Oral Hemangiomas Clinical Presentation

Updated: Mar 21, 2018
  • Author: Steven Brett Sloan, MD; Chief Editor: William D James, MD  more...
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Presentation

History

Hemangiomas and vascular malformations are diagnosed fairly easily with a careful history and a physical examination.

Capillary hemangiomas are usually not present at birth but are antedated by a pale, well-demarcated, flat area, most visible with agitation. These prodromal lesions may appear as a pale halo surrounding an area of telangiectasis or as a very fine telangiectasia similar to the port-wine stain.

Elevation occurs early during the first year of life and increases from the ages of 3-8 months, with some growth continuing into the second year of life. A stable interval of 6-12 months often follows the growth period. Then, a slow spontaneous involution, which usually begins in the center of the lesion, takes place in most cases. Involution often begins as a darkening of color followed by the appearance of numerous gray or pallid regions and fibrous septae within the lesion. Historically, most lesions have reportedly involuted by the time the patient is aged 7 years, with 86% of those lesions regressing by the time the patient is aged 5 years. [19, 20, 21, 18, 22]

The patient's sex and the size of the hemangioma do not influence the speed or the completeness of resolution. The location of the lesion does not generally influence its behavior, but lesions of the lower lip are less favorable. Patients with multiple lesions have rates of resolution similar to those with single lesions; however, separate lesions in the same individual do not necessarily grow or involute simultaneously. Lesions that have not improved after 3 years are unlikely to resolve by age 7 years. Unfortunately, early improvement does not always lead to early resolution. Involution may continue into the late teenage years.

Cavernous hemangiomas are composed of large, irregular, deep dermal and subcutaneous blood-filled channels that impart a purplish discoloration to the overlying skin. They are typically soft, poorly defined, and readily blanch with compression, giving them a characteristic "bag of worms" feel. The lesion may expand and darken with crying, when agitated, or when placed in a dependent position. Often, a capillary component overlies a cavernous component, and it may be difficult to distinguish these components histologically. Cavernous and mixed hemangiomas demonstrate the same patterns of proliferation as those of capillary lesions. However, involution is often incomplete, depending on the location and the presence of associated arteriovenous malformations.

Vascular malformations are present at birth and continue to grow with the child. The growth may become accelerated when the patient undergoes puberty or pregnancy, with the attendant hormonal changes.

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Physical Examination

On examination of the oral cavity, the vascular malformations of the mucosa and the adjacent soft tissues are usually readily apparent. The tissues have a slightly bluish hue and are soft. Venous channels become engorged when placed in a dependent position. They are readily compressible and fill slowly when released. They lack a prominent pulsation; if they represent an arteriovenous malformation, a thrill may be present.

Although the mucosal and soft tissue lesions are readily suspected by their appearance, the intrabony lesions may be difficult to distinguish on sight alone. Central jaw lesions can show hypermobility of the teeth and distortion of the arch form. [12] Severe hemorrhage following dental extraction is not an uncommon presentation of central hemangiomas of the maxilla and the mandible. [17] Common clinical findings in central hemangiomas of the jaws include gingival bleeding, postextraction bleeding, swelling, pain, mobility of the teeth, and bony expansion. [17] Root resorption of the teeth has been reported in 30% of cases, but the vitality of the teeth is usually not affected. [12]

Intramuscular vascular malformations represent a challenge on diagnosis because they exhibit few signs on clinical examination. Oftentimes, the extent of the lesion is not clinically apparent on examination, and imaging studies frequently define more extensive lesions than suspected.

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Complications

Complications of oral vasoformative tumors can be divided into 2 general types: complications related to the disease process and complications from treatment.

Complications from the disease process include hemorrhage, high-output states, infection, function problems (eg, airway, vision, hearing), thrombocytopenia, and ulceration. Ulceration is the most common complication of capillary hemangiomas and typically occurs centrally in large lesions. It may result in scarring and does not hasten resolution of the lesion. Ulceration may become secondarily infected and is readily treated with local wound care. Bleeding is one of the most common reasons that patients with oral hemangiomas and vascular malformations seek care.

Also see Complications in Treatment.

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