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1. Department of Oral and Maxillofacial Surgery
25 YEAR OLD FEMALE WITH PROGRESSIVE
SWELLING IN TONGUE AND FLOOR OF MOUTH
PRESENTER
Dr. Prashansa Gaikwad
OMFS RESIDENT
UNDER THE GUIDANCE OF

2. Dr. Prashansa Gaikwad
PG Resident, Department of Oral and maxillofacial surgery,
Mahatma Gandhi Dental College and Hospital, Jaipur.

3. An unusual case of Swelling in
the tongue and floor of mouth.

4. • Chief complaint :
➔ Pain in tongue, mainly in anterior part.
➔ Swelling in anterior part of tongue and floor of
mouth.
➔ Bluish discolouration in anterior part of tongue and
floor of mouth since 9 months.

5. • History of present illness :
• Patient was well 9 months back
• Pain was dull, throbbing, increased on eating food.
• Swelling developed gradually over 9 months slowly associated
with mild tenderness.
• Peanut size swelling in anterior region of tongue that gradually
developed to present size.
• There was no history of trauma.
• No h/o Trauma.
• No h/o difficulty in deglutition or mastication.
• No recent changes in dietary and food habits.
• No h/o of fever or malaise.
• No h/o weight loss.
• No h/o insect bite.
• No h/o evident skin lesions.

6. ● History of past illness
• No significant past medical history.
• There was no change in recent dietary habits.
• Dental history :
• Brushed teeth once daily.
• Using horizontal brushing technique.
• Suggest Modified Bass technique.
• No broken tooth or sharp cusp.
• No h/o any dental procedure empirically.

7. • No history of similar illness in family.
• No history of any known hereditary condition in family.
• No history of any syndromic condition family.
• No history any chronic or systemic disease in family.
• No history of consanguineous marriage.
• Patient is of sober habits.
• Vegetarian by diet.
● Family history:
● Personal history:

8. • Menstrual history :
• Obstetric history :
• Menarche at 14 years of age.
• Regular menstrual cycle of 28 days.
• Changes 1 pad/day during flow period.(5-6 days)
• Had no other abnormal associated symptoms.
• Currently patient is amenorrhic and breastfeeding a 11
month old girl.
• Patient had one pregnancy and birthed a female child.
• Patient had a full term vaginal delivery.
• G1P1A0
● Patient was a lactating mother of a 11 month old female
child.

9. • Duration : 9 months
• Mode of onset : Gradual
• Exact site : Anterior tongue involving dorsal + ventral surfaces
involving right floor of the mouth.
• Progression : Slow.
• Associated symptoms : mild tenderness.
• Secondary Changes : None.
• Family history of swelling : No history of TB or Neoplasm or
Syndromes.
• History associated with swelling

10. Summary
• 25 years old female.
• Bluish discoloration and swelling of anterior tongue & floor of
mouth.
• Not associated with difficulty in speech or mastication.
• No h/o systemic disease or allergies.
• No h/o any hereditary or syndromic condition.

11. Differential diagnosis based on history

12. Syndromic Association
Beckwith-Wiedemann syndrome
Down's syndrome
Hurler-Pfaundler syndrome
Blue rubber bleb nevus syndrome
Maffucci syndrome
Nutritional Causes
Pellagra
Pernicious Anemia
Vascular Causes
Hemangioma
Hematoma
Venous stasis
AV Malformation
Hormonal Causes
Tumor of the pituitary gland
Acromegaly
Local Causes
Trauma
Ranula
Irritational fibroma
Other
Acanthosis nigricans
Angioedema
Lymphangioma
Tongue cancer
Differential diagnosis
LOCAL SYSTEMIC

13. • General examination :
• Build : Well build.
• Nourishment : Well nourished.
• Pulse Rate : 86 bpm
• Blood Pressure : 128/80 mmHg (Right arm Supine position.)
• Temperature :
• Weight : 52 kg.
• Height : 5”2
• With no other abnormality present in general examination.

14. • General examination :
• No evidence of icterus, pallor, lymphadenopathy.

15. • Extra oral examination :
• Facial symmetry : No asymmetry
• Lips : Competent
• Vermillion Border : No abnormality
• Mouth opening : 3 fingers.
● No significant
Lymphadenopathy seen.
1. Extraoral
• No evident
abnormality in respect to eyes,
ear, nose.
● Local Examination

16. • Intraoral Hard tissue examination :
• All teeth normal as per age.
• Intact occlusion with no positive hard tissue findings.
• No sharp cusp of teeth in relation to the lesion.

17. • Intraoral soft tissue examination :
I. Inspection :
• Labial Mucosa : No abnormality
• Labial vestibule : No abnormality
• Buccal Mucosa : No abnormality
• Buccal vestibule : No abnormality
• Gingiva & Periodontium : No abnormality
• Palate : No abnormality

18. • Tongue : Finding present.
• Floor of mouth : Finding
present.
• Size : 5cm x 5cm approx.
• Shape: Oval.
• Color: Purple {Bluish red}
• Margin : Clearly defined.
• Number : Single.
• Pulsations : No visible
pulsations.
Tip, ventral surface
of tongue, right
lateral border,
diffuse swelling in
anterior aspect.
Mid dorsal , right
floor of mouth

19. • Intraoral soft tissue examination :
II. Palpation :
• Temperature : Warm.(Local temperature: look increased)
• Tenderness : Present.
• Surface : Smooth.
• Consistency : Uniform and compressible.
• Mobility : Immobile.
• Fluctuations : Absent.
• Pulsations : Absent

20. • Intraoral soft tissue examination :
III. In Investigation :
• Blind aspiration was done
under all aseptic conditions.
• Frank blood was aspirated.
• Usually when patient with
such swelling comes we
routinely do a diagnostic
aspiration
NEEDLE
PLACED AT
ANTERIOR
PART OF
DORSUM OF
TOUNGE

21. Summary
• 25 years old female.
• Bluish discoloration and swelling of anterior tongue, involving
dorsal and ventral surfaces and extending up to right floor of
mouth and crosses the midline anteriorly.
• No h/o systemic disease or allergies.
• Not associated with difficulty in speech or mastication.
• No gross abnormality noted on general examination.
• Frank blood aspirated from the lesion.
• No symptoms of hereditary or syndromic condition.

22. What should be differential diagnosis ?
?

23. Syndromic Association
Beckwith-Wiedemann syndrome
Down's syndrome
Hurler-Pfaundler syndrome
Blue rubber bleb nevus syndrome
Maffucci syndrome
Nutritional Causes
Pellagra
Pernicious Anemia
Vascular Causes
Hemangioma
Hematoma
Venous stasis
AV Malformation
Hormonal Causes
Tumor of the pituitary gland
Acromegaly
Local Causes
Trauma
Ranula
Irritational fibroma
Other
Acanthosis nigricans
Angioedema
Lymphangioma
Tongue cancer
Differential diagnosis

24. Differential diagnosis
Hemangioma
Hematoma
Venous stasis
AV Malformation

25. IV. Auscultation :
• It was done by handheld Doppler.
• In respect to anterior mandibular region.
• It showed increased Vascular flow in the lesion

26. • Provisional diagnosis :
Vascular malformation of anterior tongue and
floor of the mouth.

27. • Investigations :
1. Routine blood investigations.
1. CT Angiography {Head + Neck}
• CBC {Complete blood count}
• Blood Glucose
• Serum Electrolytes
• Liver function test
• Renal function test
• Prothrombin time
• Viral Markers

28. Parameters Result value Normal Value
WBC 7.2 4.0-10
RBC 5.39 3.8-4.8
Haemoglobin 14.6 g/dl 12.0-15.0 g/dl
HCT 43.3 % 36.0-46.0 %
MCV 80.2 fL 83-101 fL
MCH 27.0 pg 27.0-32.0 pg
MCHC 33.7 g/dl 31.5-34.5 g/dl
Platelets 217 150-410
Neutrophil 73.9 % 40-80 %
Lymphocyte 17.6 % 20-40 %
Monocyte 7.3 % 2.0- 10.0 %
Eosinophil 0.7 % 1.0-6.0 %
Basophil 0.5 % 0.0-2.0 %
MPV 10.1 fL 6.0-11.0 fL
PCT 0.219 % 0.15-0.50%
CBC {Complete blood count}

29. Parameters Result value Normal Value
Blood sugar R 117.0 mg/dl 80-140 mg/dl
Blood Glucose
Serum Electrolytes
Parameters Result value Normal Value
Serum sodium 139.7 mmol/L 137.0 – 145.0 mmol/L
Serum potassium 4.35 mmol/L 3.5 – 5.1 mmol/L
Serum chloride 98.9 mmol/L 98.0- 107.0 mmol/L
Liver function test
Parameters Result value Normal Value
S. Bilirubin total 0.8 mg/dl 0.2-1.3 mg/dl
S. Bilirubin direct 0.4 mg/dl <0.3 mg/dl
S. Bilirubin indirect 0.4 mg/dl 0.1-0.9 mg/ dl
SGOT/ AST 33.2 U/L 15.0-46.0 U/L
SGPT/ ALT 28.9 U/L 13.0 – 69.0 U/L
S. Alkaline phosphatase 136.0 U/L 38- 126 U/L

30. Renal function test
Parameters Result value Normal Value
Blood urea 17.0 mg/dl 15.0-45.0 mg/dl
S. Creatinine 0.5 mg/dl 0.52-1.25 mg/dl
S. Uric acid 3.4 mg/dl 2.5-6.2 mg/dl
Prothrombin time
Parameters Result value Normal Value
Prothrombin time 12.0 seconds Control – 12.0 seconds
INR 1.0 seconds
Viral Markers
Test Results
Covid – 19 {RT-PCR} Negative
Hepatitis B surface antigen Negative
Hepatitis C antibodies Non- reactive
HIV 1&2 antibodies Non- reactive

35. • Final diagnosis :
Low flow Vascular Malformation of
anterior Tongue and right floor of the
mouth.

36. Dr. Ruchika Tiwari
Professor, Department of Oral and maxillofacial surgery,
Mahatma Gandhi Dental College and Hospital, Jaipur.

37. Introduction to vascular
anomalies

40. • Dr.Sanjeev S Nair introduced a more practical classification
to helped in surgical planning ,the surgical approach and
reconstruction necessary for the type of vascular lesion.

41. • In type I superficial lesions requiring excision of skin or mucosa,
local or regional flaps have been used in defect reconstruction.
• Type II submucosal lesions require complete excision after elevation
of skin flaps.
• Type III lymphovenous malformations or venous malformations
involving glands of the head and neck are excised along with the
affected gland.
• Type IV intraosseous lesions require excision with involved bone
and reconstruction when required.
• Type V lesions involving deep visceral spaces, such as the
parapharyngeal or infratemporal fossa, require skeletal access
osteotomy for complete exposure and total excision.

42. Incidence

43. • Overall, infantile hemangiomas have an incidence of 3–10% in
the literature, but more evidenced study confirmed that it is
likely 4–5%
• A multicentric prospective study with an aim to identify
demographics of infantile hemangiomas concluded female
gender, prematurity, multiple gestations, Caucasian ethnicity,
low birth weight and advanced maternal age are the associated
risk factors .
• Among vascular lesions, venous malformations are the
common along with lymphatic ones having incidence of
1:5000–10,000, and surprisingly 40% of them usually occur in
head and neck regions

45. Hemangiomatous lesion Vascular malformation

46. Diagnosis

47. • Clinical diagnosis of hemangiomas generally
arises from:
1. Making a thorough physical examination
which considers the shape, consistency and
possible invasive lesion, with subsequent
deterioration of vital functions.
1. Rule out other associated syndromes.

48. Diagnosis
• Clinical diagnosis of superficial Venous malformations
is easy by clinical examination.
• For deep seated lesion in the head and neck,we require
further investigations.
• Imaging studies using ultrasound (US), CT, MRI
,angiography are the best diagnostic scans

49. Differentiating features between hemangiomas and
vascular malformation in their clinical presentation and
behavior .

50. Diagnostic imaging techniques like color Doppler ultrasound (CDUS), MRI,
CECT scan, digital subtraction angiography (DSA) (catheterizing the entire
vertebral or vascular tree) and MR venography for low-flow lesions has been
aiding the surgeon to manage these lesions.

52. Histopathologic features

53. • In distinction to hemangiomas, vascular malformations result
from abnormal vascular or lymphatic morphogenesis, not due
to abnormal endothelial proliferation.

54. Management

56. Management of VM
• Preliminary imaging will differentiate a high flow from a
low-flow lesion.
• In low-flow lesions with large vascular channels and spaces
in the head and neck region, total excision is a surgical
challenge and misadventure.
•
• The philosophy of management then hinges on
decompressing the lesion or partial elimination.
• This can be achieved with administration of intralesional
medicaments which may be sclerosing in nature

58. Intra lesional sclerosants
• Sclerotherapy has become the current mainstream
treatment for venous malformation. It can be used
alone or combined with surgery and/or laser therapy.
• Mechanism of action of these sclerosing agents:
• Destroying the blood vessel’s endothelial cells,
acceleration of protein coagulation in blood of
lesions, formation of thrombosis, platelets adhesion
promotion and causing vascular occlusion through
thrombotic mechanisms.

59. A case of vascular malformation of tongue &
floor of mouth

62. Treatment Plan
Preoperative
Intra-lesional
Bleomycin injection
Surgical Excision Follow up

63. Intra-lesional bleomycin injection
• Informed consent was taken from all patients
• Bleomycin: 15 IU diluted in 5ml normal saline mixed with
lidocaine
• Patient underwent puncture of the lesion and complete
aspiration of the intralesional fluid. The bleomycin was
multiply injected in a radial fashion. Patients remained under
observation for approximately 1 hour after the procedure.
• 3 injections given at an interval of 15 days.

64. Surgical excision under GA
The lesion was marked

65. Ligation of lingual artery thru submandibular
approach of ECA ligation

66. Surgical excision of lesion

67. Closure of Wound

68. Post operative pictures

69. Pre operative Picture Post operative Picture

70. Discussion

71. • Bleomycin is a cytotoxic anti-tumour antibiotic, discovered by
Umezawa in 1966.
• Recently been shown as an effective treatment for vascular
malformations via intralesional injections.
• It has Low toxicity.
• Bleomycin exhibits a dual effect on human tissue in that it can
induce DNA degradation in undercoiled strand regions during S
stage of cell cycle, and in addition has a specific Sclerosing effect
on vascular endothelium
• Minimal immunosuppression and myelosuppression.
• In adults, the maximum dose per treatment session was 10 to 15
mg or 15000 units.
Bleomycin

75. Conclusion: Intralesional interstitial bleomycin injection is a
feasible approach for early-stage AVMs and yields safe and effective
outcomes.

76. Conclusion
• The efficacy and safety of intralesional bleomycin
injection proved to be satisfactory.
• Therapeutic outcomes were good.
• There were no major complications.
• Low-flow VMs show excellent response to intralesional
bleomycin sclerotherapy.
• Decompressing / partially eliminating the lesion
combined with surgical treatment, is the most
conventional modern approach.

77. Case 2 : AV of anterior mandible
Pre- Operative
pictures
CT
Angiography
neck

78. Intra
operative
pictures

79. Post operative pictures
1st Bleomycin Injection 2nd Bleomycin Injection
3rd Bleomycin Injection

80. Pre operative Picture Post operative Picture

81. Dr. Sonia Agarwal
Assistant Professor, Department of Pathology,
Mahatma Gandhi Medical College and Hospital, Jaipur.