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Oral Surgery

Authors:-Dr. Prajwalit Kende, Dr. Harsha Puri, Dr.Rahul Jagiasi

Abstract
Intramuscular haemangioma are uncommon benign neoplasms arising 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 pre-operative diagnosis achieved clinically. The intra-masseteric location also poses special problem in terms of proximity to the facial nerve and the post-operative flattening following excision of the masseter muscle. Herein, the case is reported of a 35-year-old male who presented with a round, painless mass on the left cheek, which was interpreted as an intramuscular haemangiomaafter a magnetic resonance imaging scan.

Introduction
Intramuscular haemangioma (IMH) in the head and neck region is rare and frequently involve the masseter muscle. It tends to be relatively well circumscribed, and insidiously infiltrate the muscle resulting in a mass with deceptive gross margins. The tumor has a tendency to recur following attempts at surgical extirpation. Inaccurate pre-operative diagnosis and treatment planning may lead to incomplete excision and unnecessary risk to facial nerve injury.

Case Report A 35 year old male reported to our department with the complaint of progressive, painless swelling of the left cheek. Swelling had been present since 3-year old and had gradually increased in size. Patient had H/O trauma 8 to 10 years back followed by similar swelling. That time patient had undergone a surgery. But swelling recurred to the present day size.

 

Figure 1: Extra-oral (Frontal View Figure 2: Extra-oral (Profile View)


Figure 3: Intra-oral View On Clenching Clenching Figure 4: Intra-oral View Open Mouth


Figure 5: Orthopantomograph Figure 6: Ultrasonographic Imaging Of The Tumor


Figure 7: MRI (Axial Slice) Figure 8: MRI (Coronal Slice)

Physical examination revealed a swelling (3x4 cm) over the left masseter region, soft in consistency with smooth surface [Fig.1, Fig.2]. It was mobile but fixed with the contraction of masseter. His facial movement was normal. There was nopalpable thrill and the overlying skin was normal. Intraoral examination was unremarkable [Fig.3, Fig.4]. Routine orthopantomograph (OPG) was taken which did not reveal any significant finding [Fig.5].  Ultrasonography (USG) of left parotid and masseter was performed which showed well defined expansive lesion of size 33x31x11 mm = 6cc [Fig.6]. USG guided fine needle aspiration cytology (FNAC) was performed which showed blood. Magnetic resonance imaging (MRI) revealed a well-circumscribed, brighter mass in the left masseter muscle [Fig.7, Fig.8]. Preoperative diagnosis was intramuscular haemangioma of the masseter muscle and surgery was performed.

Discussion
Haemangioma usually occurs in the skin, subcutaneous tissue or muscle. Haemangioma of soft tissue can be divided into intramuscular and extramuscular. The most common sites for intramuscular haemangioma are the trunk and lower limbs. Only 10 to 20% of all intramuscular haemangiomas present in the head and neck, and 60% are in the masseter and trapezius 1. Other possible sites are periorbital muscle, sternomastoid, temporalis muscle, geniohyoid and medial pterygoid. Intramuscular haemangioma mostly present before the age of 30. It is believed to be benign, hamartomatous, congenital neoplasms that go undetected for long period of time until sudden growth gives rise to pain or cosmetic deformity. Traumatic and hormonal influences have been suggested and may contribute to the etiology or growth spurts 2.
Haemangioma  presents as a slowly enlarging mass with generally normal overlying skin but may have a reddish blue discoloration or even hyperthermic. The swelling is normally diffuse in nature, compressible and characteristically deep within the muscle. However, softness and compressibility may be absent due to local fibrosis and overlying musculature or to the prominent cellularity of capillary type tumors. Pulsations, bruits or thrills are uncommon but when present, arteriography is indicated as to identify large vessel communications.
These neoplasms appear to grow as non-encapsulated masses characterizedby a multicentric proliferation of cords of endothelial cellsthat subsequently canalize. The characteristic of locally invasive tumor involves growth along planes of least resistance. It is confined to one muscle in 80% of cases 2.
Histologically, the lesions are classified as (1) capillary (vessels smaller than 140 micrometer in diameter), (2) cavernous (vessels larger than 140 micrometer in diameter) or (3) mixed.  Capillary haemangioma usually presents with a short history. They are highly cellular, thus explain the firmness and lack of clinical signs to suggest vascular in nature 2. Cavernous haemangioma generally presents with longer history of symptoms, tends to be larger in size and painful. They are most common in lower extremity with only 19% occurring in the head and neck [3]. Mixed type is histologically similar to cavernous type so does its clinical presentations. CT-scanning will reveal enhancing well circumscribed intramuscular mass but unable to define tissue planes and the vascularity of the lesion. MRI shows good tissue delineation. Intramuscular haemangiomas are characteristically much brighter on T2 than on T1 weighted images. Arteriography with pre-opembolization of the feeding vessels enhances hemostasis and can facilitate excision. Fine needle aspiration biopsy is non-diagnostic.
Management of intramuscular haemangiomas should be individualized according to the tumor location and extent, tumor growth rate, anatomical accessibility, patient age and cosmetic considerations. Some of the patients can be observed with the accuracy of MRI especially in young children 1. The optimal management is wide surgical excision 2 that includes gross muscle beyond the gross limits of the tumor. Cosmetic and functional disabilities after excision have been minimal even after significant removal of surrounding normal muscle 4. The indication for surgery include symptomatic but stable tumors in older children, sudden rapid acceleration of tumor growth, gross functional impairment, local skin necrosis, thrombocytopenia, cosmetic deformity and suspicious of malignancy 4. Local recurrences occur in approximately 18% due to incomplete surgical resection. Spontaneous regression does not occur 1.  Regional and distant metastasis has not been reported.

Conclusion
Haemangiomas are benign vascular neoplasms characterized by an abnormal proliferation of blood vessels. They may occurin any vascularized tissue including skin, subcutaneous tissue muscle and bone. These tumors are common in infancy andchildhood and commonly involve subcutaneous or mucosal tissues. Intramuscular haemangiomas, a distinctive type of haemangiomaoccurring within skeletal muscle, account for less than 1% of all haemangiomas. They occur more often in trunk andextremity muscles, whereas involvement of the masseter muscle is rare. The clinician should be well aware of such lesions occurring in the head neck face region. These lesions should be diagnosed in a meticulous way so that an accurate treatment plan can be charted out and future complications may be avoided.

Bibliography:

  1. Rossiter JL, Hendrix RA, Tom LWC, Potsic WP: intramuscular tumour of head and neck. Otolaryngology – Head and Neck Surgery 1993; 108: 18-26.
  2. Wolf GT, Daniel F, Arbor A, Krause CJ: Intramuscular haemangioma of the head and neck. Laryngoscope 1985; 95: 210-13
  3. Clemis JD, Briggs DR, Changeus GW : Intramuscular haemangioma in head and neck. Canadian Journal of Otolaryngology 1975; 4: 339-46.
  4. Kenali MS, Bridger PG: Intramuscular tumour of the medial pterygoid. Australian, New Zealand Journal of Surgery 2000; 70: 462-66.