The New York State Dental Journal • APRIL 2014 35
A B S T R A C T
A dramatic presentation of a large ulcer on the dorsal
tongue of a recently hospitalized patient is presented.
The lesion was found to be nosocomial in origin, and
consistent with traumatic ulcerative granuloma with
stromal eosinophilia (TUGSE). A review of the cur-
rent pathogenic mechanisms, differential diagnosis
and management of TUGSE is included.
An ulcer is a soft tissue defect characterized by full-thickness loss
of overlying epithelium, extending beyond the basement mem-
brane. Most oral ulcers are painful due to exposure of nerve end-
ings to the oral environment. Although ulcers in general have
overlapping clinical and histopathological features, there are
subtle clues that may guide the practitioner toward a definitive
diagnosis. Oral ulcers may vary in shape, number, location, age of
onset and duration. These features, coupled with possible etiolog-
ical factors, can be used to obtain a sound initial clinical impres-
sion.1-4 This issue has been explored comprehensively, and efforts
have been made to develop clinically based diagnostic tools for
the recognition and classification of oral ulcers.5
Traumatic ulcerations of the oral mucosa are the most com-
mon type of ulcers.2 They usually result from an intimate relation-
ship between dental hard tissues and mucosal surfaces. The ex-
tensive mobility of soft tissues such as the tongue and, to a lesser
extent, labial and buccal mucosa, may result in a higher risk for
traumatic events. Exposure to sharp foodstuffs, faulty toothbrush-
ing habits and chemical insults are also important factors.5,6
Traumatic ulcerative granuloma with stromal eosinophilia
(TUGSE) is a unique self-limiting lesion of putative traumatic
genesis.3,7 It may however, present with ominous clinical fea-
tures. Because of its clinical appearance and unusual biological
behavior, TUGSE has to be differentiated from serious conditions,
such as malignancies, deep fungal and bacterial infections, and
chronic ulcerative immune-mediated conditions.3,8,9
We present in this paper an unusual case of lingual TUGSE
that was associated with trauma induced by tracheal intubation. In
addition, we discuss its pathogenic mechanism and management.
A 60-year-old Caucasian female presented to the Advanced Edu-
cation in General Dentistry (AEGD) Clinic at the University at
Buffalo School of Dental Medicine. Her chief complaint was “My
tooth is loose and I have not been able to taste food well for a
while.” Her past medical history included hypertension, rheuma-
toid arthritis and an allergy to penicillin. Medications included
naproxen 275 mg, lisinopril 20 mg, lovastatin 10 mg and chon-
An Unusual Affliction of the Tongue
Amarpreet Sabharwal, B.D.S., M.S.; Michael Hatton, D.D.S., M.S.; Alfredo Aguirre, D.D.S., M.S.
36 APRIL 2014 • The New York State Dental Journal
droitin sulfate 300 mg daily. The AEGD resident noted gross al-
teration of the dorsum of the tongue. An oral and maxillofacial
surgeon and oral and maxillofacial pathologist were asked to con-
sult on the patient.
Intraoral examination revealed a large ulceration on the an-
terior two-thirds of the dorsal tongue, measuring 2.7 cm x 1.8
cm (Figure 1). The lesion was indurated, exophytic, erythema-
tous, tender on palpation and showed extensive loss of filliform
and fungiform papillae. No other oral mucosal abnormalities
were noted. The neck was clinically normal to examination.
A detailed conversation with the patient revealed a significant
nosocomial event that occurred three months prior to our ini-
tial oral examination. The patient had been admitted to a local
hospital because of pneumonitis. Our communication with the
patient’s physician disclosed that she had been intubated with
an oral tube for one week during her hospital stay. After reso-
lution of the pulmonary infection, the patient was discharged
uneventfully from the hospital. While recuperating at home,
she noticed that her tongue was sore and felt swollen. As part
of the initial physical examination, a panoramic film was also
obtained. It revealed bilateral radiopacities in the area of the
carotid arteries (Figure 2).
To further characterize the bilateral radiopacities seen on
panoramic image, we requested a Doppler ultrasound imaging
study on carotid arteries, results of which revealed mild bilateral
plaques at the level of the carotid bulbs. No evidence of he-
modynamically significant stenosis was found (<40% blockage),
and no bruits were noted on auscultation of the carotid arter-
ies. Our initial clinical impression was a traumatic ulcer due to
a prolonged oral intubation. A two-week follow-up showed no
resolution of the lesion, and an incisional biopsy was obtained.
The patient was also referred for serum laboratory studies to
rule out nutritional deficiencies. Serum levels of iron, folic acid,
vitamin B12, niacin, riboflavin and pyridoxine were all within
The histological diagnosis was “Non-specific ulcer with florid
granulation tissue and features of traumatic ulcerative granu-
loma with stromal eosinophilia” (Figures 3 and 4). One week
postoperatively, normal healing of the biopsy incision site was
noted (Figure 5). However, the overall size and clinical appear-
ance of the lesion remained unchanged. We then prescribed a
compounded ointment of 0.05% clobetasol and 1% clotrimazole
for topical application four times per day. Evaluation of the lesion
was done at intervals of two weeks, one month (Figure 6) and
two months (Figure 7). After two months, the lesion exhibited
virtually complete resolution but displayed extensive loss of the
filliform and fungiform papillae. The patient remains free of any
mucosal lesions on multiple follow-up appointments.
Figure 1. Initial presentation of lesion on dorsum of tongue.
Figure 4. High magnification showing granulation tissue with
numerous interspersed, conspicuous eosinophils, neutrophils and
lymphocytes amid proliferating blood capillaries. (Hematoxylin-
eosin stain; magnification 200x.)
Figure 2. Panoramic film exhibiting bilateral radiopacities in
Figure 5. One-week post biopsy exhibiting normal healing of
biopsy site with persistence of lesion.
Figure 3. Necrosis of surface epithelium covered by fibrin mesh is
seen in upper field of this photomicrograph. In addition, superficial
and deep inflammatory cell infiltrates and hyperemic blood capillar-
ies are observed. (Hematoxylin-eosin stain; magnification 40x.)
Figure 6. One-month post biopsy and three weeks of topical
applications of compounded steroid/antifungal medication.
The New York State Dental Journal • APRIL 2014 37
TUGSE is a self-limiting ulcerative lesion of the oral mucosa that
frequently affects the tongue of adults. The term TUGSE was pro-
posed by Elzay in 1983.11 Using an experimental murine model,
Bhaskar and Lilly12 showed a relationship between trauma and
TUGSE lesions. However, it is now well documented that not all
TUGSE cases have a history of trauma.11-14 It has also been sug-
gested that microbial toxic products may result in an exaggerated
eosinophil response.11,15 Although, an ultra-structural investiga-
tion failed to show any microbial products, it revealed the pres-
ence of occluded blood vessels, which could lead to focal isch-
emia, thus magnifying the size of the ulcer.15
Demographic data from the two largest case series on TUGSE
show a slight female predilection, with most lesions seen in the
5th to 7th decades of life, and lasting from a few days to several
months. While the average age of presentation was 57 years, the
lesions occurred over a very wide age range (6-92 years); the dor-
sum and lateral surfaces of the tongue were involved in about half
of the cases. The buccal mucosa was the second most commonly
involved site.11,13 Interestingly, in the second largest case series
published on TUGSE, only 7/38 cases (18%) revealed a history
Clinically, TUGSE can resemble a wide variety of pathologic
entities (traumatic, infectious, neoplastic, autoimmune and reac-
tive). Pain is typically associated with ulcerative lesions of inflam-
matory origin on oral mucosal surfaces. However, in the largest
case series published so far in the English language literature, only
17% of the TUGSE lesions presented with pain.11 The presence
of indurated borders and the failure to heal mimic the clinical
presentation of oral neoplasia. In addition, primary malignan-
Figure 7. Two months post biopsy with continued use of
topical medication showing only two small areas of superficial
38 APRIL 2014 • The New York State Dental Journal Download full-text
cies from minor salivary glands, metastasis and hematological
disorders may also present as ulcerative lesions on the tongue.
Infectious diseases like histoplasmosis, blastomycosis, tuberculo-
sis and oral manifestation of systemic diseases such as Wegener’s
granulomatosis, lupus erythematosus and sarcoidosis may also
Histologically, a typical TUGSE lesion presents with an area
of ulceration covered by a fibrin mesh with interspersed neutro-
phils. The underlying connective tissue consists of granulation
tissue with CD30 + T-lymphocytes, histiocytes, plasma cells and
mast cells. Of significant concern is the predominance of CD 30+
T-lymphocytes, some of which have shown monoclonal TCRg re-
arrangement, raising the possibility of the emergence of a CD 30+
lymphoproliferative disorder of T cells.14,16,17 The most conspicu-
ous microscopic finding is the presence of intact and degranulat-
ing eosinophils in the stroma.3,11,13 Stromal eosinophilia in oral
mucosal diseases is commonly seen in fungal and parasitic infec-
tions, vesiculobullous diseases and some rare disorders, such as
Kimura’s disease, angiolymphoid hyperplasia with eosinophilia
and Langerhans cell histiocytosis.18 The significance of eosino-
philia in TUGSE remains a mystery. The studies of Elvoic et al.19
have shown deficient tumor growth factor (TGF) levels in TUGSE
compared to normal wound-healing processes. It is well known
that T cells secrete eosinophil chemotactic (interleukin-1 and tu-
mor necrosis factor) and maturation factors (interleukin-5). It is
thus plausible that an increase in the indigenous T-cell popula-
tion leads to active recruitment of eosinophils in TUGSE.13
Although TUGSE is a self-limiting disease, persistent cases
may require intervention. In such cases, it has been documented
in the literature that a biopsy may promote the restoration of
the typical cytokine microenvironment associated with normal
wound healing.19,20-22 Thus, we believe this diagnostic procedure
should be the first step in both establishing a diagnosis and in
treating such lesions. When healing is not observed, despite a bi-
opsy, intra-lesional infiltration of triamcinolone and/or topical
corticosteroid application has been proposed as a treatment op-
tion.10,23 We decided to compound an ultra-potent topical steroid
(0.05 % clobetasol ointment) with 10 mg clotrimazole for daily
q.i.d. topical applications. The results were highly satisfactory and
led to complete resolution of this recalcitrant lesion. p
Queries about this article can be sent to Dr. Hatton at firstname.lastname@example.org.
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Pain is typically associated with ulcerative
lesions of inflammatory origin on oral