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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 30  |  Issue : 4  |  Page : 417-420

Intra muscular hemangioma of masseter: A rare case scenario


Department of Oral Medicine and Radiology, Rajas Dental College and Hospital, Tirunelveli, Tamil Nadu, India

Date of Submission21-Feb-2018
Date of Acceptance04-Mar-2018
Date of Web Publication17-Jan-2019

Correspondence Address:
Dr. Kandasamy Murugan
Department of Oral Medicine and Radiology, Reader, Rajas Dental College and Hospital, Kavalkinaru Jn, Tirunelveli ..627 105, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_21_18

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   Abstract 


Intramuscular hemangioma (IMH) is a rare congenital benign vascular tumour occuring in the skeletal muscles. Mostly they occur in the muscles of lower extremity and rarely in the muscles of oral cavity. This is a case report of a 37 year old female patient with a Chief complaint of painless dependent swelling in the left middle third of the cheek region for the past 4 years. Clinical examination supported by the findings of Ultrasonography [USG] and Magnetic resonance imaging [MRI] leading to the diagnosis of intramuscular hemangioma of masseter. The diagnosis is later confirmed after Excisional biopsy followed by histopathologic evalution of the biopsied section. The masseter muscle is most frequent muscle accounting for 5% of all intramuscular hemangiomas. Due to the fibro vascular nature IMH have a rubbery, firm texture and vascular bruits or thrills are infrequent. The management has ranged from steroids to injection of sclerosing agents, radiation therapy, and surgical excision.

Keywords: Intramuscular hemangioma, magnetic resonance imaging, masseter, ultrasonography, vascular malformation


How to cite this article:
Murugan K, Ranjitha E G, Deepthi D A, Bharathi CS. Intra muscular hemangioma of masseter: A rare case scenario. J Indian Acad Oral Med Radiol 2018;30:417-20

How to cite this URL:
Murugan K, Ranjitha E G, Deepthi D A, Bharathi CS. Intra muscular hemangioma of masseter: A rare case scenario. J Indian Acad Oral Med Radiol [serial online] 2018 [cited 2019 Feb 17];30:417-20. Available from: http://www.jiaomr.in/text.asp?2018/30/4/417/250257




   Introduction Top


Hemangiomas are rare benign abnormal proliferation of blood vessels that occurs in any vascularized tissue.[1] It mostly arises in skin and subcutaneous tissues of the trunk, extremities and head and neck region.[2] Surgical intervention is needed only when a symptom arises and it carries excellent prognosis.

Intra muscular hemangiomas (IMH) are very rare, accounting for less than 1% of all hemangiomas, and less than 20% of these are found in the head and neck region. Unlike other hemangiomas, IMH does not regress spontaneously and are usually detected in the second or third decade of life. Their location and unfamiliar presentation may require sonography, magnetic resonance imaging (MRI) and rarely angiography for accurate diagnosis.[3],[4] The exact cause of IMH has been a conundrum. This is a case report of the IMH of left cheek region involving the masseter muscle.


   Case Report Top


A 37 year old female patient reported to the department of Oral Medicine and Radiology with a Chief complaint of painless dependent swelling in the left middle third of the cheek region for the past 4 years, Later she noticed a small swelling, which was initially small and then slowly progressed to attain the present size [Figure 1]. On extra oral clinical examination a mild diffuse oval shaped smooth surface swelling was present in the left middle third region of the face, of size 5 × 4 cm approximately, which extends superiorly up to left infra orbital region, inferiorly line joining left corner of mouth to lower border of ear lobe, medially up to mid pupillary line and laterally up to 2 cm in front of the tragus of ear and this swelling was only evident only when the patient was in a dependent position and it disappeared on a erect posture. Skin over the swelling appeared normal with no visible pulsations and no secondary changes like sinus, fistula and ulcerations seen. On palpation the swelling was warm, firm in consistency and slightly tender.
Figure 1: Extra oral profile showing mild diffuse oval shaped smooth surface swelling was present in the left middle third region of the face

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On intra oral examination a single diffuse swelling was evident in the left posterior buccal mucosa in relation to 27 of size 3* 2 cm irregular in shape, extending superiorly to the left posterior buccal vestibule, inferiorly 1cm above the retro molar region, no secondary changes like sinus, ulcerations seen [Figure 2]. On palpation the swelling was firm in consistency with mild tenderness. Henceforth provisional diagnosis was made as vascular malformation with the positive findings like painless dependent swelling, middle age, 4 years duration and location on the cheek region. Lymphangioma, Hemangioma and lipoma were considered in the differential diagnosis.
Figure 2: Intraoral examination showing single diffuse swelling was evident in the left posterior buccal mucosa in relation to 27

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USG [Figure 3]. revealed an isoechoic lesion 1.1 × 1.0 cm in muscle plane on left cheek with no evidence of calcification within the lesion, with no involvement of parotid gland [Figure 4] and on colour doppler minimal colour flow visualized and mass was extending to the mandible. MRI revealed 3.3 cm size soft tissue mass at masticatory space showing intermediate signal on T2W1 and strong enhancement embedded in the anterior side of left masseter muscle with no bony invasion [Figure 5]. On Incisional biopsy, below the mass a vacuole containing darkened blood was evacuvated and the mass excised. [Figure 6] and [Figure 7] and histopathology revealed dense fibrous connective tissue stroma showing vascular channels of varying size lined by thin endothelial cells. Many of the vessels were empty while some showed thrombosis and RBCs. Focal endothelial proliferate and extravasations of RBCs were noted along with deposits of hemosiderin. Inflammatory cells were minimum suggestive of cavernous hemangioma [Figure 8]. Thus based on the findings of USG, MRI and the gold standard histopathology report the final diagnosis of intramuscular hemangioma of masseter muscle was arrived.
Figure 3: Ultrasonography showing isoechoic lesion 1.1 × 1.0 cm in muscle plane on left cheek

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Figure 4: Colour Doppler Sonography showing minimal colour flow visualized and mass was extending to the mandible

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Figure 5: T2 weighted MRI (Axial view) showing 3.3 cm size soft tissue mass at masticatory space showing intermediate signal on T2W1 and strong enhancement embedded in the anterior side of left masseter muscle with no bony invasion

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Figure 6: On Incisional biopsy, below the mass a vacuole containing darkened blood was evacuvated and the mass excised

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Figure 7: Excised lesion

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Figure 8: Pictomicrograph demonstrates Focal endothelial proliferate and extravasations of RBCs were noted along with deposits of hemosiderin. Inflammatory cells were minimum suggestive of cavernous hemangioma

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   Discussion Top


The ordinal case of IMH of the masseter muscle was reported by Listen in 1843 followed by series of 45 cases of these 13.8% involved head and neck and 5% involved masseter muscle. IMH of masseter muscle showed a male predominance among the reported cases, contradicting the review of Scott's which revealed an equal sex distribution. The tumour develops before the age of 30 years in 90% of cases, thus the etiological role of either congenital origin or possibility of trauma remains a mystery.[5] Several theories have been proposed, but the most acceptable is that the IMH is a congenital mass, arising by abnormal embryonic sequestrations which are similar to congenital arteriovenous malformations.[6] A role for harmones in growth of IMH has also been speculated. They are usually asymptomatic until a growth spurt occurs at which pain occurs in about 50% of cases. A palpable fluctuant swelling or firm mass is present in up to 98% of cases.[7]

Allen and Enzinger examined 89 IMH and they categorized according to the size of the vessels as small-vessels or capillary type, which comprised vessels of less than 140 μ diameter, large-vessel or cavernous type, which comprised vessels of more than 140 μ diameter and mixed type, which consists of both small and large vessels. About 30% of small-vessel, 19% of large vessel and 5% of mixed vessel IMH are found in the head and neck. The mixed type shows greater tendency for local recurrence (28%) and the large vessel type, the least (9%).[8]

IMH should be considered in the differential diagnosis whenever a soft tissue mass encountered in the skeletal muscle of young patients and should be ruled with accurate diagnostics. MRI provides better detection and delineation of the extent of IMH because of its multiplanar capabilities and the distinct contrast between normal muscle and the IMH.

Various therapies have been applied for hemangioma of variable types ranging from sclerosing agents, radiation and surgery. A technique of embolization of hemangiomas with muscle fragments to decrease intraoperative blood loss has also been implied. The accepted optimal treatment is total excision with adjacent normal muscle. Masseter muscle hemangioma has been approached by an intraoral route, by a pre-auricular incision with development of flap lateral to it thus preserving parotid gland. However intraoral route affords relatively poor exposure for adequate tumor removal and risks injury to the facial nerve.[9] Local recurrences reported in approximately 18% of IMH, usually as a result of incomplete surgical resection. Regional and distant metastasis has not been reported.


   Conclusion Top


Thus IMH of masseter muscle is a rare entity in head and neck region and always should be considered in differential diagnosis of long standing soft tissue masses of the oro-facial region. Its diagnosis remains a challenge due to its rarity and nonspecificity. Hence rigorous factual information required for the diagnosis of IMH.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Danielle AK, Timothy AD, David GM. Hemangioma. Br J Oral Maxillofac Surg 2004;32:231-4.  Back to cited text no. 1
    
2.
Jin W, Kim GY, Lee JH, Yang DM, Kim HC, Park JS, et al. Intramuscular hemangioma with ossification: Emphasis on sonographic findings. J Ultrasound Med 2008;27:281-5.  Back to cited text no. 2
    
3.
Chatterjee R, Blackburn TK, Boyle MA. Intramuscular Hemangioma within depressor anguli oris. Br J Oral Maxillofac Surg 2007;45:234-5.  Back to cited text no. 3
    
4.
Christensen SR, Børgesen SE, Heegaard S, Prause JU. Orbital intramuscular Hemangioma. Acta Ophthalmol Scand 2002;80:336-9.  Back to cited text no. 4
    
5.
Welsh D, Hengerer AS. The diagnosis and treatment of intramuscular hemangiomas of the masseter muscle. Am J Otolaryngol 1980;1:186-90.  Back to cited text no. 5
    
6.
Ingalls GK, Bonnington GJ, Sisk AL. Intramuscular hemangioma of the mentalis muscle. Oral Surg Oral Med Oral Pathol 1985;60:476-81.  Back to cited text no. 6
    
7.
Fatma SA, Ergun O, Yalcin H, Inci K, Bilge U. Intramuscular Hemangioma of the masseter muscle in a 9-year-old girl. Acta Aniol 2007;13:42-6.  Back to cited text no. 7
    
8.
Chan MJ, McLean NR, Soames JV. Intramuscular Hemangioma of the orbicularis oris muscle. Br J Oral Maxillofac Surg 1992;30:192-4.  Back to cited text no. 8
    
9.
Ingalls GK, Bonnington GJ, Sisk AL. Intramuscular hemangioma of the mentalis muscle. Oral Surg Oral Med Oral Pathol 1985;60:476-81.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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