Intramuscular hemangioma of the masseter muscle: a case report
© licensee BioMed Central Ltd. 2009
Received: 21 October 2008
Accepted: 17 March 2009
Published: 18 May 2009
Intramuscular hemangiomas are uncommon neoplasm's arising most frequently in the masseter and trapezius muscle. Due to it's 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. A case of intramuscular hemangioma in a 17 year old girl is presented. Inadequacy of computed tomography scan and cytology in achieving a pre-operative diagnosis and also the treatment modalities are reviewed here. An estrogen receptor and progesterone receptor study has been done to verify the hormonal basis of this tumour.
A 17 year old girl from India, Asia presented with a swelling in the right cheek of five months duration. She first noticed the swelling while washing her face. Swelling gradually increased in size, becoming more pronounced during mastication and while waking up in morning. Over the last one month she developed pain over the swelling. She gave no history of trauma or oral contraceptive pill usage. On physical examination there was a swelling in the region of the right parotid measuring 3 x 2 cm which was non-tender. Swelling was 3 cm in front of the tragus and 2 cm below the zygoma. There was no compressibility and the overlying skin was normal. On clenching the masseter the swelling diminished in size. There was no facial nerve involvement and parotid duct orifice was normal.
Hemangiomas of skeletal muscle represent 0.8% of all benign vascular neoplasm . Of these 13.8% occur in the head and neck region , with the masseter muscle being the most common site, followed by the trapezius and sternocleidomastoid muscles respectively [2, 3]. Intramuscular Hemangiomas [IMH] generally occur in the first three decades of life . Although intramuscular hemangiomas have shown an equal sex distribution, involvement of the masseter has a definite male predominance .Various theories have been proposed to explain its etiology. The congenital nature is supported by the fact that it usually presents in the first three decades of life [3, 6, 7]. Others have suggested it arises from malformed tissue subjected to repeated trauma . Many have speculated a possible hormonal role on the growth of IMH as there was sudden increase in size noted on taking OC pills [1, 2, 5, 8, 9]. However our studies on ER & PR were negative.
Allen & Enzinger classified them as large vessel [>140 mm in diameter] small vessel [<140 mm in diameter] and mixed vessel types . They correspond to cavernous, capillary, and mixed type respectively. This classification is useful and correlates well with clinical presentation and recurrence rates. The capillary type of hemangioma occurred more frequently in the head and neck region. The highly cellular nature of many capillary hemangiomas may explain the lack of clinical signs usually associated with vascular lesions, thus rendering pre-op diagnosis difficult. The cavernous and mixed types occurred more frequently in the trunk and lower limbs. The mixed type had the greatest tendency for local recurrence [28%].
These tumours present as gradually enlarging mass lesions with duration often less than a year . Accurate preoperative diagnosis has been reported in less than 8% of cases in view of its intramuscular location and the overlying parotid. Bruits, thrills, compressibility are often absent unlike in other vascular malformations . The most common clinical presentation is a mass with associated pain symptoms in 50 to 60% of cases. There are usually no skin changes. Clenching the teeth could make the lesion to become more firm and fixed.
A variety of tumours can be confused clinically with an IMH. Most of them are often mistaken for salivary neoplasms & the differential diagnosis include cysts, lymphangiomas, rhabdomyosarcomas, masseteric hypertrophy, and schwannomas.
FNAC is inconclusive in arriving at a diagnosis as it yields only a bloody aspirate . Superselective arteriography with subtraction clearly defines the altered vascular pattern and flow dynamics including feeder vessels and also opens up therapeutic modalities. However it may fail to demonstrate low flow lesions adding to the diagnostic difficulty.
Though contrast CT may demonstrate the vascular nature of the tumour MRI has shown superiority in the exquisite delineation and contrast of the lesion from it's surrounding due to its multiplanar capability.
The management of IMH should be individualized based on such factors as tumour location, age, depth of invasion, Cosmesis. Many treatment modalities like cryotherapy, radiation therapy, steroid administration and embolization have been advocated but the treatment of choice at present remains surgical excision [1, 2, 9]. Local recurrence ranging from 9 to 28% have been reported even after wide excision , hence we recommend that total excision of the masseter ensures that there is no recurrence. This is associated with very little cosmetic and functional disability. Difficulty in intraoperative localization of the exact extent of the tumour due to its supple nature and the absence of a definite capsule justifies a complete excision of the masseter. The fibrosis following surgery may render reexploration and excision in case of recurrence hazardous with more risk of damage to the facial nerve.
The preauricular incision combined with a superficial parotidectomy allows for a complete excision with preservation of branches of the facial nerve with very little cosmetic and functional disability. Intraoral approaches give limited exposure to the facial nerve branches and often result in nerve injury .
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
List of abbreviations
Fine needle aspiration cytology
Magnetic resonance imaging
- Watson WL, Mc Carthy WD: Blood and lymph vessel tumors; a report of 1056 cases. Surg Gynecol Obstet. 1940, 71: 569-588.Google Scholar
- Wolf GT, Daniel F, Krause CJ, Kaufman RS: Intramuscular Hemangioma of the head and neck. Laryngoscope. 1985, 95: 210-213. 10.1288/00005537-198502000-00018.PubMedGoogle Scholar
- Ingalls GK, Bonnington GJ, Sisk AL: Intramuscular hemangioma mentalis muscle. Oral Surg Oral Med Oral pathol. 1985, 60: 476-481. 10.1016/0030-4220(85)90232-4.View ArticlePubMedGoogle Scholar
- Rossiter JL, Hendrix RA, Tom L, Potsic W: Intramuscular hemangioma of the Head and neck. Otolaryngol. Head Neck Surg. 1993, 108: 18.View ArticleGoogle Scholar
- Hoehn JG, Farrow GM, Devine KD: Invasive Hemangioma of the Head andneck. Am J Surg. 1970, 120: 495-498. 10.1016/S0002-9610(70)80014-9.View ArticlePubMedGoogle Scholar
- Biller HF, Krespi YP, Som PM: Combined therapy for vascular lesions of the head and neck with intra- arterial embolization and surgical excision. Otolaryngol Head Neck Surg. 1982, 90: 37-47.PubMedGoogle Scholar
- Welsh D, Hengerer AS: The diagnosis and treatment of intramuscular Hemangioma of the masseter muscle. Am J Otolaryngol. 1980, 1: 186-190. 10.1016/S0196-0709(80)80014-7.View ArticlePubMedGoogle Scholar
- Persky MS, Bernstein A, Cohen NL: Combined Treatment Of Head and Neck Vascular Masses with pre operative embolisation. Laryngoscope. 1984, 94: 20-27. 10.1288/00005537-198401000-00005.View ArticlePubMedGoogle Scholar
- Sayan SB, Kogo M, Kouzimi H, Watatani K, Saka M, Matsuya T, Fukuda Y: Intramuscular Hemangioma of the digastric muscle. J Osaka Univ Dent Sch. 1992, 32: 14-40.PubMedGoogle Scholar
- Allen PW, Enzinger FM: Hemangioma of skeletal muscle; an analysis of 89 cases. Cancer. 1972, 29: 8-22. 10.1002/1097-0142(197201)29:1<8::AID-CNCR2820290103>3.0.CO;2-A.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.