10.5005/jp-journals-10011-1286 Subba Rao Vanukuru et al CASE REPORT
Schwannoma Subba Rao Vanukuru, Vivekanandh Reddy Gangili, Jithendar Reddy Kubbi Navadeepak Kumar Korvipati, MS Muni Sekhar
ABSTRACT Schwannoma in the head and neck is usually arising from parapharyngeal space, but masseteric schwannoma is very rare. We report a schwannoma arising from masseter muscle in a 60-year-old male patient, who was presented with a history of painless swelling on the left cheek for 3 years and the mass was surgically removed from the left cheek of a 55-year-old man and pathological examination revealed schwannoma with Antoni A and B patterns, and numerous hyalinized masses (Verocay bodies) surrounded by spindle-shaped cells and was diagnosed as schwannoma. Keywords: Schwannoma, Vagus nerve, Sympathetic nerve, Intracapsular enucleation, Nerve function. How to cite this article: Vanukuru SR, Gangili VR, Kubbi JR, Korvipati NK, Sekhar MSM. Schwannoma. J Indian Aca Oral Med Radiol 2012;24(2):162-164.
and skin over the swelling is pinchable and is not fixed to the underlying structures (Fig. 2). On intraoral examination, there was no abnormality detected and normal flow of saliva is seen. Based on these features, we suspected that it was an epidermoid cyst, occlusal radiograph was taken with puffedcheek technique but reveals no abnormality in the parotid duct, on aspiration thick blood-tinged fluid was seen and then referred to department of oral surgery; the swelling was excised and sent for histopathology. The histopathology report reveals the spindle-shaped tumor cells arranged at focal places in palisading pattern resembling Antoni type A tissue cells in the deeper areas of the connective tissue stroma. The connective tissue at most of the outer areas demonstrates disorderly arrangement of
Source of support: Nil Conflict of interest: None declared
INTRODUCTION Benign peripheral nerve tumors of the oral cavity include schwannoma, neurofibroma, and nerve sheath myxomas, mucosal neuroma, traumatic neuroma and granular cell tumor, but oral localization is uncommon (about 10% of head and neck schwannoma).1 The most frequently involved regions are in decreasing order: Mobile portion of the tongue, palate, cheek mucosa, lips and gingiva.2 Schwannoma (neurilemmoma) is an encapsulated perineural tumor originating from Schwann cells associated with motor, sensory or autonomic peripheral nerves.3 There is no age or gender predilection. 4 Schwannomas are occasionally found in the region of the head and neck region as a slow-growing benign tumors, it has been reported to occur in head and neck region in approximately 25 to 40% of total schwannoma cases.5
Fig. 1: A swelling was seen on left side of face
CASE REPORT A 60-year-old male presented with 3 months history of painless swelling on the left cheek region which was progressive in growth and he also complains of tinnitus on the left ear (Fig. 1). On extraoral examination, a roughly oval-shaped swelling measuring of size approximately 1 × 2 cm is seen on the left cheek region. On palpation, the swelling was firm in consistency with no local raise in the temperature
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Fig. 2: Closer view of the swelling
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B
Figs 3A and B: Histopathological picture showing the Antoni type A and type B cells
cells and fibers resembling Antoni B tissue. Normal hyalinized masses (Verocay bodies) surrounded by spindleshaped cells are seen. The intervening delicate connective tissue shows haphazardly arranged collagen fibers comprising chiefly of lymphocytes. An overlying orthokeratinized stratified skin epithelium with melanin incontinence at basel layer and containing adnexal structures like sebaceous glands and hair follicle is noted. Juxta epithelial hyalinization is also evident predominantly. The histopathological diagnoses were suggestive of schwannoma (Figs 3A and B). DISCUSSION It is well known that schwannoma occurring in the head and neck region mostly originates from the vagus nerve or sympathetic nervous system. It is also known that the incidence of vagal schwannoma is 2 to 3 times higher than that of sympathetic schwannoma. Vagal schwannoma is typically characterized by dysphagia and hoarseness. Sympathetic schwannoma is characterized by Horner’s syndrome. In most cases, however, there are no symptoms, thus is difficult to identify the neurological origin based on physical examination.6,7 This tumor occurs at all ages and there was no predilection for sex. It is a slow growing, rather circumscribed, submucosally located tumor that may be painful. No characteristic clinical features appear. It may occur at any site of oral cavity. The present paper reports the unusual presentation of schwannoma on the left side of face which was mimicking like a cyst. On radiographically, no relevant findings were seen, only histopathalogically it was diagnosed as a schwannoma.
CONCLUSION In cases of schwannoma arising in the head and neck region, surgical resection may cause fatal nerve damage unlike other tumors. Therefore, treatments assuring the preservation of neurological functions are needed. REFERENCES 1. Yamazaki H, Kaneko A, Ota Y, Tsukinoki K. Schwannoma the mental nerve: Usefulness of preoperative imaging: A case report. Oral Surg Oral Med Oral Pathol Radiol Endod 2004;97. 2. Chrysomali E, Papanicolaou SI, Dekker N, Regezi JA. Benign neural tumors of the oral cavity. A comparative immunohistochemical study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:381-90. 3. Singh D, Pinjala RK. Schwannoma of the cervical vagus nerve. Pediatr Neurosurg 2007;43:403-05. 4. Chiapasco M, Ronchi P, Scola G. Neurilemmoma (schwannoma) of the oral cavity. A report of 2 clinical cases. Minerva Stomatol 1993;42:173-78. 5. Ducatman BS, Scheithauer BW, Piepgras DG, Reiman HM, Ilstrup DM. Malignant peripheral nerve sheath tumors. A clinicopathologic study of 120 cases. Cancer 1986;57: 2006-21. 6. Gilmer-Hill HS, Kline DG. Neurogenic tumors of the cervical vagus nerve: Report of four cases and review of the literature. Neurosurgery 2000;46:1498-503. 7. de Araujo CE, Ramos DM, Moyses RA, Durazzo MD, Cernea CR, Ferraz AR. Neck nerve trunks schwannomas: Clinical features and postoperative neurologic outcome. Laryngoscope 2008;118:1579-82.
ABOUT THE AUTHORS Subba Rao Vanukuru (Corresponding Author) Professor and Head, Department of Oral Medicine and Radiology, Aditya Dental College, Beed, Maharashtra, India e-mail:
[email protected]
Journal of Indian Academy of Oral Medicine and Radiology, April-June 2012;24(2):162-164
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Subba Rao Vanukuru et al
Vivekanandh Reddy Gangili
Navadeepak Kumar Korvipati
Professor and Head, Department of Oral Medicine and Radiology, SVS Institute of Dental Sciences, Mahabubnagar, Andhra Pradesh, India
Postgraduate Student, Department of Oral Medicine and Radiology SVS Institute of Dental Sciences, Mahabubnagar, Andhra Pradesh, India
Jithendar Reddy Kubbi
MS Muni Sekhar
Senior Lecturer, Department of Oral Medicine and Radilogy, SVS Institute of Dental Sciences, Mahabubnagar, Andhra Pradesh, India
Professor and Head, Department of Oral Medicine and Radiology SVS Institute of Dental Sciences, Mahabubnagar, Andhra Pradesh, India
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