Foreign body granuloma in the tongue differentiated from tongue cancer: A case r

lNTRODUCTlON

The introduction of a foreign body into the tongue can occasionally occur as food is being chewed. In most situations this can lead to pain, swelling and irritation[1]. Such foreign bodies can usually be identified and diagnosedvisual inspection, especially if they are not buried in the muscle layer[2]. A clear history of foreign body introduction into the mouth, as well as a timely visit to the physician, can be conducive to the diagnosis[3]. Penetration of the tongue by a foreign substance can cause an acute inflammatory response and foreign bodies that remain in place may elicit a granulomatous inflammatory response[4]. The cause of granuloma in the tongue can be difficult to ascertain, especially without a clear history of foreign body ingestion. In this paper, we describe the case of a foreign body granuloma in the tongue of a Chinese woman. The initial diagnosis was tongue cancer but further examination revealed a foreign body in the tongue which was removedsurgery.

艾莉没有见到戴菲儿的合格证、发票、信誉卡、保修卡、使用说明……但她相信戴菲儿所说的每一句话。因为哀伤无法掩饰。因为她看到戴菲儿的哀伤，秦川的哀伤。她听到连接在他们之间的那根看不见的细细的线绳的崩断之音。一顿饭的时间，她成为主人，戴菲儿成为玩偶，世界就是这般离奇，充满变数。

另外，进口品最大的问题在于受制于进口备案等一系列手续。不过，随着跨境电商的发展，韩妆也成为受惠者之一。例如，近日阿里巴巴宣布与浙江自贸区达成合作，加快非特殊化妆品备案流程，帮助进口化妆品同步进入中国市场。未来，通过阿里巴巴统一备案的普通进口化妆品，从注册备案到获批周期大幅加快至3个月内。

CASE PRESENTATlON

Chief complaints

The patient recovered well and there were no complications during the 2-mo follow-up period.

History of present illness

The patient sought out a general practitioner because of pain and noticeable swelling in the tongue that persisted for over 1 mo. She was given a short course of antibiotics which provided no symptom relief.The patient was referred to the Department of Stomatology, where an oral surgeon prescribed oral maxillofacial magnetic resonance imaging (MRI). The imaging revealed abnormal signal intensities, as shown in Figure 1, which are indicative of tongue cancer. The patient then visited the ENT Department for further consultation.

The results of routine tests of complete blood count, kidney function and liver function were normal.

History of past illness

本世纪以来，儿童参与武装冲突的问题引起国际社会越来越多的关注，市场和互联网上涌现的大量自传、新闻报道、纪录片、小说和电影表明媒体和艺术在共同努力让世界了解此问题。参与武装冲突的儿童多是被绑架的儿童，年龄一般在5～18岁，他们被迫接受残酷的训练，被迫参与杀人劫掠行动，这些儿童被称为娃娃兵（child soldier）。在哥伦比亚、斯里兰卡、阿富汗、伊拉克以及非洲的一些国家，如几内亚、象牙海岸、利比里亚、塞拉利昂、乌干达等娃娃兵问题非常严重。联合国儿童基金会（UNICEF）等国际组织一直都在尽力解救娃娃兵，并努力帮助解救出的娃娃兵以健康的心理回归社会。

2.围绕提升专业能力素质构建专业支撑课程。支撑课程是对学员专业能力素质起基础和支撑作用的课程，对打牢学员的学科专业基础、掌握扎实的专业理论知识，提高对部队装备和训练变换的适应能力有着重要作用。对于这类课程的定位，要充分考虑部队任职岗位及未来岗位变化对学员专业能力的要求。既要注重让学员掌握宽厚的专业基础知识，又兼顾让学员掌握专业技术学习和训练的基本方法，形成知识迁移和自主学习的能力，为学员的后续发展进行知识储备。

Personal and family history

There was no specific personal and family history.

Physical examination

Intraoral examination showed mild swelling in a longitudinal 2 cm × 1.5 cm area on the left lateral aspect of the tongue. A hardened nodule with an ill-defined margin was found on the tongue. The nodule was the same color as the surrounding tongue tissue (normal color) and no clearly identifiable foreign bodies were observed on the tongue as shown in Figure 2.

Laboratory examinations

在其2013年3月发表的“美国小学数学结构之批评”一文中，马立平博士用下图比较了传统数学(左)和发现式数学(右)在内容和结构上的差异[7]：

Imaging examinations

The oral maxillofacial MRI showed abnormal and ill-defined signal intensities on the left side of the tongue (size: 1.6 cm × 1.2 cm × 2.0 cm; Figure 1) and multiple swollen cervical lymph nodes (up to 0.7 cm in size, in the submaxillary region and carotid sheath). The primary diagnosis was tongue cancer as reported by the specialists in the Department of Radiology. However, the doctors in the ENT Department reviewed the MRI images and considered the possibility of foreign body granuloma for two reasons. First, granuloma and cancer can have similar imaging features; and second, the shadow seemed to indicate that the tongue tissue was protected from foreign bodies, as shown by images taken in the transverse plane. During the initial clinical interview the patient denied a history of foreign body ingestion. To differentiate between the two possibilities, further examinations were conducted.

Further diagnostic work-up

Informed written consent was obtained from the patient for publication of this report and any accompany images.

FlNAL DlAGNOSlS

Foreign body (fish bone) granuloma in the tongue.

TREATMENT

After the surgery, the patient received antibiotics (ceftriaxone) with systemic steroids and the postoperative recovery was uneventful. The patient was discharged on the third post-operative day.

OUTCOME AND FOLLOW-UP

A 61-year-old woman was admitted to the Ear Nose and Throat (ENT) Department of our hospital complaining of pain and noticeable swelling of the tongue.

DlSCUSSlON

A diagnosis of tongue cancer is often considered in older adults with an enlarged tongue nodule/mass and localized pain[5]. The many differential diagnoses of a tongue mass include an inflammatory lesion and schwannoma[1]. A diagnosis of a granuloma attributable to an embedded foreign body is rare when there is no clear history of foreign body ingestion or oral trauma[6]. In the present case, the differential diagnosis of an irregular nodule with a smooth surface included cavernous hemangioma, anaplastic large-cell lymphoma, endophytic squamous cell carcinoma and Kaposi sarcoma of the tongue[7-10].Differential diagnosis is important as cancer treatment and enucleation of a foreign body granuloma differ greatly in terms of surgical preparation, operation, tongue reconstruction and patient consultation[11-13].

The patient had no previous medical history.

MRI is the preferred diagnostic modality for evaluating tongue cancer because abnormal MRI signals have been strongly associated with pathological findings[14]. However, MRI is not an ideal modality for differentiating tongue cancer from embedded foreign body granuloma with foreign body[15]. The signals associated with tongue cancer are hyperintensity in a T2-weighted image (WI) and heterogeneous enhancement in an enhanced T1 WI, similar to granuloma[14,16]. In the present case, the fish bone (shown by hypointense signals in both the T1 and T2 WIs) was difficult to detect by MRI[17], and not surprisingly the primary diagnosis of tongue cancer was consistent with the abnormalities found in the tongue by MRI and with the swollen cervical lymph nodes. Besides this, shifting of metal fragments under the effects of MRI can result in potential damage of vital structures. If the doubt of a metal foreign body is present, the contraindications of MRI should be considered[18].

Several studies used ultrasound to detect a suspected embedded foreign body in the tongue[3,4,6].The foreign bodies, which included a pequi spine, metal wire, and fish bone were visualized and localized accurately, demonstrating the utility of ultrasound for guiding therapeutic interventions.Multislice computerized tomography (CT) and cone beam CT also seem useful for visualizing embedded foreign bodies, although CTs have poor performance in terms of detecting wood[15]. Thus,when an embedded foreign body is suspected in a patient with an enlarged tongue mass, ultrasonography and CT can play an important role in the differential diagnosis[19].

In our case, the lesion was “walled off” on transverse images (Figure 2). This might indicate that the mass was “delimited” by a capsule. A similar sign was observed in an early case report of a patient with foreign body granuloma[16]. Thus, this sign might be a useful indicator of the need for further examinations (other than MRI). However, this issue requires further investigation.

CONCLUSlON

We reported the case of a woman with an enlarged tongue mass initially diagnosed with tongue cancer.The ENT specialists reviewed the MRI data and corrected the diagnosis to ‘foreign body in the tongue’based on oral ultrasound examination. The granuloma containing the fish bone was completely removed during surgery and post-operative pathological examination confirmed that the lesion was a granuloma. In cases with an enlarged tongue mass, oral ultrasound and/or CT examinations are important for differential diagnosis, to facilitate selection of the appropriate treatment method.

ACKNOWLEDGEMENTS

the Research Start-up Grant for Talent of Mianyang Central Hospital of China, No. 2021YJRC-001; and the Applied Technique Research and Development Program of Mianyang City of China, No. 2019YFZJ022.

FOOTNOTES

Xu R was the patient’s doctor in charge, reviewed the literature and contributed to manuscript drafting; Jiang ZH operated on the patient and contributed to manuscript drafting; Xia L reviewed the literature and was responsible for the revision of the manuscript for important intellectual content; All authors issued final approval for the version to be submitted.

The authors acknowledge the colleagues for participating in this study. We are deeply indebted to the patient who participated in this study.

The patient was referred for ultrasound examination of the tongue. The ultrasound device used a linear probe with a 13-MHz transducer. The acoustic picture was consistent with a linear hyperechoic foreign body, specifically a piece of bone, as shown in Figure 3. When asked about the possibility of fish bone ingestion or another foreign body in the tongue, the patient could not recall whether she had recently eaten fish. However, her daughter recalled that a meal containing fish (with bones) might have been served to the patient 2 mo prior to seeking medical assistance. Complete surgical enucleation of the lesion was then conducted. The mass with the fish bone was completely removed without compromising the capsule (Figure 4A), and no hemorrhagic accident occurred. The fish bone was 1.5 cm in length (Figure 4B). Post-operative pathological examination showed that the lesion was a granuloma containing collagen fibers, macrophages and chronic inflammatory cells.

The authors declare that they have no conflict of interest.

丁苯酞联合阿替普酶对急性脑梗死患者神经功能、认知功能和Hcy等血清学指标的影响 ……………… 朱 烨等（8）：1095

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

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阿东说：“蛮好。我姆妈原先每天七点半叫阿里起来，现在叫他提前起。把录音机带着，到东湖边去放哀乐。那里没有什么人，放多大声音都不怕。”

China

Zhen-Hua Jiang 0000-0001-5239-9154; Ran Xv 0000-0002-5381-111X; Li Xia 0000-0002-5529-884X.

以贯彻落实党的十八大精神为起点，顺应时代发展，回应民生诉求，在全市范围全面实施“水更清”行动计划，水生态文明建设再谱新篇章。

Ma YJ

Filipodia

Ma YJ