Intraoral Brownish, Bluish, or Black Conditions
CHAPTER 12
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B
A
Fig. 12-10. Cavernous hemangioma. A, Of the lip. n, Of the anterolateral border of the tongue. C, Of the noor of the mouth, mimicking a ranula. (Courtesy G. MacDonald, San Jose, Calif.)
within the first year of life. 2o Only hemangiomas that occur superficially are considered in this section. The deeper hemangiomas are rarely detected and do not appear blue. The cavernous hemangioma is a soft, non fluctuant, domelike, bluish, and occasionally bosselated nodule that may vary in size from a millimeter or less to several centimeters in diameter (Fig. 12-10). It frequently appears on the lips, buccal mucosa, palate, and other sites in the oral cavity. Maffucci's syndrome features multiple enchondromas, multiple hemangiomas, and phleboliths. Laskaris and Skouteris 21 reported a case in which the intraoral hemangiomas were the only ones present.
Differential Diagnosis The hemangioma blanches and may be emptied by the application of digital pressure, which forces the blood from the vascular spaces. This feature accounts for the finding that the lesion is not fluctuant and, in turn, helps differentiate the cavernous hemangioma from the mucocele, ranula, and superficial cyst, which although soft, is fluctuant and cannot be emptied by digital pressure. (See Chapter 3 for a broader discussion of these differences.) A varicosity usually is seen as an elongated enlargement of a superficial vein rather than as a nodule or domeshaped mass. Furthermore, a pulse is not detectable within the cavernous hemangioma. This feature distinguishes the he-
mangioma from an arteriovenous shunt or an aneurysm. both which may occur as rubbery, nonfluctuant. domelike. bluish-red nodules with usually discernible throbbing. Tn addition to these characteristics, the aspiration of bluish blood with a fine-gauge needle contributes convincing evidence for a working diagnosis of cavernous hemangioma.
Management Surgical excision and injection of sclerosing agents. solid embolizing materials, or combinations thereof are used for the treatment of a hemangioma. The exact size and extent of the tumor must be determined before any treatment is undertaken, since the visible portion may represent just the tip of the lesion. Angiograms are thus used to detect the lesion's depth. 22 The excision of a moderately large or large hemangioma should not be attempted in the dental office; rather, the patient should be hospitalized and the procedure performed in an operating room. where blood is available for transfusions and where extraOl'al ligation of cervical arteries may be accomplished more readily. Cryotherapy has gained acceptance in the treatment of hemangiomas. 23 ,24.25 Results range from good to excellent. Sclerosing solutions are injected into the lesion to induce inflammation and the formation of fi.brous tissue. which scleroses and shrinks the vascular spaces (Fig. 12-11). Solutions such as sodium tetradecyl sulfate have provided good results. 26- 28 Absolute ethanol has also been used. 29