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Clinical Challenge
September 2016

Painless, Nonhealing Submental Ulcer

Author Affiliations
  • 1Department of Otorhinolaryngology–Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
  • 2Department of Pathology, Rush University Medical Center, Chicago, Illinois
JAMA Otolaryngol Head Neck Surg. 2016;142(9):913-914. doi:10.1001/jamaoto.2016.0086

A man in his 20s was evaluated for a 9-month history of a nonhealing submental ulcer that formed where a laceration caused by an assault had recently closed. The area bled, expressed serosanguineous drainage, and was prone to crust formation. He reported poor dental health and no exposure to tuberculosis. He smoked cigarettes daily and consumed alcohol socially. Significant medical history included excision of a mass at the ulcer site 8 years before that healed uneventfully. Surgical pathologic examination revealed areas of histiocytes surrounded by lymphocytes and a focus of central necrosis. Acid fast bacilli and fungal stains and cultures were negative. There was a 1.5 × 1.5-cm ulcerated, submental lesion within the mid-portion of a scar. It was nontender, bled with manipulation, and appeared to be fixed to the underlying mandible. Examination of the oral cavity revealed caries and periodontal disease. There was no palpable cervical adenopathy. The patient received a course of antibiotic therapy. When symptoms persisted, he underwent a biopsy. Because the biopsy was concerning for malignancy, an excision with frozen section margins was then performed. The lesion was present within old scar tissue and had an infiltrative growth pattern. Microscopically there were epithelioid or spindle-shaped tumor cells with atypical vesicular nuclei and pale eosinophilic cytoplasm with areas of necrosis (Figure, A). Tumor cells stained strongly positive for EMA, CD34, and pankeratin and demonstrated loss of INI-1 immunostaining (Figure, B and C).

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