schwannoma is a benign tumor arising from neuroectodermal schwann cell of cranial , intraspinal , peripheral and autonomic nerve sheaths . lesions in head and neck region account for 25 - 45% of extra - cranial schwannomas . however , it rarely involves infra - orbital nerve and are uncommon in the maxillary and buccal space . these tumors usually present as slow growing nodular mass and can mimic any benign growth in the head and neck . the treatment of extra - cranial head and neck schwannomas is surgical and the approach depends on the location and extent of the tumor and the nerve involved . this paper describes a case of schwannoma arising from infra - orbital nerve , presenting as slow growing nodular swelling in the buccal space . the lesion was approached through skin incision and completely resected . at the time of exploration , the lesion was observed to emanate from the nerve trunk of peripheral branch of infra - orbital nerve , which was dissected and preserved . only nine cases of infra - orbital nerve schwannoma are previously reported , which we discuss in relation to our experience . a 40-year - old male patient presented with a chief complaint of painless swelling over left side of face . the patient first noticed the swelling about a year back , which had grown gradually to its present size . patient also complained of mid paresthesia over left cheek since past few months . on examination , a localized , nontender , firm , round swelling of about 4 cm was evident over left side of mid - face , extending from below the infra - orbital margin to upper lip [ figure 1 ] . the skin was pinch - able over the lesion , except at the center of the lesion . the overall clinical presentation was suggestive of a benign sub - cutaneous lesion and differential diagnosis included lipoma , fibroma , dermoid cyst , epidermoid cyst and neurogenic tumor . lesion presenting as large sub - cutaneous nodular swelling ultrasonography was advised to study nature , size and extent of the lesion . the ultrasonogram showed well - defined , heterogeneous oval mass of 45 mm  30 mm  23 mm within the buccal sub - cutaneous tissue with no orbital , maxillary sinus or underlying bone involvement [ figure 2 ] . aspiration biopsy of the lesion showed spindle shaped cells predominantly arranged in antoni a pattern around verocay bodies , with less organized antoni b tissue in few places [ figure 3 ] . diagnosis of schwannoma , probably arising from terminal branch of infra - orbital nerve was established . ultrasonogram showing a heterogeneous oval mass within the sub - cutaneous tissue h and e stained section of aspirate showing verocay bodies ( arrow head ) surrounded by spindle shaped cells arranged in orderly parallel fashion ( arrows ) surgical excision of the lesion was planned and executed under local anesthesia . after attaining adequate anesthesia , linear incision of about 3 cm the lesion was well - encapsulated , and freed from surrounding tissue by blunt dissection [ figure 4a ] . portion of skin overlying the center of the lesion appeared thinned and was included in the excised nodule . at the time of exploration , the lesion was found to emanate from the nerve trunk of peripheral branch of infra - orbital nerve , which was dissected and preserved [ figure 4b ] . ( a ) exposure of the lesion through skin incision ; ( b ) dissected tumor attached to the nerve trunk of peripleral branch of infra - orbital nerve ( block arrow ) h and e stained section ( 10 ) of excised specimen showing spindle shaped cells predominantly arranged in antoni a pattern around verocay bodies ( black arrow ) , with less organized antoni b tissue in few places ( red arrow ) . vessel in schwannoma having wide lumen , fibrotic wall and adjacent hyalinization ( blue arrow ) schwannoma ( neurinoma , peripheral glioma , perineural fibriblastoma and neurilemmoma ) is ectodermal benign neoplasm , which originates from schwann cell of cranial , intraspinal , peripheral and autonomic nerve sheaths . they are common in head and neck region , accounting for 25 - 45% of extra - cranial schwannomas and 1 - 8% of all head and neck tumors . it can involve any of the 12 cranial nerves , except the olfactory and optic nerves since they lack schwann cells in their sheaths . schwannoma arising from infra - orbital nerve ( branch of maxillary division of fifth cranial nerve ) is extremely rare . to best of our knowledge , only nine cases of infra - orbital schwannoma has been previously described in english literature . depending on the site of nerve trunk or branch from which it arises , it may be located within the lower part of orbit , maxillary sinus or present as sub - cutaneous mass in infra - orbital region [ table 1 ] . intraorbital schwannoma generally develop from supraorbital or supratrochlear nerves , and less frequently from infra - orbital nerves . lesions arising from infra - orbital nerve grow to involve surrounding structures such as maxillary sinus , nasal cavity , infratemporal fossa and pterygopalatine fossa . however , it is rare to find schwannoma in the paranasal sinus , especially in the maxillary sinus . swelling in the cheek , nasal atresia , downward transversion of the palate and pain , rarely accompanying exophthalmosis are common symptoms . however in our case , a well - localized painless infra - orbital sub - cutaneous swelling was observed without any ocular lesions or involvement of underlying osseous skeleton . review of previously reported cases of schwannoma involving ion * rarely schwannomas may present with numbness in the distribution of involved nerve or with pain . our patient reported paresthesia localized over area of distribution of superior labial branch of infra - orbital nerve , which was probably due to pressure or direct involvement of the peripheral branch of the nerve . however during the surgical dissection , lesion was found to emanate from the nerve trunk of peripheral branch of infra - orbital nerve , which was dissected and preserved . none of the previous cases of infra - orbital schwannoma reported preoperative paresthesia [ table 1 ] . fine - needle aspiration cytology ( fnac ) , ultrasonography , magnetic resonance imaging and computed tomography image are diagnostic tools for schwannoma . diagnosis using fnac is characterized by the presence of spindle cells and has only 17.6% accuracy . aspiration of our lesion yielded blood tinged aspirate , which showed spindle shaped cells predominantly arranged in antoni a pattern around verocay bodies , with less organized antoni b tissue in few places confirming the diagnosis of schwanomma . the treatment of schwannomas is exclusively surgical and the appropriate approach is dictated by the extent and location of the tumor . in our case , the tumor originated from the peripheral branch of infra - orbital nerve and presented as nodular swelling immediately underlying the skin . incision placed in the natural skin crease of naso - labial fold was used to approach and completely remove the lesion . other approaches used include intra - oral vestibular incision for smaller lesions localized in the buccal space , caldwell - luc approach for tumor within the maxillary sinus , subcilliary or eyelid crease incision for intraorbital schwannoma . larger lesion involving greater areas of mid - face are treated by extra - oral weber - furgusson incision combined with ostectomy [ table 1 ] . although malignant transformation and recurrence of schwannoma is very low , a case of recurrent infra - orbital schwannoma attributed to incomplete removal of the lesion through a limited skin incision was reported . schwannoma arising from the infra - orbital nerve is rare , making the clinical diagnosis often difficult . although uncommon , schwannoma involving the peripheral branch of infra - orbital nerve may present as localized mid - face swelling and should be included in differential diagnosis of benign sub - cutaneous swelling in infra - orbital region .