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Lingual Osseous Choristoma in a 7-Year-Old

R. Kenneth Sims, IV1 • Richard Byrd, MD2,3

AFFILIATIONS:
1Medical Student, Texas A&M School of Medicine (EnMed), Houston, Texas
2Clinical Assistant Professor, Texas A&M School of Medicine, Houston, Texas

3Pediatrician, Kelsey-Seybold Clinic, Houston, Texas

CITATION:
Sims RK, Byrd R. Lingual osseous choristoma in a 7-year-old. Consultant. Published online October 24, 2022. doi:10.25270/con.2022.10.000007

Received February 23, 2022. Accepted June 30, 2022.

DISCLOSURES:
The authors report no relevant financial relationships.

DISCLAIMER:
The authors report that informed patient consent was obtained for publication of the images used herein.

CORRESPONDENCE:
R. Kenneth Sims, IV, Texas A&M College of Medicine (EnMed), 1020 Holcombe Blvd, Houston, TX 77030 (ksims1997@tamu.edu)


Introduction. A 7-year-old girl presented at her pediatrician’s office and was found to have a non-obstructed nose with pink turbinate, 2 noninflamed palatine tonsils, and an approximately 8 mm posterior midline flesh-colored tongue mass that was not seen on examination 14 months earlier (Figure 1).

Patient history. The patient had a history of nighttime snoring, daytime somnolence, and mouth breathing over several years. Her symptoms worsened over the previous 2 weeks. At her evaluation at the pediatrician’s office, she was referred to an otorhinolaryngologist for further evaluation.

 

Figure 1. Photo of the patient's protruded tongue with posteriorly located tongue mass.

At the otorhinolaryngologist’s office, the tongue mass was confirmed, and the patient was noted to have normal nasal cavity mucosa with a midline septum and no turbinate hypertrophy. Palatine tonsils were not enlarged. The uvula was midline. No cervical adenopathy or thyromegaly were appreciated.

Diagnostic examination. A lateral radiograph of the neck was obtained, revealing moderately enlarged adenoid tissue and a partially calcified posterior tongue mass (Figure 2). An ultrasound of the patient's neck revealed a normal thyroid gland, no thyroid nodules, and no evidence of a thyroglossal duct cyst.

Treatment and management. A surgeon discussed treatment options with the patient’s parents and they agreed that the patient would undergo an adenoidectomy under general anesthesia with removal of the posterior tongue mass to be submitted for pathology.

Figure 2. Lateral radiograph with tongue mass (circled) and enlarged adenoid tissue (arrows).

After extensive decalcification of the posterior tongue mass prior to sectioning, histological examination characterized a well-circumscribed fragment of bone covered with squamous epithelium. A diagnosis of lingual osseous choristoma was made.

Patient outcome. At 2 years postoperative, the patient’s mother reported, “she cannot even tell there was a tongue bump, and [the patient] has not complained. She no longer snores, has daytime sleepiness, or mouth breathing.” The patient’s mother also stated that “surgery did very well and there has not been a relapse.”

Discussion. A choristoma is a heterotopic tissue growth derived from any of the embryological germ cell layers.1 There are various types of choristomas, such as osseous, cartilaginous, gastric mucosal, and glial.1 Osseous choristomas are rare, typically benign, hard, well-circumscribed, pedunculated masses.1,2 They are known to grow on the tongue and consist of mature compact bone covered by lingual stratified squamous epithelium.1-3 The exact pathogenesis of osseous choristomas is not well understood, but prominent theories suggest formation is due to congenital malformation, prior trauma, or chronic inflammation.4 Histologically, many lingual osseous choristomas have been noted to contain osteocytes, osteoblasts, and haversian canals.2 They tend to grow in the maxillofacial region and are usually midline and immediately anterior to the foramen cecum of the tongue.2,3 The mass can range in size from 3 mm to 50 mm.1

Most cases (70%) of lingual osseous choristomas occur among female patients and patients under 40 years of age (average age 28 years).2 Several case reports show incidence in the pediatric population as well, with the youngest child being 5 years old.2

Approximately half of patients are asymptomatic, but up to 68% of symptomatic patients report gagging or globus sensation.2 Other symptoms may include dysphagia, tongue swelling, pain, and dysphonia.2

The pediatric-focused differential diagnosis for lingual osseous choristoma includes benign neoplasms such as a mucocele, lymphangioma, dermoid cyst, fibroma, lingual thyroid nodule, and schwannoma, as well as malignant growths such as sarcoma, papilloma, and Burkitt lymphoma (Table).5-16 In addition, local or systemic infiltrative processes, such as amyloidoma, may present similarly to lingual osseous choristoma.16

The most common treatment method is excisional biopsy; laser or carbon dioxide ablation has also been used.2

 

Table. Differential Diagnosis of Tongue Masses5-16

Diagnosis

Etiology

Oral Presentation

Treatment

Osseous choristoma

Benign, mesoderm-derived heterotopic growth of compact bone

Single, hard, well-circumscribed, pink, pedunculated; often midline and posterior

Excisional biopsy

Mucocele

Salivary gland duct obstruction. Secretions dissect into surrounding tissue.

Painless; Exophytic lesion, sometimes pedunculated; Nonspecific oral location.

Excisional biopsy

Lymphangioma

Benign tumor of lymphatic vessels

Pink to reddish-blue, soft, compressible

Excisional biopsy

Dermoid cyst

Random malformation during fetal development

Multicystic mass

Excisional biopsy

Papilloma

HPV 6 or 11 infection

Single, isolated, pedunculated with finger-like projections

Excisional biopsy or laser ablation

Fibroma

Dense collagen collection from chronic inflammation; trauma

Dome-shaped, pink, smooth

Excisional biopsy

Lingual thyroid nodule

Failure of complete thyroid tissue descent during fetal development

Posterior dorsal surface of tongue, midline; smooth and nodular

If obstructive, excisional biopsy and thyroid hormone replacement

Sarcoma

Mesenchyme-derived malignant cell growth

Variable; nonulcerated, painless, lobulated, or smooth

Excisional biopsy with adjunct radiation and/or chemotherapy

           

Conclusion. Lingual osseous choristomas are rare lesions derived from ectopic embryological tissue and often present in early to mid-adulthood, as well as in the pediatric population. Though these lesions are not malignant, they may cause symptoms which impact quality of life. Furthermore, proper diagnosis of a pediatric tongue mass requires histological examination to rule out other etiologies, such as malignancy, making excisional biopsy the mainstay treatment for patients with this presentation. As for the patient in this case report, appropriate diagnostic and surgical steps were taken to rule out more severe tongue mass etiologies and achieve an accurate diagnosis. The patient is doing well 2 years after surgery.

References

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