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Year : 2014  |  Volume : 6  |  Issue : 1  |  Page : 2-4

Intra-muscular hemangioma: A review

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 Publication15-May-2014

Correspondence Address:
Amarnath Shenoy
Department of Conservative Dentistry and Endodontics, Yenepoya Dental College, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-8844.132563

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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

How to cite this URL:
Nayak S, Shenoy A. Intra-muscular hemangioma: A review. J Orofac Sci [serial online] 2014 [cited 2022 May 26];6:2-4. Available from:

  Introduction Top

Hemangiomas are rare benign vascular neoplasms [1] and they are abnormal proliferation of blood vessels. They may occur in any vascularized tissue. [2] 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 [3] 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%). [4],[5] 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. [6],[7] The exact cause of intramuscular hemangioma has been an enigma. [8] 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. [9]

Until recently, only 5 cases of IMH have been reported in the head and neck region. It includes diagastric muscle, [2] massetor muscle, [2] and myolohyoid muscle. [1],[5]

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. [10] 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. [1]
Table 1: All reported intra muscular hemangiomas
of sternocleidomastoid muscle

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Table 2: Lntramuscular hemangiomas of temporalis

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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. [11],[12] 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. [11] 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. [12]

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. [5] More than 90% of IMH are detected before the fourth decade. [7] 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. [10]

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. [1],[11] 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. [1] 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. [11]

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. [10] 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. [9]

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. [12] Local recurrences occur in approximately 18% of IMH, usually as a result of incomplete surgical resection. Regional and distant metastasis has not been reported. [9]

Sclerotherapy is done; [13]

  • 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 Top

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.

  References Top

1.Chan MJ, McLean NR, Soames JV. Intramuscular haemangioma of the orbicularis oris muscle. Br J Oral Maxillofac Surg 1992;30:192-4  Back to cited text no. 1
2.Danielle AK, Timothy AD, David GM. Heamangioma. Br J Oral Maxillofac Surg 2004;32:231-4.  Back to cited text no. 2
3.Kale US, Ruckley RW, Edge CJ. Cavernous haemangioma of the parapharyngeal space. Indian J Otolaryngol Head Neck Surg 2006;58:77-80.  Back to cited text no. 3
  Medknow Journal  
4.Jin W, Kim GY, Lee JH, Yang DM, Kim HC, Park JS, et al. Intramuscular hemangioma with ossification: Emphasis on sonographic findings. J Ultrasound Med 2008;27:281-5.  Back to cited text no. 4
5.Kim DH, Hwang M, Kang YK, Kim IJ, Park YK. Intramuscular hemangioma mimicking myofascial pain syndrome: A case report. J Korean Med Sci 2007;22:580-2.  Back to cited text no. 5
6.Chatterjee R, Blackburn TK, Boyle MA. Intramuscular haemangioma within depressor anguli oris. Br J Oral Maxillofac Surg 2007;45:234-5.  Back to cited text no. 6
7.Steen RC, Svend EB, Steffen H, Jan UP. Orbital intramuscular haemangioma. Acta Opthalmol Scand 2002;80:336-9.  Back to cited text no. 7
8.Rectal muscle haemangioma - A case note with analysis of previously reported cases. Available from: 2180108. [Last accessed on 2013 Feb 13].  Back to cited text no. 8
9.Kenali MS, Bridger PG. Intramuscular haemangioma of the medial pterygoid. Aust N Z J Surg 2000;70:462-6.  Back to cited text no. 9
10.Fatma SA, Ergun O, Yalcin H, Inci K, Bilge U. Intramuscular haemangioma of the masseter muscle in a 9-year-old girl. Acta Aniol 2007;13:42-6.  Back to cited text no. 10
11.Welsh D, Hengerer AS. The diagnosis and treatment of intramuscular hemangiomas of the masseter muscle. Am J Otolaryngol 1980;1:186-90.  Back to cited text no. 11
12.Ingalls GK, Bonnington GJ, Sisk AL. Intramuscular hemangioma of the mentalis muscle. Oral Surg Oral Med Oral Pathol 1985;60:476-81.   Back to cited text no. 12
13.Brown RA, Crichton K, Malouf GM. Intramuscular haemangioma of the thigh in a basketball player. Br J Sports Med 2004;38:346-8.  Back to cited text no. 13


  [Table 1], [Table 2], [Table 3]

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