Intra Muscular Hemangioma of

Masseter: A Rare Case

Scenario
1

Murugan K, ranjitha EG, deepthi DA,

Bharathi CS. Intra muscular hemangioma of masseter: A rare case
scenario.
J indian acad oral med radiol 2018;30:417-20.

Dr. Yasir Shafeeq

1st yr Post graduate
 CONTENTS
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INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION
REFERENCES
 INTRODUCTION
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Hemangiomas are rare benign abnormal proliferation of

blood vessels that occurs in any vascularized tissue.
It mostly arises in skin and subcutaneous tissues of the
trunk, extremities and head and neck region.
Surgical intervention is needed only when a symptom arises
and it carries excellent prognosis.
Intra muscular hemangiomas (IMH) are very rare,accounting
for less than 1% of all hemangiomas, and less than 20% of
these are found in the head and neck region.
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Unlike other hemangiomas, IMH does not regress

spontaneously and are usually detected in the second
or third decade of life.
Their location and unfamiliar presentation may
require sonography,magnetic resonance imaging
(MRI) and rarely angiography for accurate diagnosis.
The exact cause of IMH has been a conundrum.
This is a case report of the IMH of left cheek region
involving the masseter muscle.
 CASE REPORT
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 A 37 year old female patient reported to the
department of oral medicine and radiology with a
c h i e f c o m p l a i n t o f pa i n l e s s d e p e n d e n t s w e l l i n g i n
t h e l e f t m i d d l e t h i r d o f t h e c h e e k r e g i on f o r t h e pa s t
4 years.
 L a t e r s h e n o t i c e d a s m a l l s we l l i ng , w h i c h wa s
i n i t i a l l y s m a l l a n d t he n sl o wl y pr o g r e sse d t o
a t ta i n t he p r e s e n t si z e
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 On extra oral clinical examination a mild diffuse oval shaped
smooth surface swelling was present in the left middle third region
of the face, of size 5 × 4 cm approximately, which extends
superiorly up to left infra orbital region, inferiorly line joining left
corner of mouth to lower border of ear lobe, medially up to mid
pupillary line and laterally up to 2 cm in front of the tragus of ear
and this swelling was only evident only when the patient was in a
dependent position and it disappeared on a erect posture.
 Skin over the swelling appeared normal with no visible pulsations
and No secondary changes like sinus, fistula and ulcerations seen.
 On palpation the swelling was warm, firm in consistency and
slightly tender.
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Extra oral profile showing

mild diffuse oval shaped
smooth
surface swelling was present
in the left middle third
region of the face
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 On intra oral examination a single diffuse swelling was evident

in the left posterior buccal mucosa in relation to 27 ,
 Size 3* 2 cm irregular in shape, extending superiorly to the left
posterior buccal vestibule, inferiorly 1cm above the retro molar
region, no secondary changes like sinus,ulcerations seen.
 On palpation the swelling was firm in consistency with mild
tenderness.
 provisional diagnosis was made as vascular malformation with
the positive findings like painless dependent swelling,middle
age, 4 years duration and location on the cheek region.
Lymphangioma, Hemangioma and lipoma were considered in the
differential diagnosis.
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Intraoral examination
showing single diffuse
swelling was
evident in the left
posterior buccal mucosa
in relation to 27
 USG revealed an isoechoic lesion 1.1 × 1.0 cm in muscle plane on left cheek with
no evidence of calcification within the lesion.
 No involvement of parotid gland and on colour doppler minimal colour flow
visualized and mass was extending to the mandible.
 MRI revealed 3.3 cm size soft tissue mass at masticatory space showing
intermediate signal on T2W1 and strong enhancement embedded in the anterior
side of left masseter muscle with no bony invasion.

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 T2 weighted MRI (Axial view)
showing 3.3 cm size soft tissue
mass at masticatory space
showing intermediate signal on
T2W1 and strong enhancement
embedded in the anterior side
of left masseter muscle
with no bony invasion.

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 On Incisional biopsy, below the mass a vacuole containing darkened
blood was evacuvated and the mass excised.
 Histopathology revealed dense fibrous connective tissue stroma
showing vascular channels of varying size lined by thin endothelial
cells.
 Many of the vessels were empty while some showed thrombosis and
RBCs. Focal endothelial proliferate and extravasations of RBCs
were noted along with deposits of hemosiderin.
 Inflammatory cells were minimum suggestive of cavernous
hemangioma.
 Thus based on the findings of USG, MRI and the gold standard
histopathology report the final diagnosis of intramuscular
hemangioma of masseter muscle was arrived.

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 On Incisional biopsy,
below the mass a vacuole
containing
darkened blood was
evacuvated and the mass
excised

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 Pictomicrograph demonstrates
Focal endothelial proliferate and
extravasations of RBCs were
noted along with deposits of
hemosiderin.
Inflammatory cells were
minimum suggestive of cavernous
hemangioma
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 Discussion
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 The ordinal case of IMH of the masseter muscle was reported by

Listen in 1843 followed by series of 45 cases of these 13.8%
involved head and neck and 5% involved masseter muscle.
 IMH of masseter muscle showed a male predominance among
the reported cases, contradicting the review of Scott’s which
revealed an equal sex distribution.
 The tumour develops at the age of 30 years in 90% of cases, thus
the etiological role of either congenital origin or possibility of
trauma remains a mystery.
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 Several theories have been proposed, but the most acceptable is

that the IMH is a congenital mass, arising by abnormal embryonic
sequestrations which are similar to congenital arteriovenous
malformations.
 A role for harmones in growth of IMH has also been speculated.
They are usually asymptomatic until a growth spurt occurs at
which pain occurs in about 50% of cases.
 A palpable fluctuant swelling or firm mass is present in up to 98%
of cases.
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Allen and Enzinger examined 89 IMH and they categorized

according to the size of the vessels as small‑vessels or
capillary type, which comprised vessels of less than 140 μ
diameter.
Large‑vessel or cavernous type, which comprised vessels of
more than 140 μ diameter and mixed type, which consists
of both small and large vessels.
About 30% of small‑vessel,19% of large vessel and 5% of
mixed vessel IMH are found in the head and neck.
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The mixed type shows greater tendency for local recurrence

(28%) and the large vessel type, the least (9%).
IMH should be considered in the differential diagnosis
whenever a soft tissue mass encountered in the skeletal
muscle of young patients and should be ruled with accurate
diagnostics.
MRI provides better detection and delineation of the extent
of IMH because of its multiplanar capabilities andthe
distinct contrast between normal muscle and the IMH.
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Various therapies have been applied for hemangioma of

variable types ranging from sclerosing agents, radiation
and surgery.
A technique of embolization of hemangiomas with muscle
fragments to decrease intraoperative blood loss has also
been implied.
The accepted optimal treatment is total excision with
adjacent normal muscle.
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Masseter muscle hemangioma has been approached by an

intraoral route, by a pre‑auricular incision with development of
flap lateral to it thus preserving parotid gland.
However intraoral route affords relatively poor exposure for
adequate tumor removal and risks injury to the facial nerve.
Local recurrences reported in approximately 18%of IMH,
usually as a result of incomplete surgical resection.
Regional and distant metastasis has not been reported.
 Conclusion
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 Thus IMH of masseter muscle is a rare entity in head and
Neck region and always should be considered in differential
D i a g n o s i s o f l o n g s t a n d i n g s o f t t i s s u e m a s s e s o f t h e o r o ‑f a c i a l
Region.
 Its diagnosis remains a challenge due to its rarity and
N o n s p e c i f i c i t y.
 Hence rigorous factual information required
For the diagnosis of IMH.
 References
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