The Laryngoscope
Lippincott Williams & Wilkins, Inc., Philadelphia
©
2002 The American Laryngological,
Rhinological and Otological Society, Inc.
Obstructive Congenital Epulis: Prenatal
Diagnosis and Perinatal Management
Pankaj Kumar, MD; Harold Hyon Soo Kim, MD; Gerald D. Zahtz, MD; Elsa Valderrama, MD;
Andrew M. Steele, MD
Objective: To describe a multidisciplinary ap-
proach for delivery room management of congenital
epulis. Study Design: Case reports. Methods: Report-
ing of two cases of congenital epulis and review of the
literature. Results: Antepartum ultrasonography
demonstrated massive intraoral masses in two fe-
tuses whereby concerns regarding the patency of the
airway at birth necessitated development of a multi-
disciplinary team of maternal–fetal medicine, neona-
tal–perinatal medicine, anesthesiology, and otolaryn-
gology. Surgical excision was performed before
delivery in one infant and after complete delivery in
the other without a need for endotracheal intubation
and general anesthesia. Feeding was started early,
and both infants were discharged after brief hospital
stays. Pathological findings were consistent with con-
genital epulis. Differential diagnosis and options for
surgical intervention are discussed, including ex
utero intrapartum treatment. Conclusions: A multi-
disciplinary approach to antenatally identified con-
genital intraoral masses facilitates care at birth. Sur-
gical treatment in this milieu may be simple and
complete at the time of delivery. Key Words: Congen-
ital epulis, ex utero intrapartum treatment, airway
obstruction.
ment of choice. We report two cases of congenital epulis
identified as intraoral masses by antepartum ultrasonog-
raphy that were successfully resected at the time of deliv-
ery. Both of these cases were remarkable, one for the
necessity of immediate resection because of large size and
possible airway compromise and the other because of early
identification at 29.5 weeks of gestation. The clinical, mor-
phological, and histological features and differential diag-
nosis of congenital epulis and various management op-
tions are presented.
CASE REPORTS
Case 1
A 35-year-old white woman, gravida 3, para 2, was referred
to the Division of Maternal–Fetal Medicine at Long Island Jewish
Medical Center, New York, when an antepartum ultrasound at 35
weeks of gestation revealed an intraoral mass. Routine antepar-
tum laboratory test results were unremarkable. Maternal history
was significant for a previous child with trisomy 21. Repeat
ultrasonography at 36 weeks revealed two homogeneous, solid
masses with narrow stalks protruding from the mouth (Fig. 1).
The patient was followed with weekly sonograms, and the masses
seemed to increase in size. Fetal swallowing appeared to be
normal, and there was normal amniotic fluid volume. Color flow
Doppler indicated a patent nasal airway. At 37 weeks, amniocen-
tesis revealed a normal, 46 XX karyotype and an immature lung
profile. A multidisciplinary meeting among physicians in mater-
nal–fetal medicine, neonatal–perinatal medicine, anesthesia, and
otolaryngology was held. A management plan was developed con-
sidering risks and benefits of various approaches. A decision was
made to resect the lesions on delivery of the head if there was
airway compromise secondary to the mass. The neonatologist and
otolaryngologist discussed the plan with the family. At 39 weeks
of gestation, when a mature lung profile was expected, an elective
cesarean section was performed with the patient under spinal
anesthesia and with the multidisciplinary team in attendance.
The operating room was prepared for care of both the mother and
the newborn. Equipment at hand for the infant included a radiant
warming table, suction device, oxygen source, and usual equip-
ment for resuscitation. In addition, a tracheostomy set was avail-
able. Personnel in the operating room included two teams of
physicians and nurses, each team dedicated to either the mother
or the child. The maternal team included obstetricians, obstetri-
cal anesthesiologist, and surgical nurses. The other team con-
sisted of otolaryngologists (attending and his resident), neonatol-
ogists (attending and the fellow), a pediatric anesthesiologist, and
Laryngoscope, 112:1935–1939, 2002
INTRODUCTION
Congenital epulis, also known as congenital gingival
granular cell tumor, is a rare, benign intraoral tumor
found only in the newborn. It arises predominantly from
1
the maxillary or mandibular alveolar ridges and usually
regresses spontaneously without recurrence. However,
large or multiple lesions may interfere with respiration or
deglutition. In such a case, surgical excision is the treat-
Presented as a Poster at the Eastern Section Meeting of the Trio-
logical Society, Philadelphia, PA, January 26, 2002.
From the Division of Neonatal–Perinatal Medicine (P.K., A.S.) and the
Departments of Otolaryngology (H.K., G.Z.) and Pathology (E.V.), Schneider
Children’s Hospital, Long Island Jewish Medical Center, The University
Hospital and Long Island Campus for the Albert Einstein College of Med-
icine, New Hyde Park, New York, U.S.A.
Editor’s Note: This Manuscript was accepted for publication July 2,
2002.
Send Correspondence to Andrew M. Steele, MD, Division of Neona-
tal–Perinatal Medicine, Schneider Children’s Hospital, New Hyde Park,
69-01 7th Avenue, New York, NY 11040, U.S.A. E-mail: steele@lij.edu
2
Laryngoscope 112: November 2002
Kumar et al.: Obstructive Congenital Epulis
1935