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Case Report

Cavernous hemangioma in the floor of oral cavity

masquerading as a ranula
Puneeta Vohra, Vinod Vijay Chandar, Ranjit Patil1, Saumya Verma2
Department of Oral Medicine and Radiology, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, 1King George
Medical University, Lucknow, Uttar Pradesh, 2Hazaribag College of Dental Sciences, Hazaribag, Jharkhand, India

ABSTRACT

A painless, bluish, submucosal swelling on one side of the floor of the mouth usually indicates the presence of a ranula.
Rarely, such a swelling may be caused by an inflammatory disease process in a salivary gland, a neoplasm in the sublingual
salivary gland, hemangiomas, a lymphatic nodular swelling, amyloidosis, or embryologic cysts/dermoid cyst. We report a
35-year-old female patient with swelling in the floor of her mouth that was clinically diagnosed as a ranula due to negative
diascopy, the site of swelling, and the age of patient. Because of a strong clinical suspicion of a ranula, diagnostic methods
such as angiography and magnetic resonance imaging (MRI) were not used in our case. A preoperative diagnosis was not
truly established. We report a case of hemangioma in the floor of the mouth masquerading as a ranula. Although a rarity,
vascular malformations should always be ruled out by using digital subtraction angiography and MRI studies before going
for surgical intervention.
Key words: Floor of oral cavity, hemangioma, ranula

Introduction or skeletal. This case report describes a patient with

swelling in the floor of her mouth that was clinically

S
ubmucosal swelling in the floor of the mouth
often represents a disease process of the salivary
glands (e.g., sublingual, submandibular, minor).
Typically, a chronic, painless, one-sided swelling on the
floor of the mouth that is bluish and soft indicates a
ranula. Rarely, such a swelling may be associated with
an inflammatory disease process in a salivary gland, a
benign or malignant neoplasm in the sublingual salivary
gland, lymphatic nodular swelling, or embryologic
cysts. Such processes are thought to arise from tissue
normally located in the regions mentioned; so the source
may be, for example, vascular, neurogenic, dentigerous,
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diagnosed as a ranula. During surgery, however, a
vascular tumor was suspected, and histologic testing
confirmed that the lesion was a cavernous hemangioma.
Case Report
A 35-year-old female patient reported to the outpatient
department of KM Shah Dental Hospital with swelling
in the right side of the floor of the mouth since 3 months.
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DOI: How to cite this article: Vohra P, Chandar VV, Patil R, Verma S.
10.4103/0972-1363.170161
Cavernous hemangioma in the floor of oral cavity masquerading as
a ranula. J Indian Acad Oral Med Radiol 2015;27:286-90.

Address for correspondence: Dr. Puneeta Vohra, Department of Oral Medicine and Radiology, Faculty of Dental Sciences, SGT
University Hospital, Budhera, Gurgaon - 122505, Haryana, India. E-mail: drpuneeta_mithi@yahoo.co.in
Received: 03-12-2014  Accepted: 15-10-2015  Published: 21-11-2015

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Vohra P et al.: A hemangioma masquerading as ranula
Patient was relatively asymptomatic 3 months back.
Swelling was accidentally noted by a dentist while
extracting a grossly carious 36. She ignored the swelling
initially; but as the swelling was gradually increasing in
size and causing intermittent pain, she visited a cancer
hospital. Investigations were done and they had sent the
patient to the OPD of the dental hospital for opinion. Her
symptoms were medium-grade with intermittent pain,
and there was difficulty in chewing, speech, and tongue
movements. The size of the swelling was unaltered
before or after taking meals. She had no difficulty in
swallowing and reported no bleeding from the mouth.
She was a housewife, vegetarian, with normal sleep and
appetite, and used to clean her teeth once daily with
tooth brush and paste in the morning. No deleterious
oral habits were reported. No extraoral swelling in
the orofacial and neck region was present [Figure 1].
Right submandibular lymph node was enlarged,
tender, palpable, firm in consistency and non-fixed.
Intraoral clinical examination confirmed the presence
of a clinically missing 36 and a carious 48. Gingiva
was reddish pink, firm in consistency, resilient, and at
normal position and contour; stippling was present and
bleeding on probing was not present; oral hygiene and
periodontal status were fair.
Examination of area of chief complaint revealed a large,
bluish swelling on the right side of the floor of her mouth
measuring 3 × 1.5 cm approximately [Figure 2]. Swelling
was evident on the right side of the floor of the mouth
with respect to 46, 45, 44, and 43, and extended from the
lingual surface of the teeth to the midline in the floor
of the mouth, not crossing the midline mediolaterally,
and from the mesial surface of the first premolar to
the distal surface of the first molar anteroposteriorly.
The mass was covered with normal mucosa, with no
obvious ulceration. Movement of the tongue, which
deviated toward the right, was slightly affected. On
bimanual and bidigital palpation, the mass was found
Figure 1: Extraoral view
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to be soft, tender, non-pulsatile, and to have a consistent
compressibility, but did not blanch on pressure. It was
not attached to the lower jaw and not associated with
the submandibular salivary gland. However, it was
attached to the sublingual salivary gland. The swelling
did not extend beyond the submandibular triangle,
and the clinical opinion was that it was localized on the
floor of the mouth, above the mylohyoid muscle. With
detailed clinical examination and history of patient,
a provisional diagnosis of ranula was made with a
differential diagnoses of hemangioma, lymphangioma,
pleomorphic adenoma, and congenital dermoid cyst.
Detailed hematological investigation was carried out,
which revealed the following: Hemoglobin (Hb)- 8.3
g/dl, erythrocyte sedimentation rate (ESR)- 15 mm/h,
WBC count- 7500 cells/mm3, random blood sugar (RBS)-
74 mg/dl, and serum creatinine- 0.8 mg/dl. This was
followed by fine needle aspiration cytology (FNAC)
performed from the swelling on the floor of the mouth.
The smears revealed mainly RBCs with a few polymorphs
and lymphocytes. No malignant/dysplastic cells were
seen. Orthopantomograph (OPG) and maxillary cross-
sectional occlusal view were done, but did not reveal
any radiographic findings. Ultrasonography (USG)
was done, which did not reveal any abnormal blood
flow or phleboliths. Plain and contrast computed
tomography (CT) neck was done, which revealed a non-
enhancing soft-tissue lesion of size 31.3 × 13.9 mm with
distinct borders and of density 52-55 HU, with no rim
enhancement or any abnormal uptake of contrast evident
[Figure 3]. Focus of calcification was noted within the
lesion. No bony erosion was seen [Figure 4]. These
findings gave an impression which was suggestive of a
lymphangioma, dermoid cyst and hemangioma, but did
not rule out ranula. After this, the patient was surgically
treated, surgical excision of the lesion was done, and the
specimen was sent for biopsy [Figures 5 and 6]. Gross
examination of the specimen revealed a mass of 3 × 3
cm in size, brownish black in color, firm in consistency,
Figure 2: Intraoral view with bluish swelling in the floor of oral cavity
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Vohra P et al.: A hemangioma masquerading as ranula

Figure 3: Sagittal view of swelling on CT scan Figure 4: Axial view on CT scan

Figure 6: Post-surgical photograph after removal of sutures

Figure 5: Surgical resection of the mass from the floor of oral cavity
and with a lobulated surface [Figure 7]. Histopathologic
examination revealed irregular dilated vascular spaces
lined by flattened endothelial cells in a fibrous connective
tissue stroma. Endothelium-lined vascular spaces were
engorged with large aggregates of erythrocytes, which
confirmed the diagnosis of cavernous hemangioma
[Figure 8]. Three years later, the patient is well and has
no complications or recurrence.
Discussion
Hemangiomas and vascular malformations are benign
lesions of blood vessels that appear relatively often in
the head and neck region. Hemangiomas particularly
favor the head and neck region, with 65% of them
occurring in this region, even though the head and
neck comprise only 14% of the human body.[1] Various
terms and classes have been suggested to describe
these types of lesions. The renaissance began in 1982
when Mulliken and Glowacki introduced a “biological”
classification that dispensed with the old, confusing
terminology and offered a set of clear, concise terms
and definitions.[2] They recognized two distinct entities,
hemangioma and vascular malformations, on the basis
of clinical and biological differences.[2-5] In accordance
with this classification scheme, hemangiomas are
characterized by a rapid, primitive stage of development
after the initial period of formation, followed by a slow
stage of regression. Microscopically, hyperplasia in the
endothelium of the basilar membrane is evident early in
the primitive stage of development, which is followed
by fibrosis with decreased cellularity in the involution
phase.[2] Most hemangiomas (70-90%) appear in the first
4 weeks of life, and the regression stage typically begins
after age 7.[2-4] Vascular malformations are present at birth
and progress slowly as the infant grows. Histologically,
they consist of vascular channels that are covered by
normal endothelial cells. Vascular malformations do
not regress later in life and after a traumatic injury or
secondary to hormonal influences, they swell suddenly
and develop rapidly.[3,5] Hemangiomas and vascular
malformations can localize exclusively to the skin or
in deeper tissue and involve the skin, at which point
the lesion is visible and easily recognized. Rarely, such
lesions localize in extremely deep tissues and can remain

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Vohra P et al.: A hemangioma masquerading as ranula
Figure 7: Pathological sample
undiagnosed for years, especially if they do not produce
any clinical symptoms.[5,6] Often, deep hemangiomas
that are not perceptible within the first few years of life
and begin to regress are discovered only by chance.[2]
Development of a phlebolith within the hemangioma
from a thrombus may cause symptoms and usually
leads to diagnosis of the hemangioma. [7] Similarly,
vascular dysplasias that localize to deep tissues are
usually diagnosed only after abrupt growth is caused
by trauma or hormonal influences.[8] The most common
regions of deep localization of hemangiomas are muscle,
liver, and bone.[1,9,10] Approximately 1% of hemangiomas
localize in the muscles of the head and neck, most
commonly the masseter and trapezius muscles. [9,11]
They also can localize in the parotid gland, larynx, and
paranasal sinus, and few isolated cases of localization
in the mentalis muscle have been reported. [10,12,13]
Adhering to the diagnostic approach for deep vascular
lesions can be difficult. Often, control X-ray films are
not helpful. However, findings on USG, CT, magnetic
resonance imaging (MRI), and angiography can be very
useful.[5,13,14] Because clinical suspicion was strongly in
favor of a ranula due to negative diascopy, the site of
swelling, and the age of patient, diagnostic methods
such as angiography and MRI were not applied in our
case. Obtaining a biopsy specimen from such vascular
tumors in the floor of the mouth which is a rare site for
hemangioma can also can be challenging. When biopsy is
essential to secure histologic proof, measures to prevent
hemorrhage must be in place.
Treatment, too, is difficult in such lesions and often
has poor results; but in our case, there was no history
of reoccurrence. Lesions causing no significant clinical
problems may be left alone, but the patient should be
kept under regular follow-up. Thorough evaluation
and a precise diagnosis help to determine the most
effective therapeutic option, which may be surgery,
sclerotherapy, pharmacotherapy, interlesional steroids,
Journal of Indian Academy of Oral Medicine & Radiology | Apr-Jun 2015 | Vol 27 | Issue 2
Figure 8: Histomicrograph showing endothelium-lined vascular spaces
or irradiation. [5,6] In our case, surgical intervention
was chosen because the initial clinical diagnosis was
a ranula. If the correct diagnosis had been made,
however, surgery would have been contraindicated
because of the clinical problems as well as the dangers
of hemorrhage. A multidisciplinary approach is
required in treating hemangiomas, as the hemangioma
can be associated with liver, spleen, skin, pancreas,
brain, and also with syndromes. Referral should
be made to general physician, neurosurgeon, and
dermatology departments, respectively. Latest
investigation modalities include USG, color Doppler,
MRI, dynamic gadolinium (Gd)-enhanced MRI,
nuclear medicine, RBC-tagged technetium-99m
(99mtc), scintigraphy with single-photon emission
CT (SPECT), and digital subtraction angiography
(DSA). Latest treatment modalities include laser
photocoagulation with Nd:YAG, photocoagulation
for vascular malformations and hemangiomas in
childhood, sclerotherapy by morrhuate sodium and
sodium psylliate, carbon dioxide snow, cryotherapy,
and compression.[15,16]
Declaration of Patient Consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/
have given his/her/their consent for his/her/their
images and other clinical information to be reported in
the journal. The patients understand that their names
and initials will not be published and due efforts will
be made to conceal their identity, but anonymity cannot
be guaranteed.
Acknowledgment
The authors are grateful to the Department of Oral Diagnosis,
Medicine and Radiology, KM Shah Dental College and
Hospital, Vadodara.
Financial support and sponsorship
Nil.
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Vohra P et al.: A hemangioma masquerading as ranula
Conflicts of interest
There are no conflicts of interest.
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