Figure 1
T1-weighted images
Axial (A) and coronal (B) T1-weighted images showed an iso-intense mass at the left paramedian tip of the tongue
An uncommon location of a schwannoma
SectionHead & neck imaging
Case TypeClinical Cases
AuthorsMatteoli Marco, Brunelli Laura, Tesei Jacopo, Finocchi Vanina, Fantozzi Luigi Maria
Connected authors
27 years, female
Clinical History
A 27-year-old woman presented with a slowly enlarging painless swelling at the tip of the tongue. She was in good health, had history of local traumas and no familial history of malignancy. Intraoral examination revealed a well-demarcated, soft/elastic, spherical mass, in the left paramedian site of the tip of the tongue.
Imaging Findings
Linear ultrasound examination of the lesion with 15Mhz sound identified a well demarked, round, hypoechoic, heterogeneous mass, with a maximum diameter of 1 cm; colour flow imaging and power Doppler showed peripheral high flow and centripetal vascularisation (Fig 1a, b).
An MRI examination was carried out.
The study was aimed at the region of the tongue and documented the presence of an oval formation of about 9 mm in maximum diameter, in the tip of tongue, paramedian to the left, which was iso-intense on T1-weighted images (Fig. 2), hyperintense on T2-weighted images (Fig. 3), and showed peripheral enhancement after contrast administration (Fig. 4). It was compatible with solid tissue. No suppression of signal was seen on the T1-Fat Sat series.
The lesion enhanced with a centripetal pattern, peripherally in the early images (Fig. 4b), showing full filling in later phases (Fig. 4a). The diffusion shows no restriction of diffusion, ruling out an inflammatory aetiology (Fig. 5).
An MRI examination was carried out.
The study was aimed at the region of the tongue and documented the presence of an oval formation of about 9 mm in maximum diameter, in the tip of tongue, paramedian to the left, which was iso-intense on T1-weighted images (Fig. 2), hyperintense on T2-weighted images (Fig. 3), and showed peripheral enhancement after contrast administration (Fig. 4). It was compatible with solid tissue. No suppression of signal was seen on the T1-Fat Sat series.
The lesion enhanced with a centripetal pattern, peripherally in the early images (Fig. 4b), showing full filling in later phases (Fig. 4a). The diffusion shows no restriction of diffusion, ruling out an inflammatory aetiology (Fig. 5).
Discussion
The patient was taken to the operating room for a transoral excision under general anesthesia.
The microscopic examination revealed that the tumour had a myxomatous stroma with some areas showing cells arranged in a nuclear pattern consistent with Verocay body’s. Immunohistochemically, the tumour cells were diffusely positive to S-100 protein. From the histological features, a diagnosis of conventional schwannoma was formulated.
Schwannoma is a benign lesion derived from the Schwann cells that may arise from any myelinated nerve fibre [3]. Approximately 25–45% of all schwannomas occur in the head and neck [3]. Less commonly, schwannomas present in the oral cavity, and of this subset, the tongue is the most frequently involved [1, 2]
Schwannoma of the tongue is a relatively rare tumour of the head and neck [3], although it has been previously described [3, 4] mainly at the base of the tongue (2/3 posterior and 1/3 anterior), but very rarely in correspondence with the tip [4]. It always presents as a painless mass on the lingual surface and tumour sizes are variable, depending on the duration from onset to presentation. Most schwannomas are found during a routine physical examination.
Magnetic resonance imaging of schwannoma of the tongue found in literature [4, 7] illustrated a well circumscribed mass hyperintense-isointense on T1 weighted sequence, hyperintense on T2, and rapid inhomogeneous enhancement after gadolinium.
Our case was unique for this uncommon behaviour, completely iso-intense on T1, very hyperintense on T2 and slowly, but homogeneously enhancing with gadolinium.
Despite the clinical hypothesis of cystic formation due to the consistence of the mass and the position of it, differential diagnosis based on the MRI and echographic findings were an atypical haemangioma [8], a mixoid neurothekeoma [9], a Fibromyxoid tumour of soft parts [10], a tongue mucocele [11, 12], a unique oral manifestation of sarcoidosis [13], a ranula [5, 6] or a desmoid cyst [14]
In conclusion, schwannoma of the tip of the tongue must be taken into consideration as a differential diagnosis in the painless swellings of this region of the tongue in young patients without a history of trauma or smoking.
The microscopic examination revealed that the tumour had a myxomatous stroma with some areas showing cells arranged in a nuclear pattern consistent with Verocay body’s. Immunohistochemically, the tumour cells were diffusely positive to S-100 protein. From the histological features, a diagnosis of conventional schwannoma was formulated.
Schwannoma is a benign lesion derived from the Schwann cells that may arise from any myelinated nerve fibre [3]. Approximately 25–45% of all schwannomas occur in the head and neck [3]. Less commonly, schwannomas present in the oral cavity, and of this subset, the tongue is the most frequently involved [1, 2]
Schwannoma of the tongue is a relatively rare tumour of the head and neck [3], although it has been previously described [3, 4] mainly at the base of the tongue (2/3 posterior and 1/3 anterior), but very rarely in correspondence with the tip [4]. It always presents as a painless mass on the lingual surface and tumour sizes are variable, depending on the duration from onset to presentation. Most schwannomas are found during a routine physical examination.
Magnetic resonance imaging of schwannoma of the tongue found in literature [4, 7] illustrated a well circumscribed mass hyperintense-isointense on T1 weighted sequence, hyperintense on T2, and rapid inhomogeneous enhancement after gadolinium.
Our case was unique for this uncommon behaviour, completely iso-intense on T1, very hyperintense on T2 and slowly, but homogeneously enhancing with gadolinium.
Despite the clinical hypothesis of cystic formation due to the consistence of the mass and the position of it, differential diagnosis based on the MRI and echographic findings were an atypical haemangioma [8], a mixoid neurothekeoma [9], a Fibromyxoid tumour of soft parts [10], a tongue mucocele [11, 12], a unique oral manifestation of sarcoidosis [13], a ranula [5, 6] or a desmoid cyst [14]
In conclusion, schwannoma of the tip of the tongue must be taken into consideration as a differential diagnosis in the painless swellings of this region of the tongue in young patients without a history of trauma or smoking.
Differential Diagnosis List
Schwannoma of the tip of the tongue
Ranula
Atypical haemangioma
Mixoid neurothekeoma
Fibromixoid tumour of the soft parts
Sarcoidosis nodule
Desmoid cyst
Mucocele
Final Diagnosis
Schwannoma of the tip of the tongue
References
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[2] Batra K, Rai AK, Chaudhary N, et al. (2007) Two cases of neurilemmoma of the tongue. Ear Nose Throat J 86:679-681 (PMID: 18225629)
[3] Zachariades N (1984) Schwannoma of the oral cavity: review of the literature and report of a case. J Oral Med 39:41–43 (PMID: 6585495)
[4] Marc Cohen, Marilene B. Wang (2009) Schwannoma of the tongue: two case report and review of the literature. Eur Arch otorhinolaryngol 266:1823–1829 (PMID: 19130068)
[5] Sameer KS, Mohanty S, Correa MM, Das K. (2012) Lingual thyroglossal duct cysts--a review. Int J Pediatr Otorhinolaryngol 76 (2): 165-8. (PMID: 22192899)
[6] Schoop RA, Sassen ML. (2007) A man with a swelling underneath his tongue. Diagnostic image 151 (43): 2381. (PMID: 18019215)
[7] Daniel Jethanamest et al. (2006) Radiology Quiz Case 1. ARCH OTOLARYNGOL HEAD NECK SURG VOL 132, DEC 2006 (PMID: 17178953)
[8] Qureshi SS, Chaukar DA, Pathak KA, Sanghvi VD, Sheth T, Merchant NH, Dcruz AK. (2004) Hemangioma of base of tongue. Indian J Cancer 41:181-3 (PMID: 15659874)
[9] Kim HJ, Baek CH, Ko YH, Choi JY. (2006) Neurothekeoma of the tongue: CT, MR, and FDG PET imaging findings. AJNR Am J Neuroradiol 27 (9): 1823-5. (PMID: 17032850)
[10] Ranganathan Kannan et al. (1996) Ectomesenchymal chondromyxoid tumor of the anterior tongue A report of three cases. Oral and maxilllo facial pathology Vol. 82 No. 4 (PMID: 8899780)
[11] Acar B, Günbey E, Babademez MA, Karabulut H, Oktem H, Karasen RM. (2010) A rare presentation of mucocele of the tongue. J Craniofac Surg 21 (6): 2032 (PMID: 21119499)
[12] Michael Lypka, M.D., D.M.D., and Jeffrey Hammoudeh, M.D., D.D.S. (2011) Tongue Mucocele. N Engl J Med 365:e9July 28, (PMID: 21793741)
[13] Blinder D, Yahatom R, Taicher S. (1997) Oral manifestations of sarcoidosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 83 (4): 458-61 (PMID: 9127377)
[14] Lozano Blanco I, Pérez Climent F, Carbonell Sanchis R, Giménez Vaillo F, Oliver Guasp C. (1995) Giant dermoid cyst of the floor of the mouth. An Otorrinolaringol Ibero Am 22(6):601-8. (PMID: 8579233)
Case information
| URL: | https://www.eurorad.org/case/10283 |
| DOI: | 10.1594/EURORAD/CASE.10283 |
| ISSN: | 1563-4086 |
Figure 2
T2-fat sat weighted images
Axial (A) an sagittal (B) T2-fat sat weighted images showed a homogeneous hyper-intense mass.
Figure 3
HASTE sequence
Diffusion weighted (HASTE) sequences showed no restriction of diffusion.
Figure 4
T1-weighted images with gadolinium contrast
Axial (B) and coronal (A) T1-weighted images with gadolinium contrast showed a centripetal, angioma-like enhancement with peripheral enhancement in the early phase (A) and complete homogeneous enhancement in the later phase (B).
T1-weighted images
Axial (A) and coronal (B) T1-weighted images showed an iso-intense mass at the left paramedian tip of the tongue
Radiology Unit. S.Andrea Hospital. Roma, Sapienza University.
Radiology Unit. S.Andrea Hospital. Roma, Sapienza University.
T2-fat sat weighted images
Axial (A) an sagittal (B) T2-fat sat weighted images showed a homogeneous hyper-intense mass.
Radiology Unit. S.Andrea Hospital. Sapienza University. Rome. Italy
Radiology Unit. S.Andrea Hospital. Sapienza University. Rome. Italy
HASTE sequence
Diffusion weighted (HASTE) sequences showed no restriction of diffusion.
Radiology Unit. S.Andrea Hospital. Sapienza University. Rome. Italy
Radiology Unit. S.Andrea Hospital. Sapienza University. Rome. Italy
T1-weighted images with gadolinium contrast
Axial (B) and coronal (A) T1-weighted images with gadolinium contrast showed a centripetal, angioma-like enhancement with peripheral enhancement in the early phase (A) and complete homogeneous enhancement in the later phase (B).
Radiology Unit. S.Andrea Hospital. Sapienza University. Rome. Italy
Radiology Unit. S.Andrea Hospital. Sapienza University. Rome. Italy
Trans-oral sonography of the tip of the tongue
Sonography with 15 Mhz sound revealed an hypo-echoic mass, with thick walls and an “angioma like” Doppler pattern.
Radiology Unit. S.Andrea Hospital. Rome, Sapienza University.
Radiology Unit. S.Andrea Hospital. Rome, Sapienza University.
Sonography with 15 Mhz sound revealed an hypo-echoic mass, with thick walls and an “angioma like” Doppler pattern.
Radiology Unit. S.Andrea Hospital. Rome, Sapienza University.
Radiology Unit. S.Andrea Hospital. Rome, Sapienza University.