Papilloma of the Tongue: About a Clinical Case at the Center Hospitalier Universitaire CHU Gabriel Toure in Bamako ()
1. Introduction
Tongue papillomas are benign epithelial tumors of the tongue lining. It is a precancerous lesion of viral origin caused by the Human papilloma virus HPV. The prevalence of papillomavirus infections in this anatomical area has increased sharply in recent years [1].
Human papillomavirus (HPV) infection is recognized as one of the most common sexually transmitted infections [2]. The association of the human papillomavirus with cervical cancer has also been recognized for several years and more recently, its association with other types of cancer has also been observed, especially in the ENT (Otolaryngology) sphere [3]. It constitutes a major diagnostic and therapeutic problem. Clinically, papillomas look like other benign papillary epithelial tumors like common warts and genital warts.
Oral papillomatosis occurs at any age with a higher frequency in the thirties and is mainly observed on the palatal, lingual, labial and gingival mucosa in decreasing order of importance [4].
Surgical removal is the treatment of choice by routine excision or laser ablation [3] [4].
We describe the clinical and histological manifestations of a particular type of oral papilloma in a young woman.
2. Observation
It was a young woman aged 28 years resident in Siguiri (Guinea), housewife, married for 9 years, heterosexual, received in consultation on 15/O2/2018 for a painless masse on the anterior third of the back of the tongue.
We propose to describe the clinical and histological manifestations of a particular type of oral papilloma in a young woman.
The history of the disease goes back to about six months marked by the progressive installation of a painless, non-bleeding swollen tongue evolving on a permanent background associated with a swelling of the left lower eyelid, emaciation, non fever quantified, diarrhea, and anorexia. In front of this table, she performed several medical treatments such as unspecified tablet and mouthwash without success. Faced with the increase in the number and volume of the swelling, she consults us for better treatment. She had no particular medical or surgical history.
She had two pregnancies with two parities with a living child, and a deceased child.
Regarding her lifestyle, she started sex at the age of 15 with a notion of three sexual partners before marriage and frequent oral sex.
Oral examination found a mass in cauliflower (bunch of grapes) developed on the anterior third of the back of the tongue, painful not bleeding on contact, sessile and of soft consistency (Figure 1).
The examination of the cervico-facial skin found a swelling in the level of the lower left eyelid of furunculated appearance aspect.
The general examination found a temperature at 37.8˚C, a weight at 48 kgs; a height of 160 cm with a body mass index (BMI) of 18.75.
The gyneco-obstetric examination did not find a condyloma in the genital area.
HIV serology test came back as type 1 positive with a CD4 count of 244ml.
The excision of the lesion was performed under general anesthesia with orotracheal intubation. The consequences were simple, allowing it to be discharged 3 days postoperatively (Figure 2).
Histopatological examination (HPE) of the mass showed an acanthotic stratified para-keratinized squamous epithelium containing small parts of connective tissue and koilocytes containing connective tissue nuclei evoking papilloma (Figure 3).
We did not notice a recurrence after a follow-up at 6 months and 9 months.
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Figure 1. Whitish lesion in cauliflower on the back of the tongue.
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Figure 2. Excision of the lesion and stitches on the banks.
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Figure 3. Histological appearance of the papilloma.
3. Comments
Oral papillomatosis occurs at any age, especially between 20 and 40 years old, and is found in both men and women [5].
Lingual localization is the most common but can be localized in any part of the oral cavity [5] [6].
The papilloma can be isolated as in the present observation or multiple associated with other locations. According to the literature, the papilloma is generally asymptomatic as is the case in our patient [5] [6] [7].
Human papilloma virus is implicated in the development of oral papilloma. This oral localization is mainly due to contamination by types 6 and 11 which have a low risk of malignant transformation and would be in approximately 70% responsible for the lesions. HPV at high risk of developing malignant pathology are 16 and 18 [2] [3] [5].
The coexistence of oral papilloma and HIV immunodeficiency found in our patient has been reported in the literature. People who are immunosuppressed with HIV with a CD4 count of less than 200/ml are more likely to be exposed to human papillomavirus infection [5].
Papilloma is a sexually transmitted infection. Transmission by contaminated objects has also been described. The mode of transmission by direct contact could be evoked in our patient before the notion of oral-genital relationships.
The oral location in the present study could be explained by sexual behavior. The site of predilection is the tongue and the palate but the lesion can occur on any surface of the oral cavity [1] [4].
Clinically, the papilloma is in the form of painless pink or whitish papules of cauliflower appearance based on implantation more often pedunculated as reported in our case [1].
The differential diagnosis is made with condyloma and warts. Warts have a predilection for the gum and the alveolar ridge, while the condylomas are larger than the papilloma with a wider base and appear from pink to red. . Blood tests such as the enzyme immunoassay and the polymerase chain reaction test can be performed to detect the presence of the virus [1] [6] [7]. We were unable to carry out this examination given the inadequacy of the technical platform.
The diagnosis of certainty is based on the histology which confirmed the papilloma. Surgical removal of the lesion is the treatment of choice for oral squamous papillomas, either by surgical or electrocautery excision, cryosurgery, intralesional interferon injections or laser ablation [7] [8]. In the present study, the treatment chosen was complete excision under general anesthesia. The recurrence rate is low especially in the isolated form [1] [6]. The recurrence factors are incomplete excision and HIV infection.
Although associated with HIV, we did not notice a recurrence after a 6 and 9 month follow-up.
4. Conclusion
Tongue papilloma is a benign proliferative lesion characterized by slow, painless growth. Its pathogenesis is linked to HPV. Early diagnosis and surgical excision should be done to avoid recurrence.