Venous vascular malformation of the parotid gland

Abstract

Venous vascular malformations of the parotid gland are very rare vascular tumors, especially among adults. This case report discusses the presentation and challenges of diagnosing a venous vascular malformation of the parotid gland in a patient with previous oncologic history. Our patient is a 45‐year‐old female with a history of breast cancer, meningioma, and secreting pituitary adenoma who presented with a malformation on magnetic resonance imaging, incidentally demonstrating a T2 intense mass in the superficial lobe of the right parotid gland. She was otherwise asymptomatic. Ultrasound‐guided fine needle aspiration was nondiagnostic. She underwent a right inferior superficial parotidectomy. Histologic section analysis demonstrated a well‐delineated vascular tumor made of large vascular spaces with thin walls surrounded by a parotid tissue consistent with a venous vascular malformation of the parotid gland. Venous vascular malformations are exceedingly rare, especially among adults. Ultrasound‐guided fine needle aspiration can be of limited value. Parotidectomy may be electively considered for diagnostic and therapeutic purposes.

CASE

A 45‐year‐old female with a history of breast cancer, left parafalcine frontoparietal meningioma, and secreting pituitary adenoma presented to clinic after recent magnetic resonance imaging (MRI) of her cervical spine incidentally demonstrated a T2 intense mass in the superficial lobe of the right parotid gland (Figure 1). She denied noting palpable lesions of her face. Upon review of her previously obtained MRI imaging, the mass had been present since at least 3 years prior. Given her prior history of breast cancer, she was concerned about the mass and sought medical evaluation.

Figure 1.

Magnetic resonance imaging demonstrating a well‐defined lesion (arrow) in the superficial lobe of the right parotid gland with homogenous (A) slightly higher signal intensity in T1 and (B) T2 hyperintensity.

There were no appreciable facial lesions on physical examination, and her facial nerve was noted to be intact bilaterally. In‐office ultrasound demonstrated a hypoechoic mass measuring 13 mm in the greatest dimension in the superficial lobe of the right parotid gland, just superficial to the retromandibular vein. Ultrasound‐guided fine‐needle aspiration was performed but nondiagnostic. Management options including observation with serial imaging versus surgical excision of the mass were discussed in detail, and the patient elected to undergo a right superficial parotidectomy given her previous history of cancer.

A right inferior superficial parotidectomy was performed, and the mass was identified between the marginal mandibular nerve and the retromandibular vein. The mass was approximately 1 cm, oblong, firm to palpation, and possessed an intact dark red capsule. Histologic section analysis demonstrated a well‐delineated vascular tumor made of large vascular spaces with thin walls surrounded by a parotid tissue consistent with a venous vascular malformation of the parotid gland (Figure 2).

Figure 2.

Hematoxylin and eosin stain demonstrating a well‐delineated vascular tumor surrounded by parotid tissue at ×100 magnification. The tumor is made of large vascular spaces with thin walls lined by a single layer of benign endothelial cells.

DISCUSSION

Venous vascular malformations are benign vascular tumors accounting for only 0.4%–0.6% of all tumors in the parotid gland. ¹ , ² They are more commonly found in children, with 90% of cases developing within the first three decades of life. ¹  Although they tend to regress spontaneously among children, venous vascular malformations are much less likely to involute among adults. ² Patients may rarely note bluish discoloration of the skin overlying the hemangioma. These lesions generally grow slowly and often remain asymptomatic until sudden growth induces pain or cosmetic concerns. ³ , ⁴ It is more common for such lesions to be found incidentally in imaging studies as in the case with this patient.

Ultrasonography is a critical imaging modality for salivary gland lesions; however, its use may be limited for diagnosing parotid venous vascular malformations due to their nonspecific hypoechoic appearance. Similarly, fine needle aspiration or core needle biopsies primarily yield blood products and are generally nondiagnostic. MRI is the preferred imaging modality for diagnosis of parotid venous vascular malformations and characteristically demonstrates a well‐defined lesion with homogenous T1 hypointensity and T2 hyperintensity with variable vascularity. ¹ Even with imaging, however, venous vascular malformations of the parotid gland are most commonly diagnosed after histopathological examination of the parotidectomy specimen.

Since venous vascular malformations of the parotid gland are unlikely to regress among adults, the mainstay of treatment is complete surgical resection. Presurgical embolization may be considered pre‐operatively, especially for larger lesions. Limited reports have demonstrated the efficacy of transarterial embolization as a stand‐alone treatment for venous vascular malformations of the parotid gland in infants; however, its efficacy among adults is unknown. ⁵

AUTHOR CONTRIBUTIONS

Amir A. Hakimi: Drafting manuscript creation of figures. Eric L. Wu: Critical revision of manuscript and figures. Jonathan Giurintano: Critical revision of manuscript and figures.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS STATEMENT

The authors have nothing to report.

Hakimi AA, Wu EL, Giurintano J. Venous vascular malformation of the parotid gland. World J Otorhinolaryngol Head Neck Surg. 2024;10:350‐352. 10.1002/wjo2.160

DATA AVAILABILITY STATEMENT

Not applicable, no data to be provided.