Bluish compressible lesion of the tongue that blanches

§Chief complaint

Soft bluish lump on the tongue present since childhood

§Medical & dental history

• 01No coagulopathy; no bleeding disorder
• 02No trauma or biting history at the site

§Clinical examination

• 01Soft, compressible bluish-purple lesion 20 mm on the dorsolateral tongue
• 02Blanches completely on diascopy (positive blanching sign)
• 03No pulsation, no bruit, no thrill
• 04Enlarges when the head is placed below the heart

§ figuresFigures (1)

Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Haemangioma figures pending faculty review.

§Differential diagnosis

§Final diagnosis

Venous malformation (low-flow vascular lesion) of the tongue

Blanching on pressure with positional enlargement and no thrill or bruit defines a low-flow venous lesion. A pulsatile, thrilling mass would be a high-flow arteriovenous malformation and would be dangerous to biopsy or excise without embolisation.

§Investigations

• 01Doppler ultrasound — low-flow venous channels, no arterial feeders
• 02MRI — high T2 signal, lobulated lesion with phleboliths
• 03Biopsy avoided as a first-line investigation in a vascular lesion

§Treatment plan

• 01Observation if asymptomatic
• 02Sclerotherapy (sodium tetradecyl sulfate or bleomycin) as first-line active treatment
• 03Surgical excision for residual localised disease after sclerotherapy
• 04Never biopsy or incise an undiagnosed pulsatile lesion in the oral cavity

§Surgical procedure

• 01Two sessions of ultrasound-guided sclerotherapy at 8-week intervals
• 02Residual 6 mm nodule excised with a diode laser

§Follow-up & outcome

• 01Lesion reduced by more than 80 percent after sclerotherapy
• 02Speech and tongue mobility normal
• 03No recurrence at 18 months

§Clinical pearls / learning points

• 01Diascopy is the free, instant test at the chairside — vascular lesions blanch.
• 02Never biopsy a suspected high-flow vascular lesion in the mouth; life-threatening haemorrhage can follow.
• 03Distinguish true infantile haemangioma (proliferates then involutes) from vascular malformations (grow with the child).

§Related diseases

§Similar cases