Bleeding cavernous hemangioma of lower lip: a case report

Introduction:

Hemangioma is a common benign vascular tumor. However, bleeding cavernous hemangioma of the lower lip are a rare condition.

Case presentation:

A 67-year-old female presented with bleeding from the lower lip. The bleeding increased with palpation. A clinical diagnosis of hemangioma of the lower lip was made. It was difficult to localize with ultrasound. It was explored and excised successfully.

Clinical discussion:

Hemangioma can be superficial, deep, or mixed. Generally, hemangioma involute spontaneously. Bleeding hemangioma causing functional disturbances need to be treated, for which various modalities are available, including excision.

Conclusion:

Hemangioma of the lip is a benign tumor of vascular origin. In selected cases, excision can be performed.

highlights

• Hemangioma has an increased tendency to bleed.

• Bleeding cavernous hemangioma of the lip is a rare pathological entity.

• Recurrent bleeding hemangioma needs treatment even if it is unnoticeable.

• Hemangioma should be considered in the differential diagnosis in case of bleeding from the lower lip. Excision with ligation of its feeding vessel is an important treatment option.

Introduction

Hemangioma is the most common benign vascular tumor in newborns and childhood1. It also occurs in adults. It is three times more common in females compared to males2. It commonly occurs in the skin, and is occasionally found in the oral cavity3. The possible sites of occurrence in the oral cavity are the lip, tongue, and palate. It is classified according to the depth of soft tissue involvement into superficial, deep, and mixed4.

Clinically, it presents as mass, measuring a few millimeters which is hardly noticeable to several centimeters smooth and lobulated swelling which lead to physical abnormalities and functional disturbance5. In some cases, it also presents with ulceration, bleeding, and feeding difficulties1,6.

Usually, it involutes spontaneously. However, some selected cases need further investigation and treatment. Ultrasound is the most cost-effective diagnostic modality in lower lip disease though, some small lesion cannot be detected. Magnetic Resonance Imaging is choice of investigation in such situation7. Treatment of hemangioma depend on age of patient, location, size, and its extension8. Different modality of treatment of hemangioma like intralesional steroid , intralesional sclerosing agent, laser surgery, and excision9,10. The aim of this study is to identify the cause of bleeding in the lower lip without a noticeable mass. This case report has been reported in compliant with the SCARE criteria11.

Case report

History and clinical examination

A 67-year-old female patient reported to our institution with a chief complaint of intermittent bleeding from the lower lip for 3 months (Fig. 1). There was no aggravating and relieving factor. The bleeding was causing discomfort to the patient. The general health of the patient was normal, and medical history revealed she was a past smoker. Patient showed video of fresh bleeding from the lower lip. We thought that there was something abnormal. Examination did not reveal any significant finding on inspection. While palpating the lower lip, bleeding occurred. Based on the clinical examination, we had come to a diagnosis of hemangioma.

Figure 1.

Bleeding hemangioma of lower lip.

Investigation

Her hemoglobin was 11.5 g/dl, and her platelet count 251 000 per microliter of blood. Bleeding time and clotting time were 3 and 7 min, respectively.

An ultrasound of the lip was done which did not show any significant findings. The patient was advised for MRI to localize the leison; however, the patient was not able to afford its cost and treatment was performed on basis of history and examination.

Treatment

Exploration of the bleeding site was performed under a local anesthetic of 2% xylocaine with adrenaline. Around 5 mm tissue around point of bleeding was excised. A branch of the inferior labial artery was found as a feeding vessel, which was ligated (Fig. 2). The wound was sutured with Vicryl 3-0. A specimen was sent for histopathological examination, and the report confirmed cavernous hemangioma. A microscopic section showed tissue partly lined by stratified squamous epithelium. Beneath the stroma, plenty of dilated and congested blood vessels were seen and a deeper area showed a thick bundle of skeletal muscle. Atypia was not seen in the section studied (Fig. 3). She was followed up after 1 week. Patient improved symptomatically. There was no bleeding or regrowth of the tumor in the 6 months of follow-up period.

Figure 2.

Intraoperative picture of lower lip containing hemangioma (white arrow) with its feeding vessel; right inferior labial artery (yellow arrow).

Figure 3.

Microscopic picture showing overlying epithelium, blood filled large vascular space lined by single layer of endothelium.

Discussion

Bleeding from the lower lip is an uncommon problem. Recurrent bleeding is troublesome for the patient. It is essential to differentiate hemangioma from other bleeding lesions like vascular malformations. There is altered endothelial growth in hemangioma which are more likely to bleed following minor injuries compared to vascular malformations, which are structural anomalies of blood vessels with normal endothelial cell growth12.

Ultrasound is not always able to diagnose haemangioma. MRI is able to diagnose it with greater accuracy7. It is good to localize tumor inside the soft tissue; however, treatment can be performed on the basis of history and examination. Excised tissue was sent for histopathological examination.

Continuous bleeding from the lip should be investigated to stop the bleeding. We did a wedge excision and found the feeding vessel, the inferior labial artery. A cavernous hemangioma is small. Unlike capillary hemangioma, it is present in deep tissue and does not present with swelling. It is difficult to palpate and localize by ultrasound13.

Large, persistent hemangioma may cause physical disfigurement, functional disturbance, for which treatment becomes mandatory. Administration of systemic corticosteroids, intralesional injection of sclerosing agents, electrocoagulation, cryosurgery, laser therapy, embolization, and surgical excision are some of the treatment modalities practiced for hemangioma1,14–18.

Conclusion

Hemangioma is a benign tumor that can occur in the lower lip and in elderly patients. It can present with recurrent bleeding. Cavernous hemangioma is small and may not be detected by ultrasound. Excision is required in a bleeding cavernous hemagioma. A wedge excision with a 5-mm margin from the bleeding site is a good option in such a case.

Ethical approval

Not applicable.

Consent

Written informed consent was obtained for the publication of the case and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

This study did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

Author contribution

Dr B.S. operated the case and conceptualized the study. Dr B.S. and Dr B.S. involved in design, literature review, writing, and approved the final manuscript.

Conflicts of interest disclosure

The authors have no conflict of interest to declare.

Research registration unique identifying number (UIN)

1. Name of the registry: not applicable.

2. Unique identifying number or registration ID: not applicable.

3. Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable.

Guarantor

Professor Dr Brihaspati Sigdel, the corresponding author, accepts my role as the guarantor of this case.

Provenance and peer review

Not commissioned, externally peer reviewed.