|CASE IN POINT - SURGERY
|Year : 2016 | Volume
| Issue : 4 | Page : 214-216
Masseteric intramuscular cavernous hemangioma
Vidya K Lohe1, Samiksha Acharya2, Rahul R Bhowate1, Ravindra P Kadu3
1 Department of Oral Medicine and Radiology, Datta Meghe Institute of Medical Sciences (Deemed University), Sawangi, Meghe, Wardha, Maharashtra, India
2 Department of Oral Medicine and Radiology, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed University), Sawangi, Meghe, Wardha, Maharashtra, India
3 Department of Pathology, Jawaharlal Nehru Medical College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed University), Sawangi, Meghe, Wardha, Maharashtra, India
|Date of Web Publication||22-Sep-2016|
Vidya K Lohe
Department of Oral Medicine and Radiology, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed University), Sawangi (M), Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Hemangiomas are the most common vascular tumors. Lymphatic, capillary, venous, and arteriovenous malformations make up the majority of vascular malformations. Intramuscular hemangioma (IMH) is a relatively rare benign tumor of vascular origin accounting for less than 1% of all hemangiomas. The possible sites of occurrence in oral cavity are lips, tongue, buccal mucosa, and palate. IMH arises most frequently in the masseter and trapezius muscle. Due to its location, it is often mistaken for a parotid swelling and rarely is an accurate preoperative diagnosis achieved clinically. The intra-masseteric site also creates special problem in terms of proximity to the facial nerve. Despite its benign origin and behavior, it is always of clinical importance to the dental profession and requires appropriate management. This article reports an unusual case of a 19-year-old female patient with IMH involving the buccal mucosa, treated with complete surgical excision.
Keywords: Cavernous and capillary hemangioma, intramuscular hemangioma, masseter muscle, ultrasonography
|How to cite this article:|
Lohe VK, Acharya S, Bhowate RR, Kadu RP. Masseteric intramuscular cavernous hemangioma. Astrocyte 2016;2:214-6
| Introduction|| |
The term “hemangioma” has conventionally been used to describe a variety of developmental vascular anomalies. Currently, hemangiomas are considered to be benign tumors of infancy that display a rapid growth phase with endothelial cell proliferation, followed by gradual involution. In most of the cases, hemangioma undergoes involution, with residual telangiectatic, fatty, or scar tissue apparent in approximately 40-50% of patients. They have been described in almost all head and neck locations in a variety of presentations. They can be superficial and deep, small and large, appear most commonly as solitary lesions, but also as multiple lesions. Hemangioma may be classified as capillary or cavernous types; the former is superficial and the latter is deeper. A case of intramuscular hemangioma (IMH) of masseter muscles presenting as an unusual cheek swelling is reported in this article.
| Case Report|| |
A 19-year-old female patient reported to the Department of Oral Medicine and Radiology, with a chief complaint of “painless swelling” on the lower right posterior region inside the cheek. The history of present illness revealed that the swelling was small initially and gradually increased to the present size of 3 cm × 2 cm approximately. The patient gave history of difficulty in mastication and speech due to the presence of diffuse swelling on the right buccal mucosa, no history of paresthesia, no history of bleeding, or any other discharge from the swelling. There was no history of change in the size of swelling before or during meal times. The patient was in apparent good health and her medical and dental history was not contributory.
On inspection, extraoral examination revealed a single diffuse swelling of size 3 cm × 2 cm approximately in the right buccal mucosa which was freely movable, color was same as adjacent skin, roughly oval in shape. On palpation, all the inspectory findings were confirmed regarding size and shape, and local temperature was not raised. Swelling was soft to firm in consistency and nontender. Intra-oral examination revealed that it was covered by a mucosa of normal texture and color [Figure 1]. On digital palpation, the swelling was nontender, nonfluctuant, and soft in consistency. The swelling had ill-defined margins and was not fixed to the underlying as well as overlying structures. There was no sign of hypoesthesia or paresthesia of the area involved. The provisional diagnosis of lipoma was made and deep-seated hemangioma was kept in the differential diagnosis. Slip test was negative. Ultrasonography (USG) with color Doppler enhancement revealed the existence of a well-demarcated mass lying anterior to the masseter muscle presenting as intramuscular hypoechoic solid mass of 2.5 cm × 1.0 cm over the right cheek. Vascularity was seen on color Doppler enhancement. Right parotid and submandibular glands were normal in size and echo-texture. The lesion was excised through an intraoral approach. After raising the buccal mucosa flaps, a bluish vascular lesion was noted in the right buccal mucosa. The lesion was excised with a margin of surrounding normal muscle without significant bleeding and gross specimens achieved [Figure 2]. Histological examination showed dilated blood vessels with intravasated red blood cells with connective tissue stroma, suggestive of cavernous IMH [Figure 3] and [Figure 4]. The patient was on regular follow-up postoperatively for 1 year and no evidence of recurrence was noted.
|Figure 3: Low power view (×10) shows proliferating dilated endothelial lined blood vessels with intravasated red blood cells × connective tissue stroma.|
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|Figure 4: High power view (×40) shows dilated endothelial lined engorged blood vessel with red blood cells.|
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| Discussion|| |
Vascular anomalies are a heterogeneous group of congenital blood vessel disorders more typically referred to as birthmarks. Subcategorized into vascular tumors and malformations, each anomaly is characterized by specific morphology, pathophysiology, clinical behavior, and management approach. Hemangiomas are the most common vascular tumors. Hemangiomas are the most common tumors of infancy, occurring in 5–10% of 1-year-old children. These are much more common in females than in males (ratio: 3:1–5:1), and they occur more frequently in whites than in other racial groups. The most common location is the head and neck which accounts for 60% of all cases. Hemangiomas are benign vascular alterations characterized by the proliferation of blood vessels, commonly occurring in subcutaneous and submucous tissue.,, According to Enzinger and Weiss, hemangiomas are broadly classified into capillary, cavernous, and miscellaneous forms such as verrucous, venous, and arteriovenous hemangiomas. The histological appearance of the lesion is variable. These lesions are nonencapsulated benign neoplasm composed of differently sized vascular channels, sometimes with calcification and admixed with variable amounts of adipose, fibrous, and myxoid tissues. There may be evidence of inflammation and fibrous proliferation. IMH usually presents as a distinct, localized, rubbery swelling in the second or third decades of life. Thrills, bruit, pulsation, or skin discolorations usually associated with superficial hemangiomas are absent. Consistency may vary from soft and diffuse to firm and localized due to their deep location. Diagnosing IMH can be difficult due to its rarity and nonspecific clinical presentation. Plain radiography and fine needle aspiration cytology are usually nondiagnostic. USG and magnetic resonance imaging are the two most widely used modalities of choice. Sonography is usually the first-line imaging procedure for patients with neck swellings, but not specific for IMH. Color Doppler is useful to demonstrate the vascular structures in and around the muscle. USG is used for initial screening because of its portability, lack of ionizing radiation, and no requirement of sedation. It is relatively simple, noninvasive, and yields good results for evaluating small, superficial, and/or suspected, solid visceral lesions. Typically, USG is used to determine the basic type of lesion, direct initial management, and plan further imaging evaluation. In the present case, USG with color Doppler enhancement revealed the existence of a well-demarcated mass lying anterior to the masseter muscle which shows intramuscular hypoechoic solid mass of 2.5 cm × 1.0 cm over right cheek, and vascularity was seen on color Doppler. IMH is an uncommon, benign vascular neoplasm usually arising within the skeletal muscle of the trunk and the extremities. Although masseter has been the most common site in the head and neck region, IMH of the trapezius, orbital muscles, mentalis, digastric, geniohyoid, temporalis, sternocleidomastoid, and mylohyoid have also been reported. Lee and Lim had also reported additional two cases with intramuscular hemangioma of the mylohyoid and sternocleidomastoid muscle. Various authors had reported the cases of intramuscular hemangioma of the masseter muscle.,,,, Therefore, intramuscular hemangioma of the head and neck despite its rarity should be considered in the differential diagnosis of the head and neck masses. Complete wide excision with a cuff of the surrounding muscles is the ideal treatment. Recurrence in IMH is mainly due to incomplete excision  and nonencapsulated lesion.
| Conclusion|| |
Head and neck IMH is an uncommon, nonencapsulated vascular neoplasm characterized by painless and slow growth. IMH presents difficulties in correct preoperative diagnosis and treatment planning. Wide surgical resection beyond the gross limits of tumor is the most appropriate therapeutic option, others being mostly palliative. The recurrence rate is high. Hence, long-term clinical and radiological follow-up is recommended for timely diagnosis and treatment of recurrences.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]