BLUE/PURPLE VASCULAR LESIONS
Hemangioma
Vascular lesions presenting as proliferations of vascular channels are tumorlike hamartomas when they arise in childhood; in adults (particularly elderly persons), benign vascular proliferations are generally varicosities. The hemangiomas of childhood are found on the skin, in the scalp, and within the connective tissue of mucous membranes. Approximately 85% of childhood-onset hemangiomas spontaneously regress after puberty.
Hemangioma
Vascular lesions presenting as proliferations of vascular channels are tumorlike hamartomas when they arise in childhood; in adults (particularly elderly persons), benign vascular proliferations are generally varicosities. The hemangiomas of childhood are found on the skin, in the scalp, and within the connective tissue of mucous membranes. Approximately 85% of childhood-onset hemangiomas spontaneously regress after puberty.
Depending on the depth of the vascular proliferation within the oral submucosa, the lesion may harbor vessels close to the overlying epithelium and appear reddish blue or, if a little deeper in the connective tissue, a deep blue. Angiomatous lesions occurring within muscle (so-called intramuscular hemangiomas) may fail to show any surface discoloration. Whereas most hemangiomas are raised and nodular, some may be flat, macular, and diffuse, particularly on the facial skin, where they are referred to as port-wine stains. The port-wine hemangioma of facial skin may concomitantly involve the oral mucosa, where the angioma may continue in macular fashion or become tumefactive. Thus, the clinical appearance of benign vascular hamartomas can be quite variable, ranging from a flat reddish blue macule to a nodular blue tumefaction.
Most oral hemangiomas are located on the tongue, where they are multinodular and bluish red. The multinodularity is racemose and diffuse. Tongue angiomas frequently extend deeply between the intrinsic muscles of the tongue. The lip mucosa is another common site for hemangiomas in children; these tumors are usually localized, blue, and raised. The aforementioned port-wine stain involves the facial skin and is flat and magenta in color. When there is a concurrent history of seizures, the condition represents encephalotrigeminal angiomatosis (Sturge-Weber syndrome). Vascular lesions occur in the brain as well as on the facial skin; skull radiography may disclose vessel wall calcifications that yield bilamellar radiopaque tracks referred to as “tram line” calcifications.
Hemodynamics in angiomas are perturbed, and stasis with thrombosis is commonly encountered. Most patent vascular lesions will blanch under pressure; indeed, placing a microscope glass slide over the pigmented area and adding pressure will often demonstrate this feature dramatically. Conversely, when intraluminal clots form, they become palpable and the lesion will usually not blanch. Thrombi in angiomas may eventually calcify, and such lesions will feel hard on palpation. The calcified nodules, or phleboliths, may be radiographically evident.
Microscopically, a hemangioma may comprise numerous large dilated vascular channels lined by endothelial cells without a muscular coat; such lesions are referred to as cavernous hemangiomas. Rarely, cavernous hemangiomas may show a media muscularis. Cellular- or capillary-type hemangiomas show significant endothelial proliferation, and the vascular lumina are very small. Both types may occur only in the subepithelial connective tissue or may extend deeply between muscle fibers (so-called intramuscular hemangiomas). This biologic feature is of clinical importance since intramuscular lesions may extend quite deeply and are more difficult to manage if treatment is required for functional or esthetic reasons.
Since many hemangiomas spontaneously involute during teenage years, treatment may be withheld in children. Patients who require treatment can undergo conventional surgery, laser surgery, or cryosurgery. Larger lesions that extend into muscles are more difficult to eradicate surgically, and sclerosing agents such as 1% sodium tetradecyl sulfate may be administered by intralesional injection. These agents result in postoperative pain, and the patient must be managed with a
Most oral hemangiomas are located on the tongue, where they are multinodular and bluish red. The multinodularity is racemose and diffuse. Tongue angiomas frequently extend deeply between the intrinsic muscles of the tongue. The lip mucosa is another common site for hemangiomas in children; these tumors are usually localized, blue, and raised. The aforementioned port-wine stain involves the facial skin and is flat and magenta in color. When there is a concurrent history of seizures, the condition represents encephalotrigeminal angiomatosis (Sturge-Weber syndrome). Vascular lesions occur in the brain as well as on the facial skin; skull radiography may disclose vessel wall calcifications that yield bilamellar radiopaque tracks referred to as “tram line” calcifications.
Hemodynamics in angiomas are perturbed, and stasis with thrombosis is commonly encountered. Most patent vascular lesions will blanch under pressure; indeed, placing a microscope glass slide over the pigmented area and adding pressure will often demonstrate this feature dramatically. Conversely, when intraluminal clots form, they become palpable and the lesion will usually not blanch. Thrombi in angiomas may eventually calcify, and such lesions will feel hard on palpation. The calcified nodules, or phleboliths, may be radiographically evident.
Microscopically, a hemangioma may comprise numerous large dilated vascular channels lined by endothelial cells without a muscular coat; such lesions are referred to as cavernous hemangiomas. Rarely, cavernous hemangiomas may show a media muscularis. Cellular- or capillary-type hemangiomas show significant endothelial proliferation, and the vascular lumina are very small. Both types may occur only in the subepithelial connective tissue or may extend deeply between muscle fibers (so-called intramuscular hemangiomas). This biologic feature is of clinical importance since intramuscular lesions may extend quite deeply and are more difficult to manage if treatment is required for functional or esthetic reasons.
Since many hemangiomas spontaneously involute during teenage years, treatment may be withheld in children. Patients who require treatment can undergo conventional surgery, laser surgery, or cryosurgery. Larger lesions that extend into muscles are more difficult to eradicate surgically, and sclerosing agents such as 1% sodium tetradecyl sulfate may be administered by intralesional injection. These agents result in postoperative pain, and the patient must be managed with a
moderate-level analgesic such as oxycodone or aspirin with codeine. Cutaneous port-wine stains can be treated by subcutaneous tattooing or by argon laser (see also Chapter 5, “Red and White Lesions of the Oral Mucosa”)