eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa

Oral Hemangiomas: Differential Diagnoses & Workup

Author: Steven Brett Sloan, MD, Assistant Professor, Department of Dermatology, University of Connecticut School of Medicine; Director of Nail Disease Clinic and Chief of Dermatology, Newington Veterans Affairs Medical Center
Coauthor(s): Randall Wilk, MD, DDS, PhD, Associate Professor, Department of Oral and Maxillofacial Surgery, Louisiana State University Health Science Center
Contributor Information and Disclosures

Updated: Nov 12, 2008

Differential Diagnoses

Other Problems to Be Considered

The diagnosis of hemangiomas is straightforward from the history and the clinical examination, and the differential diagnosis is limited. For intraosseous lesions, the differential diagnosis can be more challenging, with the radiographic appearance being similar to that of a giant cell lesion or an ameloblastoma.

Workup

Laboratory Studies

  • Usually, no laboratory studies are useful in the diagnosis or management of oral hemangiomas.

Imaging Studies

  • Workup of oral hemangiomas requires some form of imaging to determine their extent and flow characteristics.

    • Angiography is considered the most definitive of the studies, although the angiographic appearance of intraosseous lesions is less well defined than that of soft tissue lesions.15
    • Ultrasonography can be used to determine that a lesion is angiomatous in nature (ie, hemangioma, lymphangioma), but it cannot be used to differentiate a hemangioma from a lymphangioma.
    • Contrast-enhanced MRI can be used to differentiate a hemangioma from a lymphangioma in the oral cavity.23 MRI appears to be highly reliable for lesions of either soft tissue or bone.
    • On plain films or panoramic radiographs, a central vascular malformation of the bone usually has a honeycombed appearance or cystic radiolucencies.15 Intraosseous vascular malformations show a nonspecific reticulated or honeycombed pattern that is well demarcated from normal bone. A sunburst effect, created by spicules radiating from the center, is often present.
    • CT scans often show an expansile process with a high-density amorphous mass that may be suggestive of fibrous dysplasia.

Procedures

  • Procedures other than a clinical history or examination, including aspiration of intraosseous lesions, that are used to diagnose oral hemangiomas readily produce frank blood. Performing a biopsy of oral hemangiomas can be potentially dangerous.

Histologic Findings

Histopathologically, vasoformative tumors share many similar microscopic features, and overlap between hemangiomas and vascular malformations exists. Hemangiomas are subclassified as capillary or cavernous, depending on the size of the vascular channels. Vascular malformations, as true structural anomalies, exhibit a normal rate of endothelial cell turnover. Spaces are lined by endothelium without muscular support. An increase in normal- and abnormal appearing blood vessels occurs. The endothelial cells of early lesions may be plump, obscuring the lumen of the capillaries. Phleboliths may develop as a result of dystrophic calcification in thrombi. Intimal thickening or diverse arteriovenous connections can sometimes be seen in serial sections. Johann et al showed that histological diagnosis alone is not sufficient to correct diagnoses of oral hemangioma. Moreover, immunohistochemistry to GLUT1 is a useful and easy diagnostic method that may be used to avoid such misdiagnosis.24

Salient histopathologic findings of vasoformative tumors that distinguish them are as follows:

  • Hemangiomas (proliferative phase)
    • Endothelial cell hyperplasia forming syncytial masses
    • Thickened (multilaminated) endothelial basement membrane
    • Ready incorporation of tritiated thymidine in endothelial cells
    • Presence of large numbers of mast cells
  • Hemangiomas (involuting phase)
    • Less mitotic activity
    • Little or no uptake of tritiated thymidine in endothelial cells
    • Foci of fibrofatty infiltration
    • Normal mast cell counts
  • Vascular malformations
    • No endothelial cell proliferation
    • Contain large vascular channels lined by endothelium
    • Unilamellar basement membrane
    • Does not incorporate tritiated thymidine in endothelial cells
    • Normal mast cell counts

More on Oral Hemangiomas

Overview: Oral Hemangiomas
Differential Diagnoses & Workup: Oral Hemangiomas
Treatment & Medication: Oral Hemangiomas
Follow-up: Oral Hemangiomas
References
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Further Reading

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Keywords

oral vasoformative tumor, arterial malformation, capillary malformation, lymphatic malformation, vascular malformation, venous malformation, intraosseous hemangioma, intramuscular hemangioma, jaw hemangioma, arteriovenous hemangioma, capillary hemangioma, cavernous hemangioma, mixed hemangioma, strawberry hemangioma, juvenile hemangioma, parotid hemangioma, hemangiomatosis, port-wine stain

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Contributor Information and Disclosures

Author

Steven Brett Sloan, MD, Assistant Professor, Department of Dermatology, University of Connecticut School of Medicine; Director of Nail Disease Clinic and Chief of Dermatology, Newington Veterans Affairs Medical Center
Steven Brett Sloan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Connecticut State Medical Society, New England Dermatological Society, and Texas Dermatological Society
Disclosure: Nothing to disclose.

Coauthor(s)

Randall Wilk, MD, DDS, PhD, Associate Professor, Department of Oral and Maxillofacial Surgery, Louisiana State University Health Science Center
Randall Wilk, MD, DDS, PhD is a member of the following medical societies: American Association of Oral and Maxillofacial Surgeons, American Dental Association, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Neil Shear, MD, Professor and Chief of Dermatology, Professor of Medicine, Pediatrics and Pharmacology, University of Toronto Faculty of Medicine; Head of Dermatology, Sunnybrook Women's College Health Sciences Center and Women's College Hospital, Canada
Neil Shear, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Clinical Pharmacology and Therapeutics, Canadian Dermatology Association, Canadian Medical Association, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Drore Eisen, MD, DDS, Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati
Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, and American Dental Association
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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