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Traumatic ulcerative granuloma


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TUG is an interesting lesion that is often under-recognized by pathologists (other than oral pathologists). It presents clinically as an ulcer most often on the lateral or ventral tongue that usually has been present for several weeks, and measures such as filing down sharp teeth in the area has not resolved the lesion, raising the suspicion for cancer. It even feels indurated on palpation. However, trauma to the site is reported in less than 50% of cases.

Histologically, depending on when the lesion is biopsied, it will show myositis, with the usual fragmentation of muscle and muscle giant cells. The muscle sometimes shows a “checkerboard pattern”. What is very characteristic is the presence of many histiocytes between the fragmented muscles fibers, usually with eosinophils. The old name for it was “traumatic ulcerative granuloma with stromal eosinophilia (TUGSE)”. However, not every lesion has eosinophils. I suspect that very early or very late lesions do not show eosinophils.

So what are some of salient features?
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[*]It occurs only where there is muscle of course.
[*]The tongue is the most common site because it is frequently and easily traumatized.
[*]It is histologically characteristic, but remember that the pathogenesis is penetrating inflammation of the mucosa involving muscle. As such, it can occur as a result of trauma, but may also be seen in any ulcerative condition that because of its chronicity, becomes deeply penetrating eg. ulcerative oral lichen planus and major aphthous ulcers.
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The conventional trauma-associated type occurs mainly in older adults, but there is another peak at 6 months of age when the lower incisors erupt and the infant rakes the tongue over the teeth. I am not sure how common this is. In the adult type, it may be that the tongue is more flaccid with age as it loses tone making it easier to traumatize.
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Dr. Phillip McKee

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I remember photographing very many examples of this entity for Sook when she was preparing her book on oral pathology. It is very much a case of once seen hopefully never forgotten.
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