The role of imaging and surgery in the management of vascular tumors of the masseter muscle

Effectiveness and safety of percutaneous sclerotherapy using absolute ethanol and/or polidocanol for maxillofacial venous malformations involving the masticatory muscles: A case series

OBJECTIVE

This study evaluated the effectiveness and safety of percutaneous sclerotherapy for maxillofacial venous malformations.

STUDY DESIGN

Patients who had venous malformations involving the masticatory muscles and who underwent sclerotherapy were enrolled in this retrospective study.

RESULTS

Twenty-four patients (13 female, 11 male; mean age 21 years) were analyzed. Major clinical symptoms were swelling (100%) and intralesional pain (54%). Intramuscular lesions involved the masseter muscle only in 38% of cases, both the masseter and temporalis muscles in 33%, all masticatory muscles in 21%, and the temporalis muscle only in 8%. Extramuscular involvement was observed in 58% of patients. Absolute ethanol and polidocanol were used as sclerosants. The mean number of sclerotherapy sessions per patient was 6.6 (range, 1-32). The mean follow-up duration after the first sclerotherapy session was 64.8 months (range, 6-178). The complications included paralysis of the facial nerve (25%), intraoral ulceration (8%), and hemoglobinuria (8%). The effectiveness of treatment was rated as excellent in 33% of cases, good in 46%, and fair in 21%. Better results were obtained in patients without extramuscular involvement.

CONCLUSION

Percutaneous sclerotherapy can be effective and safe for maxillofacial intramuscular venous malformations, especially for localized lesions of the masseter muscle.

Image Guided Sclerotherapy of Masseteric Venous Malformations

Objective:

To describe results of image guided sclerotherapy of venous malformations (VM) localized in the masseter muscle.

Methods:

Retrospective review of prospectively maintained data was done to include consecutive cases treated over 5-year period, with minimum 6 months follow-up. Sclerotherapy was done using ultrasound (US) guided needle puncture(s) of the lesions percutaneously, and 3% polidocanol foam injected under image guidance.

Results:

Seventeen cases (10 male, 7 female) with mean age 15.6 years (range 6-28 years) were identified. Clinical presentation was with facial asymmetry, becoming pronounced on jaw clenching, and three cases had mild local pain. On US, the lesions appeared as partially compressible masses with anechoic spaces, showing color filling on releasing probe pressure. Fourteen had phleboliths. Eight patients had undergone magnetic resonance imaging, lesions appearing as oval, homogenous, lobulated, T2 hyperintense masses, with heterogeneous contrast enhancement. Number of sclerotherapy sessions were—single in four cases, two in eight cases and three in five cases, for total of 35 sessions (average 2.05 session per patient). The mean dose of drug injected per session was 1.85 mL and total mean dose per patient was 2.79 mL. Post-procedure vomiting occurred in one patient while all had local swelling and mild pain, lasting between 3 to 7 days. No facial nerve palsy or sloughing/ulceration/skin necrosis was noted. On US follow-up (6-26 months, mean 15.9 months), 12 patients had small echogenic masses without any vascularity, and five had small anechoic areas <25%. All patients had complete resolution of swelling and pain.

Conclusions:

For VMs localized to the masseter muscle, image guided sclerotherapy is highly effective and safe, and recommended as first line treatment.

Transcervical excision of intramasseteric cavernous hemangioma: A case report

Intramuscular hemangiomas (IMHs) of the masseter muscle are extremely rare in the head and neck region and, thus, are often misdiagnosed as parotid tumors prior to surgery. Excisional resection remains the standard treatment for IMH. Since these tumors are located on the proximal side of the facial nerve, it is important to preserve the facial nerve during surgery. This study reports the case of a 57-year-old male who presented with a progressive tender swelling on the right side of the face, which had been present for >6 months. Computed tomography of the neck revealed a heterogeneous highly-vascularized mass located in the superficial layer of the masseter muscle. The patient subsequently underwent surgical resection via a collar incision, and pathological examination revealed a cavernous IMH. During the one-year follow-up period, the patient exhibited a good prognosis, and one-year magnetic resonance imaging revealed no local recurrence.

Intramuscular cavernous haemangioma of masseter muscle - a case report of surgical excision

Intramuscular haemangioma are rare benign congenital neoplasm of proliferative vascular in nature due to increased endothelial cell turnover. Less than 20% of these are found in head and neck region. The masseter muscle accounts for 5% of all intramuscular haemangioma of head and neck region. They are non metastasizing tumours which may suddenly start growing in later stages. The present article will discuss the clinical presentation, diagnostic modalities and surgical treatment of cavernous Haemangioma involving masseter muscle in a 15-year-old young female patient in whom a surgical excision of whole lesion was done under general anaesthesia and no reoccurrence of the lesion was observed after one year of follow up.

The role of time-resolved imaging of contrast kinetics (TRICKS) magnetic resonance angiography (MRA) in the evaluation of head-neck vascular anomalies: a preliminary experience

OBJECTIVES

In this preliminary report, we describe our experience with time-resolved imaging of contrast kinetics-MR angiography (TRICKS-MRA) in the assessment of head-neck vascular anomalies (HNVAs).

METHODS

We prospectively studied six consecutive patients with clinically suspected or diagnosed HNVAs. All of them underwent TRICKS-MRA of the head and neck as part of the routine for treatment planning. A digital subtraction angiography (DSA) was also performed.

RESULTS

TRICKS-MRA could be achieved in all cases. Three subjects were treated based on TRICKS-MRA imaging findings and subsequent DSA examination. In all of them, DSA confirmed the vascular architecture of HNVAs shown by TRICKS-MRA. In the other three patients, a close follow up to assess the evolution of the suspected haemangioma was preferred.

CONCLUSIONS

TRICKS sequences add important diagnostic information in cases of HNVAs, helpful for therapeutic decisions and post-treatment follow up. We recommend TRICKS-MRA use (if technically possible) as part of routine MRI protocol for HNVAs, representing a possible alternative imaging tool to conventional DSA.

Slowly growing swelling on body of the mandible with paresthesia on lower lip

A 23-year-old female patient reported with the chief complaint of swelling on the lower left posterior teeth region of the jaw and paresthesia of left lower lip of 6 months of duration. On the basis of clinical findings and conventional radiographic features, odontogenic tumor or cyst was suspected. Advanced imaging i.e. CT scan, Denta Scan, MRI further provided the exact nature, extent and location of the lesion and later on by histopathological examination, it was diagnosed as an intraosseous schwannoma of the mandible. In this clinicopathologic conference section, elaborate differential diagnosis and radiological features of this rare case is presented.

Arteriovenous malformation of the mandible and parotid gland

Arteriovenous malformations (AVMs) of the jaws are relatively rare, with fewer than 200 cases reported in the literature. Their real importance lies in their potential to result in exsanguination, which usually follows an unrelated treatment, such as tooth extraction, surgical intervention, puncture wound or blunt injury in involved areas, with the dentist unaware of the existence of the AVM. The present case illustrates an AVM in an 18-year-old female with swelling on the right side of the face. This case report is unique because although there was no history of bleeding episodes, thorough examination and investigation diagnosed it as high-flow vascular malformation. We ascertain the importance of dentists' awareness of the fatal outcome of these lesions and emphasize that, prior to performing any procedure, necessary investigations should always be done.

Masseteric venous malformations: Diagnosis, treatment, and outcomes

OBJECTIVE: To describe a typical presentation of venous malformation within the masseter muscle, including physical findings and imaging, and to present the University of California, San Francisco's (UCSF) Vascular Anomalies and Birthmark Center's (VABC) experience with sclerotherapy for these lesions. STUDY DESIGN: Case series with chart review.

SETTING: Tertiary care medical center.

SUBJECTS AND METHODS: Retrospective chart review of all patients presenting to the UCSF VABC over a 10-year period.

RESULTS: Twelve patients with isolated venous malformations of the masseter muscle were identified. All of these patients presented with pain and facial asymmetry that was more pronounced with jaw-clenching. All underwent magnetic resonance imaging demonstrating a T2 hyperintense homogenous mass contained within the masseter muscle. Eleven of 12 had evidence on imaging of phleboliths within the mass; 10 patients underwent sclerotherapy. All treated patients had initial improvement in symptoms and/or appearance. Seven of 10 have had sustained improvement at a mean follow-up of 28 months.

CONCLUSION: Masseteric venous malformations have a typical clinical presentation and imaging characteristics that should allow clinicians to distinguish them from other abnormalities presenting in this area. Percutaneous sclerotherapy should be considered as a treatment option for these patients and can result in excellent outcomes.

Pediatric salivary gland imaging

A variety of lesions occur in the pediatric salivary glands. With modern imaging techniques such as Doppler sonography, helical CT, and MRI, identification of a specific etiology is often possible. Knowledge of clinical information, normal anatomy, and imaging characteristics of salivary gland pathology are essential for appropriate radiologic evaluation. This review illustrates the various congenital, neoplastic, and inflammatory entities that can occur within the parotid, submandibular, and sublingual spaces.