Patient: 8 year old female
Main complaint and medical history:
An 8 year-old healthy female presented to the oral medicine clinic at Groote Schuur Hospital (GSH). She had been referred from a physician for the assessment of a soft tissue swelling present on the right side of the nasolabial area. The lesion was noticed since last year and remains asymptomatic and slow growing. Her parents were concerned as the swelling was now more noticeable extra-orally .
Clinical examination:
Extraoral examination revealed asymmetry between the left and right nasolabial regions with a swelling detected deep within the nasolabial fold on the right side of the face (figure1). No signs of inflammation were detected upon the overlying skin and no discomfort was reported on palpation.
Simultaneous intra-oral and extra-oral palpation of the right upper lip, vestibule and sub-nasal tissues revealed a fluctuant, mobile and slightly nodular soft tissue swelling within the submucosa. A firmer nodule within the lesion could also be detected. The lesion could be visualized intra-orally after reflection of the upper lip. The bluish hue could be detected through the mucosa; the surface was smooth, non-blanching and slightly grainy in texture with ill-defined margins extending from the border of the upper lip and into the labial vestibule (figure3).
The teeth 12,13,14,15,23,24,26,34,35,44 were still to erupt however the remaining teeth and soft tissues were in good health.
Figure 1: Extra-oral view. The right nasolabial tissues appear slightly elevated in contrast to the left side
Figure 2: lesion can be seen beneath the mucosa following lip elevation and extra-oral palpation
Figure 3: intra oral view following lip elevation. Note the bluish hue
Figure 4: Panoramic radiograph. Multiple unerupted teeth as indicated. Unfortunately accesses to alternative intra-oral radiographic views are not available at GSH
Differential diagnosis:
- Vascular malformation with or without phlebolith
- Nasolabial cyst
- Salivary neoplasia
- Dermoid or teratomatous cyst
Management:
As the vascular malformation with possible phlebolith formed the most likely of the differential diagnosed lesions, the case was discussed with the consultant maxillo-facial surgeon prior to an ultrasound examination being scheduled at Red Cross Childrens Hospital. After reviewing the images, the need for additional imaging such as magnetic resonance imaging (MRI) would be decided. Following ultrasound examination, the detected lesion was diagnosed as a non-involuting cavernous haemangioma (NICH) and referred to maxillo-facial surgery for further management.