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Oral Hemangiomas Workup

  • Author: Steven Brett Sloan, MD; Chief Editor: William D James, MD  more...
 
Updated: Feb 09, 2016
 

Laboratory Studies

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

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Imaging Studies

Workup of oral hemangiomas requires some form of imaging to determine their extent and flow characteristics. The following modalities may be helpful:

  • 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.[17]
  • 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.[17] 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.
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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.

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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
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Contributor Information and Disclosures
Author

Steven Brett Sloan, MD Associate Professor, Department of Dermatology, University of Connecticut School of Medicine; Residency Site Director, Connecticut Veterans Affairs Healthcare System; Assistant Clinical Professor, Yale University School of Medicine

Steven Brett Sloan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Connecticut State Medical Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Journal of the American Academy of Dermatology;Up to Date;Medical Review Institute of America.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

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, American Dental Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

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: Canadian Medical Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Canadian Dermatology Association, American Academy of Dermatology, American Society for Clinical Pharmacology and Therapeutics

Disclosure: Nothing to disclose.

Acknowledgements

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.

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Table 1. Classification of Vasoformative Tumors
Vasoformative Tumor New Nomenclature Old Nomenclature
Hemangiomas  
 Capillary hemangiomaStrawberry hemangioma
  Juvenile hemangioma
 Cavernous hemangioma 
 Mixed hemangiomaParotid hemangioma
Vascular malformations  
 Venous malformationCavernous hemangioma
  Hemangiomatosis
 Intramuscular venous malformationIntramuscular hemangioma
 Capillary malformationCapillary hemangioma
  Port-wine stain
 Arteriovenous malformationArteriovenous hemangioma



Arterial angioma



Arteriovenous aneurysm



Cirsoid angioma



Red angioma



Serpentine aneurysm



 Lymphatic malformationCapillary lymphangioma



Cavernous lymphangioma



Lymphangioma



Cystic hygroma



Table 2. Complications From Ablative Surgery Following Embolotherapy or Sclerotherapy for Hemangiomas and Vascular Malformations
Complications Hemangiomas, % Vascular Malformations, %
Immediate Complications
Hemorrhage2760
Airway compromise210
Hematoma1414-30
Skin necrosis1210-30
Coagulopathy714-20
Late Complications
Restricted oral opening827-40
Malocclusion820-40
Drooling2340-47
Dysphagia2320-27
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