Journal of Medicine, Radiology, Pathology & Surgery (2016), 2, 2023

CASE REPORT

Ancient Schwannoma of the tongue

Mahima V. Guledgud1, Saikrishna Degala2, Karthikeya Patil1, Meghana Maruthi1
Department of Oral Medicine & Radiology, J.S.S. Dental College & Hospital, J.S.S. University, Mysore, Karnataka, India, 2Department of Oral & Maxillofacial
Surgery, J.S.S. Dental College & Hospital, J.S.S. University, Mysore, Karnataka, India
1

Keywords:
Ancient Schwannoma, neurilemmoma,
Schwannoma, tongue
Correspondence:
Dr.Mahima V. Guledgud, Department of Oral
Medicine & Radiology, JSS Dental College &
Hospital, JSS University, Mysore-570015,
Karnataka, India. Email: mahimamds@gmail.
com

Abstract
Ancient Schwannoma is a rare Schwannoma variant which is a painless, slow-growing
benign neoplasm of Schwann cell origin. It is relatively a rare tumor in the head and
neck region. We report a case of ancient Schwannoma of the tongue in a 38-year-old
female patient, who presented with a slowly progressing painless mass over the tongue.
Investigatory impression of ultrasonography and fine-needle aspiration cytology of this
lesion was suggestive to be a benign tumor of muscle/nerve origin. An excisional biopsy
of the mass with primary closure was done. Afinal diagnosis of ancient Schwannoma was
given based on histopathological examination.

Received: 05 November 2015;

Accepted: 03 January 2016
doi: 10.15713/ins.jmrps.47

Introduction
Schwannoma, otherwise known as neurilemmoma, is a benign
neoplasm originating from Schwann cell.[1] It can originate
from any nerve covered with Schwann cell sheath, which
includes cranial nerves (except for the first and second cranial
nerves), spinal and autonomic nervous system.[2,3] It is relatively
uncommon although about 25-48% of all cases manifest in the
head and neck region.[1] The most common type is acoustic
neuroma affecting the vestibulocochlear nerve.[4] However,
about 1-2% occurs intraorally with tongue being the most
common site followed by the palate, floor of mouth, oral mucosa,
and mandible.[5,6]
Ancient Schwannoma is an uncommon Schwannoma
variant which is a slow growing encapsulated painless benign
neoplasm.[3]
Case Report
A 38-year-old known hypotensive female patient presented to us
with an asymptomatic slow growing swelling on the tip of the
tongue crossing the midline, of 20years duration. Initially, it
appeared as a pea sized swelling when the patient was 2months
pregnant at the age of 18years and gradually increased to the
present size. It was painless and there was a loss of clarity of
20

speech. History of occasional bleeding from the swelling was

elicited.
Clinical examination revealed a conical soft tissue mass
measuring about 5cm 3cm 2.5cm in its greatest dimension
on the dorsal tongue extending inferiorly onto the ventral
surface. Dorsally, it appeared pink and was velvety in texture,
firm, and hard in consistency except for the tip of the mass which
was smooth and soft. Ventrally, the mass was smooth, lobulated,
firm, and cystic not fixed to the overlying tissue with dilated
vessels [Figures1 and 2]. It was non-tender, uncompressible,
and irreducible on palpation. There was no significant weight
loss and lymphadenopathy. There was no evidence of similar
type mass elsewhere in the body.
Routine blood investigation revealed, hemoglobin
and red blood corpuscle count to be 9.8 g%
and 2.9 million cells/mm3, respectively, giving an impression
as moderate anemia. Ultrasonography [Figure 3] and fineneedle aspiration cytology (FNAC) were suggestive of benign
tumor possibly of muscle/nerve origin. The patient underwent
excisional biopsy of the mass under general anesthesia, and the
specimen was sent for histopathological examination.
The patient was taken up for the excisional biopsy under
general anesthesia. Nasoendotracheal intubation was done. The
demarcation of the incision was performed with methylene blue.
The tongue was pulled out by placing two black braided silk
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Guledgud, et al.

Ancient Schwannoma

Figure 1: (a) Dorsal view of the tongue showing a well-defined pink, velvety textured conical shaped mass, (b) conically shaped tumor of the
tip of the tongue extending onto the ventral surface of the tongue, (c) tip of the tumor which appears smooth and shiny

Figure 2: (a) Right lateral view of the tumor, (b) left lateral view of the tumor, (c) ventral surface of the tumor of the tongue showing dilated
blood vessels

Figure 3: Ultrasonography of tongue, (a) Well-defined lobulated

hypoechoic soft tissue mass measuring 3.8 cm 2.8 cm in size,
(b) ultrasonography with Doppler flowmetry: Color flow shows
moderate vascularity in the tumor

sutures 3-0 which was fixed to the surgical field, and symmetry of
both the sides was maintained. Local infiltration of lignocaine 2%
with adrenaline in the ratio of 1:80,000 was infiltrated around the
mass. As the lesion was present on the anterior one-third of the
tongue extending from the dorsal to the ventral surface, Harris,
Blair, Hendrick incision was used which allowed the excision
of the mass as a whole. Full thickness incision was made by the
blade No.15. Electrocautery was used for better hemostasis.
The mass was excised, and the rest of the tongue was sutured by
absorbable Vicryl 3-0 round body in a layered fashion. During
the surgical procedure, copious amount of saline irrigation was
used.
The excised specimen [Figure4] was sent for histopathological
examination and revealed spindle cells with elongated wavy
nuclei and fibrillar cytoplasm. Prominent nucleus, palisading

Figure 4: Excised specimen of the tumor measuring about 4.5 cm

3 cm in its greatest dimension

with verocay bodies among Antoni A and B tissues were seen

with evidence of myxoid degeneration and cystic changes.
Thereby, a final diagnosis of ancient Schwannoma was given
[Figure5].
The patient was reviewed for 3weeks post-operatively and
showed no signs of paresthesia of tongue or lip. Tongue shape
was maintained [Figure6]. Improved motor movements, speech
and swallowing were observed. No alteration in taste sensation

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Guledgud, et al.

Ancient Schwannoma

Figure 5: Classic microscopic appearance of schwannoma, (a) The

more cellular Antoni A pattern with palisading nuclei surrounding
pink areas known as verocay bodies (hematoxylin and eosin stain;
original magnification, 100), (b) the Anotoni B pattern with looser
stroma, fewer cells and myoid change (hematoxylin and eosin
stain; original magnification, 100), (c) hyalinized stromal area
(hematoxylin and eosin stain; original magnification, 100)

Figure 6: Post-operative photograph

was noted. The patient was referred for phono-audiological

evaluation for speech rehabilitation.
Discussion
Schwannomas are encapsulated nerve sheath benign neoplasms
composed of Schwann cells. Theodar Schwann (1810-1882), a
German anatomist, physicist and co-founder of the cell theory
discovered these cells which are derived from ectomesenchymal
neural crest cells during the 4thweek in utero. In 1908, Jos
Verocay discovered Schwannoma.[6] Etiology is said to be
unknown; however, it is assumed that the lesion arises from the
propagation of Schwann cells at a point inside the perineurium,
22

which causes compression and displacement of the surrounding

normal nerve.[7] It is most often difficult to find out the nerve
of origin. It is not possible to differentiate between tumors of
lingual, hypoglossal, and glossopharyngeal nerves in about 50%
of intraoral cases. The tumor can be seen associated with Von
Recklinghausens disease.[8]
Intraoral Schwannomas account to about 1-2% of all head
and neck tumors. It can present at any age, however, most
often presents at second to the fifth decade of life with no sex
predilection. The most common site involved is the tongue
followed by the palate, floor of mouth, oral mucosa, and
mandible.[5] Schwannomas are usually asymptomatic lesions
which are slow growing, smooth surfaced, solitary, and of variable
size. They usually present as a painless mass, although pain and
paresthesia can occur. Other symptoms such as dysphagia,
disturbances in mastication and phonation, and Tinels sign
(an electric like shock when the affected area is touched) might
be present depending on the size of the tumor and location. In
our case, the tumor was large in size located on the tongue, and
there was a disturbance in phonation.[8]
Considering the above-mentioned features, neurofibroma,
traumatic neuroma of long standing duration, fibroma, lipoma,
fibrolipoma, rhabdomyoma, and leiomyoma can be considered
in the differential diagnosis. In some cases, squamous cell
carcinoma, sarcomas, and glandular malignant processes may
present with similar clinical features.[4]
Diagnostic investigations include ultrasonography,
computed tomography, magnetic resonance imaging (MRI)
scan, and FNAC. On ultrasonography, tumor presents as
well-definedhypoechoic nodules which are oval or lobulated
with posterior acoustic enhancement, and on color Doppler
ultrasonography it appears hypervascular.[9] MRI scan reveals
Schwannoma of the tongue to be isointense to the muscles on
the T1-weighted images, whereas homogeneously hyperintense
on the T2-weighted images. Other features on MRI are smooth,
well-demarcated borders without invasion into the surrounding
muscles.[10] In our case, we did not perform MRI because the
mass was well circumscribed and demarcated. This feature was
confirmed on ultrasonography. Peripheral smear of FNAC
appears as a benign mesenchymal tumor.[11]
For excision of the tongue Schwannomas, various kinds
of incisions can be used. Each can lead to a different degree of
exposure, infection rates, residual tongue function, and postoperative appearance. Incisions such as Pichler incision, Kole,
Davalbakta, and Lamberty incision, Morgan et al. and Kacker
etal. incision could be used but due to the size and extent of the
lesion being reported, the Harris, Blair, Hendrick V shaped
incision was employed. It gave easy access for complete excision
of the mass with minimum removal of the uninvolved tongue
tissue. Along with the mass, tongue muscles such as transverse
and inferior longitudinal muscle fibers were also removed which
are present at the tip of the tongue and at the anterolateral border
of the tongue. In cases where only tip of the tongue is involved,
Pichler incision is commonly employed and for tongue mass
which is extending anteroposteriorly, the Kole, Davalbakta, and
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Ancient Schwannoma

Lamberty incision and Morgan et al. and Kacker et al. incision is

used.[12-15]
Histopathological examination is the only definitive key
for final diagnosis. The tumor tissue comprises of Antoni A
and Antoni B type cells. Streaming fascicles of spindle-shaped
Schwann cells is characteristic of Antoni A cells which palisade
around central, acellular eosinophilic areas known as verocay
bodies. Antoni B cells are less cellular and less organized, and
spindle cells are seen within the loose, myxomatous stroma.[1]
The term ancient Schwannoma was coined by Ackerman
and Taylor in 1951. It is an extremely rare Schwannoma variant
which is a slow growing tumor of Schwann cell origin of a
long duration. Although it cannot be clinically differentiated
from Schwannoma but histopathologically shows evidence of
degenerative changes such as hemorrhage, hemosiderin deposits,
hyalinization, inflammation, fibrosis, and nuclear atypia which
precisely indicate aging of the tumor. They are benign, slow
growing with rare malignant transformation.[3,10]
The treatment of choice is complete excision of the tumor.
The recurrence rate of Schwannoma of the tongue is said to be
low; however, the recurrence rate of vestibular Schwannoma has
been reported to be about 0.05% for enlarged translabyrinthine
approach, 0.7% for retrosigmoid approach and 1.8% for middle
cranial fossa approach.[16]
Conclusion
To conclude, the clinical appearance of ancient Schwannoma in
this case was one of its kinds-a 38-year-old female patient had
this slow growing tumor in her oral cavity for 20years! Ancient
Schwannomas are relatively rare tumors of long duration occurring
in the oral cavity which can present between second to fifth decades
of life with no sex predilection with the most common site being
the tongue. It can be differentiated with Schwannoma only by
histopathologically examination showing degenerative changes.
Complete excision of the tumor is the definitive treatment with
good prognosis. It has been reported to have low recurrence rate
and least incidence of malignant transformation.
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How to cite this article: Guledgud MV, Degala S, Patil K,

Maruthi M. Ancient Schwannoma of the tongue. JMed Radiol
Pathol Surg 2016;2:20-23.

Journal of Medicine, Radiology, Pathology & Surgery Vol. 2:1 Jan-Feb 201623