Venolymphatic malformation in the buccal space: magnetic resonance imaging features

Abstract

Clinical Presentation

Venolymphatic malformation in the buccal space is relatively rare. A 27-year-old male with a soft, compressible mass in the right posterior maxilla causing facial asymmetry and gingival bleeding underwent pre- and post-contrast magnetic resonance imaging (MRI), revealing a heterogeneous but predominantly cystic lesion involving the right buccal space, extending superficially as also deeply to involve the buccinator and the anterior masseter, and inferiorly to the buccal space and inferolateral aspect of the right pterygomaxillary fissure. No osteolysis was identified. Slightly increased signal on T1 is noted from proteinaceous material or blood products as some areas show fluid levels. It is more conspicuous on the contrast-enhanced T1-weighted images with fat suppression. It appears to have primarily high T2 signal. There are focal areas of decreased T1 and T2 signal that are non-enhancing and may represent calcified phleboliths. No evidence of dilated vascular structures is identified suggesting a high-flow lesion.

Differential Diagnosis

Includes capillary, venous, lymphatic, and arteriovenous vascular lesions, hemangioma. For phleboliths: calcified lymph nodes, atherosclerosis, sialoliths, cysticercosis, miliary skin osteomas etc.

Diagnosis and Management

The diagnosis was confirmed via clinical evaluation, MRI, and aspiration. Findings were consistent with a low-flow, venolymphatic malformation involving the right buccal space and right pterygomaxillary fissure. The lesion was embolized and resected.

Conclusion

Although diagnosis of most cases of venolymphatic malformation may not be difficult, it can be challenging if superimposed with trauma, hemorrhage, or infection. Risk of severe hemorrhage exists if extraction in the region is performed. Dynamic contrast-enhanced MRI has greater specificity of diagnosis in that it can differentiate between low-and high-flow lesions. Management of vascular malformations is based on the lesion's vascular anatomy, anatomical location, and involvement with surrounding structures. Non-invasive intervention includes endovascular embolization, sclerotherapy and laser therapy.