Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

QUIZ
Year
: 2005  |  Volume : 15  |  Issue : 1  |  Page : 131--132

Radiological quiz - paediatrics parotid hemangioma


V Karla, R Anand, MK Narula 
 Department of Radiology, Lady Hardinge Medical College, And assoc. Smt. S.K. Hospital, New Delhi, India

Correspondence Address:
M K Narula
J-13/42, Rajouri Garden, New Delhi - 110027
India




How to cite this article:
Karla V, Anand R, Narula M K. Radiological quiz - paediatrics parotid hemangioma.Indian J Radiol Imaging 2005;15:131-132


How to cite this URL:
Karla V, Anand R, Narula M K. Radiological quiz - paediatrics parotid hemangioma. Indian J Radiol Imaging [serial online] 2005 [cited 2019 Nov 16 ];15:131-132
Available from: http://www.ijri.org/text.asp?2005/15/1/131/29186


Full Text

A seven month old girl presented with progressively increasing swelling in the left parotid region since last 6 months. Patient had a history of purulent ear discharge and fever off and on for 2 months; and was clinically found to have Otitis media. Following are the Ultrasound , Doppler and CT images. What is your diagnosis?

 Radiological Diagnosis



 View Answer

 LEFT PAROTID HEMANGIOMA



Ultrasound of left parotid region shows a diffusely enlarged left parotid gland with multile anechoic areas within [Figure 1]. On colour Doppler flow imaging, left parotid showed filling in of the anechoic areas with colour and a very high vessel density suggesting vascular nature of the lesion [Figure 2][Figure 3]. CT show a well demarcated, homogeneous, intensely enhancing enlarged left parotid gland involving both superficial and deep lobes. The right parotid gland is normal. Left posterior cervical lymphadenopathy is noted. [Figure 4]. On the basis of these findings, the diagnosis of left parotid hemangioma was made: cervical lymphadenopathy being explained by the clinical diagnosis of otitis media. The child was treated with the percutaneous injection of sclerosing agents (Bleomycin 7 IU) twice at an interval of 3 weeks with marked regression in the size and reduction in vascularity of the mass.

Salivary gland tumours are uncommon in children (less than 5%).Hemangioma being the most common (more than 50%), followed by Pleomorphic adenoma, Mucoepidermoid carcinoma. Lymphangioma. Acinar cell carcinoma [1]. Congenital capillary hemangioma classified as 'True hemangioma' of infancy, according to Mulliken and Glowacki classification (1982), represent 90% of parotid gland tumours in infancy [1]. They are true benign vascular tumours which undergo rapid growth (proliferative phase) for few months in infancy before gradual spontaneous involution over a period of few years [2]. It is commoner in girls with median age of presentation being about 4 months and shows characteristic bluish discoloration of the skin [1],[2]. In comparison, cavernous hemangiomas classified as 'True vascular malformations' are secondary to abnormal development of vessels, present in the late childhood, lack the characteristic bluish discoloration of skin, may contain phleboliths (true hemangiomas do not) and are unlikely to regress spontaneously. Hence, surgical resection is the treatment of choice [3]. Hemangioma of infancy is seen on US as homogeneous mass enlarging and replacing most of the parotid gland, with fine echogenic internal septations and numerous intratumoral vessels seen as anechoic areas [2]. Colour Doppler shows filling in of the anechoic areas. Doppler criteria of high vessel density (more than 5 per square cm) as seen in our case and high Doppler shifts distinguish them from other tumours [4]. The lesion is isodense to muscle on NCCT. On contrast administration it is seen as an intensely enhancing, well defined homogeneous mass. MRI finding of an isointense mass on T1WI with intralesional flow voids help to distinguish this mass from other soft tissue lesions of infancy. The mass is hyperintense to muscle on T2WI. Involuting hemangiomas show areas of hyperintense T1W signal secondary to fatty replacement [5]. MRI can distinguish this lesion from cavernous hemangiomas which produce heterogenous T2 signal (due to phleboliths and venous lakes) and lack intralesional flow voids [5].

From therapeutic perspective, there are two options in these low flow lesions -

Conservative management and observation, as most cases of hemangioma of infancy show gradual spontaneous involution.Rapidly growing lesions assoiciated with haemorrhage causing threat to airways warrant aggressive therapy in the form of steroids, laser photo coagulation, sclerotherapy, embolization and surgical resection. Percutaneous injection of sclerosing agent (sodium tetradecy sulfate) either alone or before surgery is a safe and effective method of managing symptomatic hemangiomas [6].

References

1Som P., Curtin H.D. : Head and neck imaging, 4th edition Vol 2. St. Louis : mosby 2002: 1852-2185.
2Roebuck D.J., Ahuja A.T. : Hemangioendothelioma of the parotid gland in infants: Sonography and correlative MR Imaging AJNR 2000:21:219-223.
3Hamdi J.T., Kameswaran Ml, Saeed Abu-Eshy, Malatani T. : Cavernous hemangioma of the parotid gland. Annals of Saudi Medicine 1994;Vol.14: No.3.
4Dubois J., Patriquin H.B. Gare L., et al. Soft hemangiomas in infants and children : Diagnosis using Doppler sonography. AJR; vol. 171:247-252.
5Baker LL, Dillon W.P. Hieshima G.B: Hemangioma and vascular malformations of head and neck: MR Characterization, AJNR 1993;14:307-314.
6Donovan J.C., Donaldson J.S., Morello F.P., Pensler J. M, Vogelzang R.L., Bauer. B et al.: Symptomatic hemangiomas and vascular malformation in infants, children and young adults: Treatment with percutaneous injection of sodium tetradecyl sulfate. AJR 1997;Vol. 169:723-729.