surg. 2012;16(3):305–9. https​://doi.org/10.1007/s1000​
6-012-0315-z.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Ilker Burak Arslan  MD
Samira Abdurahmanova Ozkara  MD
Engin Baser  MD
Ibrahim Cukurova  MD
13