Bluish compressible lesion of the tongue that blanches
19-year-old female
§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)
Fig. 1Intermediate magnification micrograph of a capillary hemangioma. H&E stain. Related images Intermed. mag. High mag. Very high mag.
“Capillary hemangioma - intermed mag” · Nephron · CC BY-SA 3.0 · Wikimedia Commons
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).
§References
- ISSVA Classification of Vascular Anomalies (2018).
§Similar cases
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