|Year : 2014 | Volume
| Issue : 1 | Page : 2-4
Intra-muscular hemangioma: A review
Shruti Nayak1, Amarnath Shenoy2
1 Department of Oral Pathology and Microbiology, Yenepoya Dental College, Mangalore, Karnataka, India
2 Department of Conservative Dentistry and Endodontics, Yenepoya Dental College, Mangalore, Karnataka, India
|Date of Web Publication||15-May-2014|
Department of Conservative Dentistry and Endodontics, Yenepoya Dental College, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Intra-muscular hemangiomas (IMH) are relatively uncommon benign vascular tumors, which account for less than 1% of all hemangiomas. IMH may be presented as a perceived sporting injury. Diagnosis of this lesion is important not only because of its rarity, but also due to dangers posed by misdiagnosis and mismanagement. They must be considered in the differential diagnosis of unexplained pain and swelling in muscles. IMH occurring in the oral cavity is reviewed below.
Keywords: Hemangioma, intra-muscular, sporting pain
|How to cite this article:|
Nayak S, Shenoy A. Intra-muscular hemangioma: A review. J Orofac Sci 2014;6:2-4
| Introduction|| |
Hemangiomas are rare benign vascular neoplasms  and they are abnormal proliferation of blood vessels. They may occur in any vascularized tissue.  It is a benign soft tissue tumor occurring most often in the skin and sub-cutaneous tissues. Hemangiomas are hamartomas rather than true neoplasms as they are generally composed of vascular spaces arising from endothelial cells and not by incorporation of nearby vascular channels. They are mostly congenital with 85% seen in newborns and 1 st year infants and are not commonly seen in adults  as they regress with age.
It predominantly affects the skin and subcutaneous tissues of the trunk, followed by extremities and head and neck region (13.5-21%). In the head and neck region, it occurs very rarely in oro-facial muscles (<1%). , Surgical intervention is needed only when a symptom arises and it carries excellent prognosis.
Unlike infantile cutaneous hemangioma, intramuscular hemangioma (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 sometimes angiography for accurate diagnosis. , The exact cause of intramuscular hemangioma has been an enigma.  The most accepted nomenclature for classifying intramuscular hemangioma is based on histological appearance. Allen and Enzinger in 1972 formed a classification system based on the vessel size; capillary, cavernous or mixed small/large vessel types. This classification correlates well with location and prognosis. 
Until recently, only 5 cases of IMH have been reported in the head and neck region. It includes diagastric muscle,  massetor muscle,  and myolohyoid muscle. ,
Hemangiomas are benign proliferative vascular lesions characterized by increased endothelial turn over. These tumors usually appear after birth, grow rapidly and involute over the years within the spectrum of vascular lesions. Intra muscular hemangiomas are very rare, accounting for less than 1% of all hemangiomas, and less than 20% of these are found in the head and neck area. The masseter muscle is most frequent muscle accounting for 5% of all intramuscular hemangiomas. The trapezius, periorbital, sternocleidomastoid [Table 1] and temporalis muscle [Table 2] follow the masseter muscle [Table 3] in frequency. The tongue, extra ocular and posterior neck muscles have also been reported to be involved with hemangioma with less frequency.  Due to their fibro vascular nature IMH have a rubbery, firm texture and vascular bruits or thrills are infrequent. The lesion can be moved from side to side, but not along the direction of the muscle fibers and there is rarely any overlying skin discoloration as seen in other forms of hemangiomas. 
|Table 1: All reported intra muscular hemangiomas|
of sternocleidomastoid muscle
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|Table 3: Few of the cases listed under intramuscular|
hemangioma of the masseter muscle
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The first case of intra muscular hemangioma of the masseter muscle was reported by Listen in 1843, subsequently other reports have accumulated to a total of 457, of these 63 (13.8%) involved head and neck and 23 (5.0%) involved masseter muscle. , Intramuscular hemangioma of the masseter muscle shows a definite male predominance among the reported cases. In contrast, Scott's review of intramuscular hemangioma in general revealed an equal sex distribution. The tumor develops before the age of 30 years in approximately 90% of cases, so due to this the etiological role of either congenital origin or possibility of trauma is playing a role remains unresolved.  The cause of intramuscular hemangioma is unknown. Several theories have been proposed, but the most likely explanation is that the intramuscular hemangioma is a congenital mass, arising by abnormal embryonic sequestrations, similar to congenital arteriovenous malformations. 
IMH are non-metastasizing benign congenital tumors that, after remaining unrecognized for long periods, may suddenly start to grow in second or third decade of life.  More than 90% of IMH are detected before the fourth decade.  A possible hormonal role in growth of intramuscular hemangioma was speculated, but no specific data was available to prove this hypothesis. They are usually asymptomatic until a growth spurt occurs at which time pain occurs in about 50% of cases. A palpable fluctuant swelling or firm mass is present in up to 98% of cases. 
Histopathologically the hemangiomas have been classified into capillary and cavernous types. Now recently, Allen and Enzinger examined 89 IMH and found that they can be divided according to the size of the vessels predominantly into small-vessels or capillary type, which comprised vessels of less than 140μ diameter, large-vessel or cavernous type, which comprised vessels of more than 140μ diameter and mixed type, which consists of both small and large vessels. , About 30% of small-vessel IMH are found in the head and neck and tend to have short clinical history compared to 19% of large-vessel and 5% of mixed types.  The mixed type shows greater tendency for local recurrence (28%) and the large vessel type, the least (9%). To date no reasons have been given for the recurrence rate of mixed type. 
The diagnosis of intra muscular hemangioma requires a high index of suspicion whenever a mass of soft tissue density is encountered in the region of skeletal muscle in a young adult, hemangioma should be considered in the differential diagnosis.  MRI has been shown to provide better detection and delineation of the extent of IMH than Computed tomography. The MRI is superior because of its multiplanar capabilities and the distinct contrast between normal muscle and the IMH. IMH are characteristically much brighter on T2-than on T1-weighted images because of the increased free water present within the stagnant blood in the larger vessels.
A clear distinction; however, between capillary and cavernous types is often not possible. MRI findings suggestive of IMH include: (i) High signal intensity on both T1-and T2-weighted images; (ii) serpiginous pattern, septated-striated high signal channels and curvilinear areas of low intensity consistent with vascular spaces; (iii) focal heterogeneities representing areas of thrombosis, fibrosis or calcification; and(iv) adjacent focal muscular atrophy. Arteriography is useful as a pre-operative embolization of feeding vessels, which enhances homeostasis. Fine-needle aspiration cytology in most reported series is frequently non-diagnostic. 
The differential diagnosis of mass in masseter includes congenital cysts, muscle fiber herniation, lymphadenopathy, cystic hygroma, sialocele of parotid duct and various parotid and muscle neoplasm. Several forms of therapy have been advocated for the various types of hemangiomas, including cutaneous, cavernous or capillary, subglottic and intramuscular types. The management has ranged from steroids to injection of sclerosing agents, radiation therapy, and surgical excision. Recently, there have been reports of pre-operative embolization of hemangiomas with muscle fragments as a technique to decrease intraoperative blood loss. It is unlikely that these procedures will be indicated before removal in cases of small muscle hemangiomas such as those presenting because of small caliber of feeding vessels. The accepted optimal treatment of a muscle hemangioma is its total excision with a surrounding cuff of normal muscle. Masseter muscle hemangioma has been approached by an intraoral route, by a pre-auricular incision with a superficial parotidectomy, and by a pre-auricular incision with development of flap lateral to it and preserving parotid gland. However certain factors must be considered before selecting the surgical approach. The intraoral route affords relatively poor exposure for adequate tumor removal and risks injury to the facial nerve.  Local recurrences occur in approximately 18% of IMH, usually as a result of incomplete surgical resection. Regional and distant metastasis has not been reported. 
Sclerotherapy is done; 
- When the lesion is too large or too close to some important, structures or organs.
- When the patient does not need a surgery.
- When there is a need to debulk the tumor before surgery or cosmetic treatment.
There is a better outcome if the lesion is localized and results are good if excision is complete. If incomplete the symptoms are continuous. Nonoperative treatment has limited success.
| Conclusion|| |
Intra muscular hemangioma may start to grow in childhood and should be considered in the differential diagnosis of isolated muscle enlargement. MRI and color Doppler Sonography are very helpful in diagnostic work-up and the treatment of choice should be individualized in view of the clinical status of the patient.
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[Table 1], [Table 2], [Table 3]