Benign Symptomatic Squamous Papilloma of the Uvula: A Case Report and Review of the Literature

Squamous papillomas are benign lesions that are associated with human papillomavirus infection. Oral squamous papilloma of the uvula is uncommon and rarely causes symptoms. In this case report, we present a rare case of symptomatic squamous papilloma of the uvula where the patient complained of mass-related symptoms such as dysphagia and choking sensation. The lesion was surgically excised using electrocautery with excellent outcomes. In addition, we reviewed literature related to the lesion.


Introduction
Oral squamous papillomas (OSPs) are asymptomatic neoplasms of the oral cavity, growing mostly in the soft palate [1]. Although these neoplasms are benign, their appearance is worrisome when they mimic other malignant oral lesions [2]. In rare cases, some patients present with disturbing symptoms such as dysphagia, odynophagia, and globus sensation; in serious conditions, patients might present with obstructive symptoms, especially if the lesion has a substantial overgrowth [3]. The definitive diagnosis depends on clinical and histopathological examinations [1]. Treatment modalities differ; however, treatment mainly relies on the surgical removal of the lesion [3]. In this case report, we present a rare case of symptomatic squamous papilloma of the uvula growing up to 2 cm. The lesion was excised using electrocautery with excellent outcomes.

Case Presentation
A 24-year-old female presented with a complaint of dysphagia to solids and odynophagia for 2 months. These symptoms started progressively and were associated with continuous throat clearing, globus sensation, and on-and-off choking sensation, especially during sleep. Upon examination, a long pedicled lesion was noticed extending from the uvula. Flexible nasopharyngoscopy revealed an elongated uvula touching the posterior part of the tongue. Post-nasal drip and acid reflux were noticed in the pharyngeal cavity. No ulceration or discoloration was seen on the lesion.
The patient underwent surgery under general anesthesia, in which the lesion was excised using electrocautery. A macroscopic histopathology examination revealed a soft tissue measuring 2 cm x 0.5 cm x 0.3 cm. Microscopic findings showed a polyp lined by benign stratified squamous epithelium ( Figure 1). The stroma showed collagen and stellate cells -results consistent with squamous cell papilloma (Figures 1, 2). The patient's postoperative course remains unremarkable with complete resolution of symptoms, even though she had been discharged on oral proton pump inhibitors for acid reflux, oral antihistamines, and steroid inhalers.

Discussion
OSPs are benign, asymptomatic soft tissue neoplasms of the oral cavity. Their macroscopic appearance is characterized by pedunculated, usually, solitary exophytic extensions with a cauliflower-like surface [2]. It is reported that OSPs are associated with human papillomavirus (HPV) especially HPV-6, HPV-11, and HPV-16 and predominantly occur in the second to fourth decades [3].
Symptomatic squamous papillomas are rare. The location and size of the lesion play a role in the emergence of symptoms [1,4]. Five similar case reports of symptomatic uvular papillomas have been found in the literature ( Table 1). Less than 25% of oral squamous papillomas are greater than 1 cm [5]. However, only one of the five cases was reported to be greater than 1.5 cm, all of which had similar mass-related symptoms. In this study, the patient had a relatively large mass of about 2 cm.  In a case series involving 464 cases of oral papillomas, 34% of the cases were in the palatal complex (hard palate, soft palate, tongue, and uvula). Only 4% of the cases were located in the uvula [1].

Reference Gender Age Symptoms
Another retrospective study was conducted to analyze 207 biopsies of oral papillomas performed from 1996 to 2012. Most of the lesions occurred in the soft palate (23%). The second most common site was the posterior border of the tongue (20.9%). The lesions were more predominant in males than females (ratio = 1.26:1) [2].

Conclusions
Symptomatic squamous papillomas are influenced by the location. For instance, uvular papilloma can be associated with symptoms due to its distinct site of occurrence. Although it is rare, uvular squamous papilloma is reported to be associated with mass-related symptoms such as dysphagia and choking sensation. Although lesions greater than 1 cm are few, even small-sized uvular papillomas appear to cause symptoms. The treatment of choice predominantly relies on electrocautery.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.