Case Report

Intraosseous Cavernous Hemangioma

A Rare Presentation in Maxilla

Burak Kaya, MD; Servet Elçin Işılgan, MD; Cem Çerkez, MD; Volkan Otrakçı, MD; Savaş Serel, MD

Disclosures

ePlasty. 2014;14 

In This Article

Discussion

Hemangiomas are benign vascular lesions that are typically identified during infancy and are known to regress by adolescence.[2] Although head and neck region is not an uncommon localization for hemangiomas, most arise from soft tissues. Intraosseous hemangiomas are very rare, slow-growing benign vascular anomalies accounting for 1% of all benign bone tumors. The most frequent sites of involvement are calvarium and vertebral column.[3] The maxillofacial involvement is rare and mandible, maxilla, and nasal bones are the most frequently affected sites, respectively.[2,3]

They are classified as cavernous or capillary type according to their vascular network histopathologically. The cavernous hemangioma is composed of large thin-walled vessels and sinusoids lined with a single layer of endothelium. However, a small fine vascular network filled with blood forms the capillary hemangioma. Capillary hemangiomas are usually present at birth. In contrast, most cavernous hemangiomas occur in adulthood. Almost all intraosseous hemangiomas of the facial skeleton are to be cavernous type.[4] The differential diagnoses for intraosseous cavernous hemangioma include fibrous dysplasia, osteoma, Langerhans cell histiocytosis, dermoid tumor, and multiple myeloma.

Women in the fourth and fifth decades of life are mostly affected.[5] Although the cause of intraosseous hemangioma is still uncertain, local trauma is thought to be one possible factor. In our patient, there was no such predisposition for intraosseous hemangioma development. As intraosseous hemangioma tends to grow very slowly, it remains clinically silent until the tumor becomes large. Therefore, early detection is crucial to a lesser cosmetic deformity.

Computed tomography is considered the most useful imaging technique because of its unique characterization of trabecular and cortical details, showing the honeycomb appearance.[1] MRI provides information about any associated soft tissue element. In our case, close proximity of the mass to the orbit made MRI compulsory.

The goal of the treatment in hemangioma is to remove the tumor completely without any functional deficit, cosmetic deformity, or significant tissue loss. Biopsy of the lesion in order to exclude malignancy should be done cautiously because of the risk of severe bleeding.[6]

In the past, radiotherapy and sclerotherapy were the treatment of choice. But today radiotherapy may only be reserved for cases in which surgery is not feasible due to the adverse effects such as tissue necrosis, retardation of growth of bones and teeth, telangiectasia, and malignant degeneration, and sclerosing agents are used for soft-tissue hemangiomas of the head and neck. Other treatment modalities include angiography with embolization, curettage, and cryotherapy.[7–10]

Total surgical excision is the preferred method of treatment for intraosseous hemangiomas with reconstruction. Depending on the size of the defect and the surgeon preferences, autologous or heterologous materials can be used. Some techniques include hydroxyapatite associated with titanium mesh for reconstruction,[11] Medpor,[12] and bone grafting.[13] In our patient, Medpor was preferred to reconstruct orbital floor, the infraorbital orbital rim, and anterior wall of maxillary sinus because the patient would not accept any other scar. The result has been satisfactory, achieving a natural smooth malar contour and adequate orbital rim.

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