Carla Duffoo DO,1 Ghassan Tranesh MD,1 Mohammed Barawi MD1 1Department of Gastroenterology, 2Department of Pathology, St. John Medical Center, Detroit, MI
INTRODUCTION
Squamous papillomas of the oral cavity are common, benign, painless lesions that arise from the squamous epithelium of the lips, tongue, pharynx, esophagus and others. They are most often found in the mucosa of the hard and soft palate, but they can also be found in the uvula. Although there is an association with the human papilloma virus (HPV), they are neither transmissible nor threatening.1 These lesions, although benign, are thought to be pre-malignant.2 They are also generally asymptomatic; only two cases of symptomatic squamous papillomas arising from the uvula have been reported in the literature.3,4 Here we present a case of a symptomatic squamous papilloma of the oral cavity.
CASE REPORT
A 41-year-old African American woman presented to our institution with nausea, vomiting and several episodes of hematemesis. She also described a feeling that “something was stuck in the back of her throat,” and she had been able to manipulate an ‘object’ and push it to the side of her inner cheek, but on occasion this ‘object’ would protrude out of her mouth when she coughed. She reported having a choking sensation and difficulty swallowing solids but not liquids. She did not report any weight loss, odynophagia, abdominal pain, hematochezia or melena. She also denied having any previous episodes of similar symptoms and had no history of gastrointestinal bleeding. She denied any oral intake over the previous 24 hours and had no history of food impaction. The patient underwent an esophagogastroduodenoscopy (EGD) two years prior to this presentation, which only revealed the presence of gastritis. Upon presentation to the hospital, her vital signs were stable, except for mild tachycardia. Her hemoglobin was 13.2 g/dL. A computerized tomography (CT) of the neck was unremarkable except for a possible right parotid gland lymph node versus nodule. Due to her complaints of acute dysphagia and hematemesis, the patient underwent an urgent EGD. On endoscopy, a long, finger-like polypoid lesion was seen projecting from the soft palate; this lesion measured approximately 2 cm in length. The lesion had a cauliflower like tip with areas of superficial ulceration (Figures 1 (a) and (b)). The remainder of the exam was normal. It was difficult to clearly visualize the exact origin of this lesion; therefore, an otorhinolaryngology (ENT) consult was requested. The patient underwent a flexible fiberoptic evaluation, which revealed an elongated polypoid lesion arising from the uvula. She was taken to the operating room for surgical excision of the lesion. Pathology revealed a 2 cm long polypoid, pedunculated, papillary tissue that was pink-tan in color, containing a fibrovascular core consistent with a squamous papilloma with acute and chronic inflammation that was not associated with HPV (Figures 2 (a) and (b)). The patient’s postoperative course was uneventful and she reported complete resolution of her symptoms.
DISCUSSION
Squamous cell papillomas are small exophytic growths composed mostly of parakeratinized, stratified, squamous epithelium that are arranged in papillary projections, giving them a cauliflower-like appearance.5 They are common benign neoplasms of the oral mucosa that typically present as a single pedunculated mass and are often found on the hard and soft palate. The tongue was described as the most common site of growth in one series,6 while others report that the soft palate-uvula complex was the most common site.7,5 In our patient, the lesion was seen as a long, polypoid elongation of the uvula with a cauliflower-like appearance at the tip (Figures 1 (a) and (b)). These lesions are not considered contagious or transmissible, however the literature suggests an association with HPV-6 and HPV-11.3 Squamous papillomas of the oral cavity are generally diagnosed in people ages 30 to 50 years; however, in one series, the age range was 2 to 91 years.5 There is conflicting information regarding the impact of gender on the predisposition for this condition, but it seems that these lesions may be more common in men. One study revealed a greater percentage of white patients, while other series did not make a reference to racial distribution.5 These lesions tend to be asymptomatic and are often found incidentally. There have been two case reports of symptomatic squamous papillomas, with dysphagia as the presenting symptom.3,4 None of the cases reported hematemesis as a complaint. The cases in which the papilloma caused symptoms reported that the lesion was greater than 1 cm in length; this was the case in our patient who presented with complaints of dysphagia and hematemesis. We believe the hematemesis was due to vomiting of ingested blood as a result of mechanical trauma to the papilloma as it protruded out from the patient’s mouth when she coughed. In one series, 24% of cases (34/141) had lesions that were greater than 1 cm in length, and of those, 7.8% (11/141) were between 2 cm and 3 cm long.5 It is postulated that the greater the length of the papilloma, the more likely it is to cause symptoms. Squamous papillomas of the oral cavity are not typically associated with malignancy, unlike those found in the larynx,3 but surgical removal is the treatment of choice. Recurrence after excision is uncommon.